Management of acute colonic diverticulitis in the general and surgical emergency departments

Acute left colonic diverticulitis is a very common disease that primarily affects the older population in the Western world. The pathogenesis of acute inflammation of the diverticula may not be as simple as once thought, and the disease cascade could involve a combination of chronic inflammation and altered gut microbiota. Several lifestyle risk factors such as obesity, low-fibre diet, smoking, use of non-steroid anti-inflammatory drugs, inadequate physical activity and others have been associated with a higher risk for diverticulitis. It has been proven that uncomplicated diverticulitis in immunocompetent patients without systemic signs of infection can be treated symptomatically. Outpatient treatment with peroral antibiotics is effective for managing patients with uncomplicated diverticulitis and signs of systemic inflammation. New, less- invasive surgical options have been recognised as appropriate for a select group of patients with complicated diverticulitis. Laparoscopic lavage and drainage are suitable for abscesses where the bowel wall is intact. Resection with primary anastomosis with or without ileostomy is now considered an option for some patients that would historically have to undergo Hartmann’s procedure. The latter still remains the most common operating option even in tertiary referral centres around the world as it is suitable for more complicated cases and critically ill patients. Current evidence does not support routine colonoscopic evaluation for uncomplicated diverticulitis in younger patients without risk factors. Recurrent diverticulitis is now understood to be more benign than was previously thought. Elective resection of the sigmoid colon is therefore no longer a standard treatment for all patients with two or more episodes of acute diverticulitis.

Diverticulitis; Classification; Conservative treatment; Surgery; Follow-up

[1] Sabiston DC, Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery: the biological basis of modern surgical practice. Wb Saunders: Philadelphia. 2017.

[2] Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, et al. Diverticulitis: an Update from the Age Old Paradigm. Current Problems in Surgery. 2020; 57: 100862.

[3] Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019; 156: 1282–1298.e1.

[4] Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, corn, and popcorn consumption and the incidence of diverticular disease. The Journal of the American Medical Association. 2008; 300: 907–914.

[5] Shahedi K, Fuller G, Bolus R, Cohen E, Vu M, Shah R, et al. Long-term Risk of Acute Diverticulitis among Patients with Incidental Diverticulosis Found during Colonoscopy. Clinical Gastroenterology and Hepatology. 2013; 11: 1609–1613.

[6] Loffeld RJ. Long-term follow-up and development of diverticulitis in patients diagnosed with diverticulosis of the colon. International Journal of Colorectal Disease. 2016; 31: 15–17.

[7] Bharucha AE, Parthasarathy G, Ditah I, Fletcher JG, Ewelukwa O, Pendlimari R, et al. Temporal Trends in the Incidence and Natural History of Diverticulitis: a Population-Based Study. The American Journal of Gastroenterology. 2015; 110: 1589–1596.

[8] Böhm SK, Kruis W. Lifestyle and other risk factors for diverticulitis. Minerva Gastroenterologica e Dietologica. 2017; 63: 110–118.

[9] Liu PH, Cao Y, Keeley BR, Tam I, Wu K, Strate LL, et al. Adherence to a Healthy Lifestyle is Associated with a Lower Risk of Diverticulitis among Men. The American Journal of Gastroenterology. 2017; 112: 1868–1876.

[10] Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clinic Proceedings. 2016; 91: 1094–1104.

[11] Kechagias A, Rautio T, Kechagias G, Mäkelä J. The role of C-reactive protein in the prediction of the clinical severity of acute diverticulitis. The American Surgeon. 2014; 80: 391–395.

[12] van de Wall BJ, Draaisma WA, van der Kaaij RT, Consten EC, Wiezer MJ, Broeders IA. The value of inflammation markers and body temperature in acute diverticulitis. Colorectal Disease. 2013; 15: 621–626.

[13] Mäkelä JT, Klintrup K, Takala H, Rautio T. The role of C-reactive protein in prediction of the severity of acute diverticulitis in an emergency unit. Scandinavian Journal of Gastroenterology. 2015; 50: 536–541.

[14] Sartelli M, Weber DG, Kluger Y, Ansaloni L, Coccolini F, Abu-Zidan F, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World Journal of Emergency Surgery. 2020; 15: 32.

[15] Toorenvliet BR, Bakker RFR, Breslau PJ, Merkus JWS, Hamming JF. Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Colorectal Disease. 2010; 12: 179–186.

[16] Laméris W, van Randen A, van Gulik TM, Busch ORC, Winkelhagen J, Bossuyt PMM, et al. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Diseases of the Colon and Rectum. 2010; 53: 896–904.

[17] Andeweg CS, Knobben L, Hendriks JCM, Bleichrodt RP, van Goor H. How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. Annals of Surgery. 2011; 253: 940–946.

[18] Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM, et al. WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World Journal of Emergency Surgery. 2016; 11: 37.

[19] Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP. Toward an evidence-based step-up approach in diagnosing diverticulitis. Scandinavian Journal of Gastroenterology. 2014; 49: 775–784.

[20] Kaiser AM, Jiang J, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, et al. The management of complicated diverticulitis and the role of computed tomography. The American Journal of Gastroenterology. 2005; 100: 910–917.

[21] Ambrosetti P, Becker C, Terrier F. Colonic diverticulitis: impact of imaging on surgical management – a prospective study of 542 patients. European Radiology. 2002; 12: 1145–1149.

[22] Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database of Systematic Reviews. 2012; 11: CD009092.

[23] Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. The British Journal of Surgery. 2012; 99: 532–539.

[24] Mali JP, Mentula PJ, Leppäniemi AK, Sallinen VJ. Symptomatic Treatment for Uncomplicated Acute Diverticulitis: a Prospective Cohort Study. Diseases of the Colon and Rectum. 2016; 59: 529–534.

[25] Daniels L, Ünlü Ç, de Korte N, van Dieren S, Stockmann HB, Vrouenraets BC, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. The British Journal of Surgery. 2017; 104: 52–61.

[26] van Dijk ST, Daniels L, Ünlü Ç, de Korte N, van Dieren S, Stockmann HB, et al. Long-Term Effects of Omitting Antibiotics in Uncomplicated Acute Diverticulitis. American Journal of Gastroenterology. 2018; 113: 1045–1052.

[27] Ridgway PF, Latif A, Shabbir J, Ofriokuma F, Hurley MJ, Evoy D, et al. Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Disease. 2009; 11: 941–946.

[28] Biondo S, Golda T, Kreisler E, Espin E, Vallribera F, Oteiza F, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Annals of Surgery. 2014; 259: 38–44.

[29] van Dijk ST, Bos K, de Boer MGJ, Draaisma WA, van Enst WA, Felt RJF, et al. A systematic review and meta-analysis of outpatient treatment for acute diverticulitis. International Journal of Colorectal Disease. 2018; 33: 505–512.

[30] Cirocchi R, Randolph JJ, Binda GA, Gioia S, Henry BM, Tomaszewski KA, et al. Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis. Techniques in Coloproctology. 2019; 23: 87–100.

[31] Hong MK, Tomlin AM, Hayes IP, Skandarajah AR. Operative interven-tion rates for acute diverticulitis: a multicentre state-wide study. ANZ Journal of Surgery. 2015; 85: 734–738.

[32] Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M, Mauvais F, Houivet E, et al. Hartmann’s Procedure or Primary Anastomosis for Generalized Peritonitis due to Perforated Diverticulitis: a Prospective Multicenter Randomized Trial (DIVERTI). Journal of the American College of Surgeons. 2017; 225: 798–805.

[33] Lambrichts DPV, Vennix S, Musters GD, Mulder IM, Swank HA, Hoofwijk AGM, et al. Hartmann’s procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial. The Lancet Gastroenterology and Hepatology. 2019; 4: 599–610.

[34] Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, et al. Long-Term Follow-up after an Initial Episode of Diverticulitis: what are the Predictors of Recurrence? Diseases of the Colon & Rectum. 2011; 54: 283–288.

[35] Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. The Journal of the American Medical Association. 2014; 311: 287–297.

[36] Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR. Diverticulitis: a progressive disease? do multiple recurrences predict less favorable outcomes? Annals of Surgery. 2006; 243: 876–883.

[37] Francis NK, Sylla P, Abou-Khalil M, Arolfo S, Berler D, Curtis NJ, et al. EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice. Surgical Endoscopy. 2019; 33: 2726–2741.

[38] Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. the ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992; 101: 1644–1655.

[39] Schein M, Rogers PN. Schein’s Common Sense Emergency Abdominal Surgery. In Moshe Schein, Paul Rogers, Ahmad Assalia (eds.). Springer: Berlin Heidelberg. 2015.