Management of Diverticulitis in 2017

Abstract

Diverticulitis has become increasingly more common in the 20^th century and is now one of the most frequent indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical presentation can vary widely from mild, uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically, all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid “Hartmann’s” stump. However, the treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore, the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and complicated left-sided diverticulitis in 2017.

Introduction

Although diverticular disease was first described in the late 1700s by Alexis Littre, diverticulitis was not considered a clinical problem until the early 20^th century.[1, 2] The incidence of diverticular disease then rose dramatically over the next century, likely due in part to the decrease of dietary fiber in the Western diet, as first described by Painter and Burkitt in their landmark 1971 article.[3] Diverticulosis is now quite common in the United States and has been found in as many as 10% of people > 40 years and 70% of those > 80 years.[4, 5] Diverticulitis, defined as inflammation and infection related to diverticula, occurs in 20% of patients with diverticulosis[6] and results in over 200,000 yearly hospitalizations in the United States.[7, 8]

The pathogenesis of diverticular disease is multifactorial and is thought to be related to low-grade inflammation, alterations in colonic microbiota, and immune, enteric nerve, and muscular system dysfunction. Patients with diverticulitis have higher numbers of mast cells present in all layers of the colonic wall,[9] and also have significant lymphocytic and neutrophilic infiltrates, depending on the severity of disease.[10–12] Part of this chronic inflammatory process may result from imbalance in the normal colonic flora.[13] Gut microbiota in patients on low- versus high- fiber diets vary dramatically,[14] and DNA sequencing confirms that the colonic microbiota vary according to consumption of dietary fiber.[15, 16] Finally, colonic dysmotility can also be associated with diverticular disease. Patients with diverticulosis have been shown to have increased duration of lower frequency contractile activity of the involved colon[17] and reduced density of interstitial cells of Cajal. Additionally, sigmoid colon specimens with diverticular disease have higher in vitro sensitivity to acetylcholine, lower smooth muscle choline acetyltransferase activity, and upregulation of smooth muscle muscarinic M3 receptors, all of which suggest alterations in the enteric nervous and muscular systems.[18]

Colonic diverticula tend to arise in areas of weakness of the colonic wall, most frequently occurring between the mesenteric and anti-mesenteric teniae where the vasa recta penetrate the muscle. Microscopic studies show muscular atrophy at these sites, making them particularly susceptible to herniation of the mucosa in the setting of increased intraluminal pressure. With obstruction of a diverticula and resulting venous congestion, inflammation and ultimately microperforation can occur. The extent of the perforation determines the clinical nature of the disease, which then dictates its management.

In 1942, Reginald Smithwick reported his series of over 300 patients at the Massachusetts General Hospital, and showed that the 10% who underwent colonic resection had superior outcomes, stimulating a shift towards operative management.[19] Henri Hartmann developed his eponymous two-stage sigmoid resection with end colostomy and oversewn rectosigmoid stump for cancer in 1923,[20] but this was later modified by Boyden and Nelsen for use in acute diverticulitis in the 1950s.[21, 22] Surgical resection for the management of diverticulitis thus gained popularity over the subsequent decades. However, the treatment paradigm has now shifted, with recent literature suggesting that many patients would benefit from less aggressive, frequently nonoperative, management. The purpose of this review is to summarize our approach to managing diverticulitis based on the continuously evolving literature. While diverticulitis can affect any location of the colon, this review will focus on the management of the most common entity, left-sided diverticular disease.

Symptoms

The clinical presentation of diverticular disease varies widely, with many patients having merely asymptomatic diverticulosis with no adverse sequelae. In patients with left-sided diverticulitis, the most common presenting complaint is left lower quadrant abdominal pain, which is usually accompanied by fever and leukocytosis. Patients may also present with nausea, vomiting, changes in bowel function, and dysuria.[5] Other symptoms may be present in the setting of other complications, such as hematochezia with diverticular bleeding or fecaluria, pneumaturia, and/or pyuria with a colovesical fistula. Generalized peritonitis may be elicited in severe cases of acute diverticulitis with free perforation.

Diagnosis

The initial evaluation of a patient with suspected acute diverticulitis should begin with a complete history and physical exam, and, in some clear-cut cases of recurrent disease, the diagnosis can be made without further imaging studies. When the diagnosis is in question, or the patient has severe symptoms and possibly complicated diverticulitis, computed tomography (CT) axial imaging should be performed. CT can distinguish diverticulitis from other conditions, including irritable bowel disease, gastroenteritis, or gynecologic disease. While the presence of sigmoid inflammation and diverticulosis can be identified by CT imaging, inflammation secondary to diverticulitis versus colon cancer or other etiologies cannot be reliably differentiated by imaging, so all patients with a first time episode should be followed with a colonoscopy to rule out malignancy.[23] The colonoscopy should be done in a delayed (four to six weeks) fashion to minimize the risks of perforation from over-distension.

In addition to being used for diagnostic purposes, CT scans can stratify patients by disease severity and identify patients with complications of diverticulitis, such as abscess, stricture, or pneumoperitoneum (Figure 1). Mild diverticulitis is usually associated with thickening of the colon wall and peri-colonic inflammatory changes such as fat stranding. In cases of complicated diverticulitis, the commonly used Hinchey classification can be applied (Table 1). Those with type I disease have only localized para-colonic abscesses, type II includes disease with distant or pelvic abscesses, and types III and IV have generalized purulent and feculent peritonitis, respectively.[24] An additional classification system from the European Association for Endoscopic Surgeons is based only on clinical, rather than radiographic, findings (Table 2), with three grades of disease ranging from symptomatic and uncomplicated (grade I) to recurrent uncomplicated (grade II) to complicated disease (grade III), which can include hemorrhage, abscess, phlegmon, perforation, peritonitis, stricture, fistula, or obstruction.[25]

Figure 1.

Computed tomographic imaging from a patient presenting with uncomplicated sigmoid diverticulitis (a), and another patient presenting with complicated diverticulitis with a complex pelvic abscess (b).

Table 1.

Hinchey classification of complicated diverticulitis (Adapted from Hinchey et al.[24])

Stage	Description
I	Localized pericolic abscess
II	Distant (retroperitoneal or pelvic) abscess
III	Generalized purulent peritonitis, caused by rupture of a pericolic or pelvic abscess, noncommunicating with bowel lumen
IV	Generalized feculent peritonitis, caused by free perforation of a diverticulum, communicating with bowel lumen

Table 2.

The clinical classification of diverticulitis from the European Association for Endoscopic Surgeons (adapted from Kohler et al.[25])

Grade	Definition
I	Symptomatic uncomplicated disease, initial
II	Symptomatic uncomplicated disease, recurrent
III	Complicated disease (initial or recurrent), to include any of the following: abscess, phlegmon, hemorrhage, fistula, stricture, obstruction, perforation, and/or peritonitis

Prevention

It is widely believed that low intake of dietary fiber predisposes people on Western diets to elevated colonic pressures and the development of diverticulosis.[3] A recent prospective cohort study of nearly 50,000 men with no known history of diverticulosis showed that diets high in red meat were associated with higher incidence of diverticulitis over nearly three decades of follow-up, whereas diets high in fiber were associated with decreased incidence of diverticulitis.[26] Unfortunately, despite the strong epidemiologic association between fiber intake and the eventual development of diverticulosis, no study to date has been able to show a reversal of the process or a reduction in episodes of diverticulitis with the adoption of a high fiber diet.[27]

Furthermore, there are limited data regarding the role of pharmacologic intervention, including mesalamine, rifaxamine, and probiotics, to prevent diverticulitis. A recent meta-analysis of six randomized controlled trials of over 1,000 total patients comparing mesalamine to placebo found that the incidence of diverticulitis was lower among patients receiving mesalamine.[28] While fewer patients on mesalamine developed diverticulitis than those on other therapies, including a high-fiber diet and low-dose rifaxamine, these results were not statistically significant. Multiple studies have attempted to study the role of probiotics in the prevention and treatment of diverticular disease, but a recent systemic review concluded that the quality of evidence was too poor to make any conclusions.[29]

Treatment

Management of diverticulitis depends on the presentation. The most important distinction is to first determine if the patient has complicated or uncomplicated diverticulitis (Figure 2). Of those patients with uncomplicated diverticulitis, initial management is generally nonoperative, although elective resection can be considered in select patients, including some of those with recurrent episodes. Conversely, complicated diverticulitis often results in intervention, either electively or emergently, although emergent surgery is mostly reserved for patients with Hinchey type III or IV diverticulitis with peritonitis.

Figure 2.

Management of diverticulitis depends first upon whether a patient has uncomplicated or complicated disease, and treatment can then be approached in a variety of ways.

Uncomplicated Diverticulitis

Even amongst patients with uncomplicated diverticulitis, the spectrum of symptoms can vary widely. In those with minimal symptoms, outpatient management with or without oral antibiotics to cover colonic flora (including gram negative rods and anaerobes) is often sufficient. However, in patients with fever, systemic symptoms, or intolerance to oral intake, inpatient treatment with intravenous antibiotics and perhaps a short period of bowel rest may be appropriate. In these patients, clinical improvement can be monitored with serial abdominal examinations as well as temperature and white blood cell count. After resolution of the acute symptoms, patients with a first-time episode of diverticulitis should be referred for colonoscopy to rule out mucosal disease (such as cancer or inflammatory bowel disease) as the underlying etiology, as these cannot be reliably ruled out based on CT imaging.[23]

While antibiotics have been the standard of care for uncomplicated diverticulitis for many years, recent studies have suggested that antibiotics may not always be necessary. In 2014, Chabok et al. conducted a randomized, controlled trial in Sweden of 623 patients with CT-confirmed uncomplicated diverticulitis, randomized to either antibiotics or no antibiotics.[30] They found no difference in abdominal pain, abdominal tenderness, or temperature curves between the two groups (Figure 3). Diverticulitis-related complications, such as perforation or abscess formation, only occurred in 1.9% of those not on antibiotics and 1.0% of those on antibiotics (P = 0.302), and there were no differences in rates of sigmoid resection, hospital length of stay, or recurrent diverticulitis at one-year follow-up.

Figure 3.

In a randomized, controlled trial of antibiotics versus no antibiotics, there were no differences in abdominal pain, temperature, or abdominal tenderness over time (from Chabok et al.[30])

A similar Dutch trial randomized 528 patients with CT-proven uncomplicated diverticulitis to observation or antibiotics.[31] The median recovery time was 14 versus 12 days in the observation and antibiotics groups, respectively (P = 0.15). They found no statistically significant differences in secondary endpoints, including episodes of complicated diverticulitis (observation: 3.8% vs. antibiotics: 2.6%, P = 0.38), ongoing diverticulitis (7.3% vs. 4.1%, P = 0.18), recurrent disease (3.4% vs. 3.0%, P = 0.49), sigmoid resection (3.8% vs. 2.3%, P = 0.32), readmission (18% vs. 12%, P = 0.15), adverse events (49% vs. 55%, P = 0.22), or mortality (1.1% vs 0.4%, P = 0.43). Notably, hospital stay was shorter in the observation group (2 vs. 3 days, P < 0.01). These two large, well-designed trials support the notion that uncomplicated diverticulitis may be more of an inflammatory rather than infectious condition, and that antibiotics may not be necessary to hasten recovery and prevent recurrent episodes or complications of diverticulitis, and that observation alone should be considered in select patients.

While the literature is clear that nonoperative management is the appropriate first strategy for the treatment of uncomplicated diverticulitis, patients with smoldering disease that is poorly or unresponsive to medical management often need escalation of care. Boostrom et al. evaluated 684 patients with uncomplicated diverticulitis undergoing sigmoid resection at the Mayo Clinic and found that 10% of those had disease that they characterized as smoldering or chronic.[32] These patients all had at least three months of continuous symptoms, with a medium of three completed courses of antibiotics (range 2–11). All patients underwent resection with primary anastomosis and only 5 of 66 were temporarily diverted. Only 2% of patients had major complications, and 90% of patients had complete resolution of all symptoms. Therefore, our practice is to offer surgical resection with primary anastomosis to patients with chronic, smoldering disease.

Recurrent, Uncomplicated Diverticulitis

While there is consensus that the acute management of uncomplicated diverticulitis does not involve surgical intervention, the role of elective colectomy to prevent recurrent diverticulitis is less well defined. Previously, elective colectomy was recommended following the second episode of uncomplicated or first episode of complicated diverticulitis, given concern that these patients were more likely to have recurrent disease. However, these recommendations arose from the era before routine use of CT scans and antibiotics,[33] and they are now in question.

Elective sigmoid colectomy is a prophylactic procedure designed to prevent recurrent diverticulitis. Therefore, understanding the predictors of recurrent disease may help define which patients would benefit from resection. Hall et al. performed a retrospective review of 672 patients treated nonoperatively for diverticulitis at the Lahey Clinic.[34] Of these, 36% developed recurrent disease over a median five years of follow-up, but only 3.9% of patients developed complicated recurrence. Multivariable predictors of any recurrence were retroperitoneal abscess (Hazard Ratio [HR] 4.5), family history (HR 2.2), and involved colonic segment > 5 cm (HR 1.7), whereas right colonic disease was protective compared to left-sided disease (HR 0.27).

Many clinicians and patients fear that their next episode will be a more severe episode, even necessitating emergent operation with temporary colostomy. In past decades, this concern about a colostomy often led to elective surgery but, as Hall and his colleagues demonstrated with the < 4% rate of recurrent complicated disease, most patients with an initially uncomplicated episode will never develop severe complications.[34] To evaluate which patients do present with perforation, Chapman et al. retrospectively analyzed 337 patients with complicated diverticulitis between 1990 and 2003.[35] Over half of patients presented with complicated disease as their first episode (Figure 4). Of the most severe cases, in which patients with perforation died, 90% had no prior history of diverticulitis.

Figure 4.

Of 337 patients presenting with complicated disease, the majority of patients had no prior history of diverticulitis, and almost all patients with severe disease resulting from death presented after the first episode (adapted from Chapman et al.[35])

Other studies have shown even lower rates of diverticulitis history amongst patients presenting with complications. Somasekar et al. retrospectively evaluated all patients admitted with complicated diverticulitis.[36] Of these, 84% had perforations and 9% had fistulas, but only 26% had documented diverticulosis, and even fewer, 3%, had had prior acute diverticulitis. Similarly, in a cohort of 100 patients with generalized peritonitis who underwent laparoscopic lavage, only five had documented diverticulosis, and none had had a prior episode of diverticulitis.[37] Additionally, using the Washington State Comprehensive Hospital Abstract Reporting System, Anaya et al. studied over 25,000 patients hospitalized for a first episode of diverticulitis between 1987 and 2001.[38] Of these, the recurrence rate of diverticulitis was 27% in patients younger than 50, but only 17% in those 50 years or older, and only 7.5% and 5.5% of these, respectively, re-presented with perforation. Reported differently, elective colectomy after an initial episode of diverticulitis in young patients would have led to 13 unnecessary colectomies to prevent one colectomy with colostomy, and even more unnecessary colectomies in patients older than 50 years. Given these data, patients should not be encouraged to undergo elective colectomy merely to avoid a more serious recurrence of diverticulitis, as this more serious recurrence is unlikely to occur. Put another way, for most patients who require emergency colectomy with colostomy for perforated diverticulitis, it is their first episode of the disease.

As this new dogma has become accepted, the rates of elective colectomy for diverticulitis have declined.[39] In an analysis of all patients admitted to hospitals in Ontario with acute diverticulitis managed nonoperatively, rates of elective colectomy within one-year of discharge dropped from 9.6% in 2002 to 3.9% in 2011. Even after adjusting for patient characteristics, the rate of elective colectomy declined by nearly 1% per year. Of these elective cases, one-third were performed laparoscopically, and only 7.5% received an ostomy.[39] Importantly, the decline in elective treatment is not resulting in higher rates of patients presenting with complicated diverticulitis. Ricciardi et al. used the Nationwide Inpatient Sample to identify 680,390 patients with diverticulitis hospital admissions between 1991 and 2005, and the rates of free perforation amongst those admitted was constant at about 1.5% throughout the entire study period.[40]

Which patients should undergo elective resection? Two recent decision analysis models have suggested that patients should undergo elective surgery after the third or fourth episode of uncomplicated diverticulitis.[41, 42] By waiting for the fourth attack, patients older than 50 years would have 0.5% less deaths, 0.7% less colostomies, and would save $1,035 per patient compared to operating after the second episode. In younger patients, operating after the fourth episode results in 0.1% fewer deaths, 2% fewer colostomies, and saves $5,429 per patient.[42] A recent systematic review also suggested that there were no data to support resection after a second attack of diverticulitis, and that the decision for elective colectomy should instead be based on patient preference in terms of disease severity and quality of life.[43] Clearly, the decision to proceed with elective sigmoid colectomy should be individualized to the patient. Those patients on immunosuppression, who have a more chronic, smoldering disease, and who have poor access to medical care, among others, may still benefit from elective resection.

Complicated Diverticulitis without Free Perforation

The proper management of acute complicated diverticulitis depends on the clinical presentation. In patients without generalized peritonitis or pneumoperitoneum, treatment should focus on relieving symptoms and managing complications. Gregersen et al. performed a systematic review of patients presenting with Hinchey stage Ib or II diverticulitis.[44] These are patients with defined abscesses, and most are treated initially with antibiotics and CT-guided percutaneous drainage. They identified 42 studies with 8,766 patients, and found that initial non-operative treatment failed in 20%. Patients with abscesses less than 3 cm in diameter were sufficiently treated with antibiotics alone, often as an outpatient. Patients treated with percutaneous drainage had less recurrence than those treated with antibiotics alone (16% vs. 22%), but did have a small rate of procedure-related complications (2.5%).

After resolution of the acute episode, however, recurrence rates are quite high in patients with history of perforation with abscess. Another meta-analysis from Lamb and Kaiser found that 40% of patients developed recurrence while awaiting elective resection after resolution of their initial episode.[45] Therefore, for a patient with complicated diverticulitis without free perforation, diffuse peritonitis, or systemic sepsis, we recommend antibiotics for all patients, percutaneous drainage for abscesses > 3 cm in diameter, and planned elective surgery following the index presentation.

Complicated Diverticulitis with Free Perforation

The traditional approach to the emergent surgical management of complicated diverticulitis has been the procedure described by Henri Hartmann, in which an open sigmoid colectomy is performed with end colostomy, leaving a rectal stump.[22, 20] However, even in the emergent setting, recent studies have suggested that the standard Hartmann’s procedure may not always be needed. For instance, Myers et al. evaluated 100 patients who needed emergent operation for pneumoperitoneum and peritonitis (Hinchey III or IV).[37] Of these, only four patients underwent traditional Hartmann’s procedure, whereas 92 underwent planned laparoscopic peritoneal lavage and drainage. The overall operative mortality was low at 3%. With follow-up between 12 and 84 months, only two of 100 patients were readmitted with recurrent diverticulitis, and no patients needed re-intervention for complications or a subsequent colostomy. However, not all series have reported such optimistic results with laparoscopic lavage. A multicenter randomized trial from 21 centers in Scandinavia compared laparoscopic lavage to primary resection for acute, perforated diverticulitis.[46] They randomized all patients with suspected perforated diverticulitis, a clinical indication for emergent surgery, and pneumoperitoneum on abdominal CT to laparoscopic drainage or open resection. Notably, all patients found to have Hinchey IV fecal peritonitis (14% in each group) were treated with colon resection regardless of treatment allocation. The primary outcome was severe postoperative complications, as defined by a Clavien-Dindo score > IIIa; no statistically significant difference was found in rate of the primary outcome (31% in lavage patients vs. 26%, P = 0.53). There was also no difference in mortality at 90 days (14% vs. 12%, P = 0.67). However, the reoperation rate was higher in the laparoscopic lavage group (20% vs. 5.7%, P = 0.01), and four sigmoid carcinomas were missed with laparoscopic lavage. Based on these data, the authors concluded that laparoscopic lavage was not indicated for the treatment of perforated diverticulitis.

A meta-analysis of three randomized trials of 358 patients comparing laparoscopic lavage to open resection reached a different conclusion.[47] Angenete et al. found that at 12 months, the relative risk of having a reoperation was actually lower for patients who underwent laparoscopic lavage compared to those who underwent colon resection, and there were no differences in mortality or major morbidity. Therefore, they felt that, as Hartmann’s resection was more costly and resulted in higher rates of reintervention, that laparoscopic lavage could be a valid alternative to surgery with resection in select patients with purulent diverticulitis. However, given the mixed evidence on the efficacy of laparoscopic lavage, we recommend against this practice in the routine management of patients with perforated diverticulitis and peritonitis.

In the patients that do undergo an emergent colon resection for purulent or feculent peritonitis, new findings suggest an alternative to the traditional Hartmann’s procedure. A multicenter trial involving 62 patients with perforated Hinchey III or IV left colonic diverticulitis randomized the patients to either Hartmann’s procedure or sigmoid colectomy with primary anastomosis and diverting loop ileostomy.[48] Patients in both groups were to have planned stoma reversals at three months. They found no difference in mortality (Hartmann’s: 13% vs. primary anastomosis: 9%) or overall complications (80% vs. 84%), but patients undergoing primary anastomosis were more likely to undergo stoma reversal (90% vs. 57%), had fewer serious complications (Grades IIIb-IV: 0% vs. 20%), had shorter hospital stays (6 vs. 9 days), and had lower hospital costs ($16,717 vs. $24,014). While this was a small study, it is the first randomized, controlled trial to favor primary anastomosis with diverting ileostomy over Hartmann’s for patients with perforated diverticulitis, which again suggests that the indiscriminate use of the more conservative Hartmann’s procedure may not be necessary and may even be harmful in some circumstances.

Management in Special Populations

Certain populations merit special consideration. Young patients have often been thought to develop more virulent disease; because of this, some argue that all patients below the age of 50 should be offered elective colon resection after the first attack of uncomplicated diverticulitis. However, more recent data indicate that this logic is flawed. Vignati et al. surveyed 40 patients under the age of 50 treated with intravenous antibiotics and bowel rest and found that at a 5- to 9-year follow-up, none of these patients required colostomies, and only one-third of them had undergone surgery. Later, Guzzo et al. showed that patients with uncomplicated diverticulitis under the age of 50 had the same rates of symptom resolution with antibiotics alone as did similar patients over the age of 50, and again, only 40% ever underwent operative intervention.[50] When stratified by disease severity, young patients have no difference in recurrence rate compared to their older counterparts.[51] As such, we believe that young patients should be treated according to the same criteria as older patients, and that there is no justification for routine surgery after a single episode of uncomplicated diverticulitis.[49, 5]

Conversely, diverticulitis in immunocompromised patients can be more virulent with a higher incidence of free perforation and fecal peritonitis. Immunocompromised patients have a higher likelihood of failure of nonoperative management. In one small series of 10 immunocompromised patients, despite presentation with little to no symptoms, they experienced a 100% failure rate of response to antibiotics alone, and more often underwent urgent surgery with a significantly higher mortality rate (40% vs. 2% in non-immunocompromised patients).[52] Subsequent studies of transplant recipients,[53, 54] patients on chronic corticosteroids,[55] and those with human immunodeficiency virus and CD4 counts < 200 cells/microL[56], all more frequently developed diverticulitis and, when they did, they presented with more severe disease, more likely failed medical management, and had significantly higher rates of mortality and major complications following surgery. Although these series are small, we believe that the data are compelling enough to recommend intervention on immunocompromised patients after the first episode of diverticulitis, usually during the index hospitalization.

Quality and Outcomes

The most recent American Society of Colon and Rectal Surgeons (ASCRS) guidelines reflect the changing literature, as well as our current views. Following an episode of complicated diverticulitis, elective colectomy should typically be considered.[57] Urgent sigmoid colectomy is required for patients with diffuse peritonitis and for those in whom nonoperative management fails. During resection, the decision to restore bowel continuity must incorporate patient factors, intraoperative factors, and surgeon preferences, but primary anastomosis is feasible even in the acute setting, with or without a temporary diverting loop ileostomy. If possible, a laparoscopic approach is preferred, and a leak test should always be performed after creating an anastomosis. In light of the conflicting literature, laparoscopic lavage is not currently recommended, and is not a routine part of our practice.

Interestingly, regardless of whether colectomy is performed electively or emergently, there remains a small cohort of patients that develop recurrence of diverticulitis after resection. Andeweg et al. reported on 183 patients who underwent emergent sigmoid resection and found an 8.7% recurrence rate of diverticulitis over a mean follow-up of eight years.[58] A similar analysis of 236 patients who underwent elective resection found a 5% recurrence rate by six years.[59] While resection may prevent most future episodes of diverticulitis, it does not completely resolve all abdominal complaints. Egger et al. performed structured postoperative interviews of 129 patients, and many of these patients reported ongoing abdominal symptoms after surgery (constipation in 37%, painful abdominal distension in 23%, abdominal cramps in 23%, and frequent painful diarrhea in 23%).[60] Therefore, surgical resection is not a definitive cure for diverticulitis and its associated abdominal complaints and should be reserved for select patients with specific indications and reasonable expectations.

Conclusions

Diverticulitis is a complex inflammatory condition with a wide spectrum of clinical presentations. In patients with acute, uncomplicated disease, nonoperative management is indicated, and antibiotics may not be necessary. Elective surgery for recurrent, uncomplicated diverticulitis should be limited to patients with several recurrences and strong preferences. Patients with complicated disease still warrant elective resection in most cases, although surgery can usually be delayed by initial antibiotics and percutaneous abscess drainage. In patients with purulent peritonitis, laparoscopic lavage may allow you to avoid emergent resection, although resection is still indicated in patients with fecal peritonitis. Even in the acute setting, if resection is indicated, one can consider a primary anastomosis with temporary loop ileostomy. Further research may better delineate which patients may still benefit from a more conservative approach.

Continued Medical Education Questions.

1. What proportion of people over the age of 80 in the United States have diverticulosis?

   1. 10%
   2. 50%
   3. 70%
   4. 100%
2. Where are diverticula most likely to occur?

   1. Where the blood vessels penetrate the wall
   2. Along the teniae
   3. In close proximity to colonic polyps
   4. In the right colon
3. When should colonoscopy be performed for patients with diverticulitis?

   1. Colonoscopy is not necessary
   2. During the index admission
   3. At least two weeks after resolution of symptoms
   4. At least six months after resolution of symptoms
4. Antibiotics are:

   1. Always required for acute episodes of diverticulitis
   2. May not be necessary in some patients with uncomplicated disease
   3. Not needed for patients with intraabdominal abscess undergoing percutaneous drainage
   4. Chosen to cover gram positive cocci and gram negative rods.
5. Recent trends in elective colectomy and rates of complicated diverticulitis are as follows:

   1. Elective colectomy is decreasing and complicated diverticulitis has remained stable
   2. Elective colectomy is decreasing and complicated diverticulitis is increasing
   3. Elective colectomy is increasing and complicated diverticulitis is decreasing
   4. Elective colectomy is increasing and complicated diverticulitis has remained stable
6. The management of a patient presenting with diverticulitis and a localized 5 cm abscess should include:

   1. Antibiotics alone
   2. Antibiotics, percutaneous CT-guided drainage, and nonoperative management
   3. Antibiotics, percutaneous CT-guided drainage, and delayed elective colectomy
   4. Antibiotics and urgent washout and resection
7. The appropriate management for Hinchey Stage III purulent diverticulitis is:

   1. Laparoscopic peritoneal lavage and drainage
   2. Hartmann’s procedure
   3. Sigmoidectomy with primary anastomosis and diverting loop ileostomy
   4. All of the above could be appropriate
8. The appropriate management for Hinchey Stage IV feculent diverticulitis is:

   1. Laparoscopic peritoneal lavage and drainage
   2. Hartmann’s procedure
   3. Sigmoidectomy with primary anastomosis and diverting loop ileostomy
   4. All of the above could be appropriate