What is the best course of treatment for a 59-year-old male patient with persistent diarrhea and a history of diverticulitis, who has tried Imodium (loperamide) and bismuth subsalicylate, and recently underwent a colonoscopy and computed tomography (CT) scan of the chest, abdomen, and pelvis?

From the Guidelines

I strongly recommend managing the patient's diverticulitis without antibiotics initially, unless there are signs of complications or high risk of progression, and focusing on symptomatic relief with antidiarrheal medication and probiotics, as suggested by the most recent guidelines from the American College of Physicians 1. The patient's symptoms of persistent diarrhea despite over-the-counter remedies like Imodium and bismuth subsalicylate suggest a need for stronger antidiarrheal medication.

• Diphenoxylate with atropine can be considered for symptom relief, as it works by slowing intestinal motility.
• The addition of probiotics is important to help restore normal gut bacteria that may be disrupted by diarrhea or antibiotics.
• However, the use of antibiotics such as Augmentin 875/125mg should be reserved for patients with complicated diverticulitis or those at high risk of progression, as suggested by the AGA clinical practice update on medical management of colonic diverticulitis 1. The patient should be advised to stay well-hydrated during treatment and to follow up if symptoms persist beyond the treatment period.
• Additionally, the recommended upper endoscopy should be scheduled to investigate the esophageal wall thickening noted on the CT scan, even though this may be unrelated to the current diarrhea symptoms.
• It is also important to consider the potential harms of CT imaging, including incidental findings, radiation exposure, and side effects of or allergic reactions to any contrast used, as noted in the ACP guideline 1.
• The patient's history of diverticulitis and recent colonoscopy should be taken into account when making treatment decisions, and the patient should be monitored for any signs of complications or progression of the disease.

From the Research

Patient's Condition and Treatment

• The patient is a 59-year-old male with complaints of diarrhea and stomach pain, and has been diagnosed with diverticulitis.
• He has tried Imodium and bismuth subsalicylate, but the diarrhea persists.
• The patient has also tried fiber, but stopped taking it as he felt it made his stool worse.
• He has undergone a colonoscopy and a CT Chest/Abdomen/Pelvis with Contrast, which showed no acute traumatic process, a small hiatal hernia, and nonspecific mild wall thickening in the distal esophagus.
• The patient is being started on diphenoxylate with atropine, probiotics, and Augmentin.

Use of Probiotics in IBS Treatment

• Studies have shown that probiotics can be effective in improving overall IBS symptom scores and abdominal pain in the general IBS population 2.
• A systematic review with network meta-analysis found that Lactobacillus and Bifidobacterium were the most effective probiotics for relieving global IBS symptoms 3.
• Another study found that adding probiotics to a low FODMAP diet did not make an additional contribution to symptom response and adherence to the diet 4.

Low FODMAP Diet in IBS Treatment

• A low FODMAP diet has been shown to have a positive effect on symptoms in IBS patients, with a significant reduction in symptoms in 50-80% of patients 4, 2.
• However, the quality of the evidence for the low FODMAP diet remains questionable, and it is only recommended as a second-line treatment guided by qualified clinicians with specialized training 2.

Treatment Options for the Patient

• The patient's treatment plan includes probiotics, which have been shown to be effective in improving IBS symptoms 3, 2.
• The use of a low FODMAP diet may also be considered, but it is essential to weigh the potential benefits and risks, and to ensure that the patient is guided by a qualified clinician 2.