International, Expert-Based, Consensus Statement Regarding the Management of Acute Diverticulitis.

Diverticulitis is the cause of 300,000 inpatient admissions in the United States each year. Surgical evaluation and treatment are commonly required for the treatment of diverticulitis. This chapter discusses the diagnosis, triage, and treatment of acute diverticulitis. Medical treatment, as well as the indications for surgical treatment for diverticulitis, is discussed. Current controversies, including the need for antibiotics for a patient with acute uncomplicated diverticulitis, necessity of colonoscopy after resolution of an acute episode, and indications for urgent surgery, are reviewed. This review contains 10 figures, 3 tables, and 67 references. keywords: acute diverticulitis, colonic fistula, complicated diverticulitis, diverticular abscess, diverticular disease, diverticulitis, diverticulosis, perforated diverticulitis, uncomplicated diverticulitis

Aim This study aimed to assess the safety and efficacy of ambulatory treatment in patients with uncomplicated acute diverticulitis (AD) compared with inpatient treatment. Methods This is a retrospective comparative study conducted in two hospitals. All patients presented to the emergency department with CT-confirmed Hichney 1a AD during the period from 01/01/2022 to 31/12/2022 were included in this study. Patients with complicated diverticulitis or CT was not performed were excluded. All patients were followed for 12 months for re-admission and AD recurrence. Data analysis was performed with SPSS 27. Results A total of 137 patients were presented during the study period with CT-confirmed Hinchey 1a AD. The median age was 62 (24-94) years old, with a female-to-male ratio of 1.7:1. In the majority of patients (75.9%), WBCS was < 15 and CRP < 100. Moreover, 37.2% had previous AD, and it was complicated in 5.8%. For 12 months of follow-up, 19% of the cases developed diverticulitis recurrence. However, only 1 patient required surgery, and no patient required radiology intervention. No mortality was reported. A luminal investigation (CT colonoscopy or endoscopy) was organized in 61.3%, and colon cancer was detected in one patient. A comparison of patients who were treated as ambulatory (n=35) versus inpatient (n= 102) showed no significant difference regarding re-admission and recurrence of AD (P= 0.22) and surgical intervention (P=0.5) during 1-year follow-up. Conclusion With comparable results to inpatient treatment, the Ambulatory treatment of Hinchey 1a AD is safe and feasible and provides a reduction of treatment expenses.

The aim of this study was to evaluate the role of ultrasound in the diagnosis and management of acute diverticulitis and its capacity to predict posterior complications in patients undergoing medical treatment. A review was made of the histories of 208 hospitalized patients (262 admissions) initially diagnosed with acute diverticulitis over a 5-year period. Ultrasound was performed in all patients upon first admission. Diverticulitis was retrospectively classified as either simple or complicated, the latter being defined by the presence of extraluminal air and/or abscesses. Diverticulitis was finally diagnosed in 203 patients. Ultrasound exhibited a sensitivity of 86% in 77 cases subjected to surgery, and of 94% in the global 203 patients (192 true-positive and 11 false-negative findings). Of 34 patients with diverticulitis and emergency surgery, 10 had false-negative US exams. Twenty of the 73 cases (27%) with signs of complicated diverticulitis in the initial ultrasound study required emergency surgery, compared with only 4 of the 119 patients (3%) with US evidence of simple diverticulitis (p<0.001). Of the 169 patients with diverticulitis undergoing conservative management, 54 (32%) developed complications during follow-up. The patients under age 50 years with signs of complicated diverticulitis suffered more complications (65%) than the rest of groups (p<0.001). In subjects with recurrences (26%), these were either similar to or less than the first episode in 84% of the cases. The present study shows that ultrasound constitutes a feasible technique for diagnosing acute diverticulitis. The severity of diverticulitis according to US is statistically predictive of surgical risk during the acute phase. Severity is also related to the appearance of posterior complications in patients undergoing conservative management, although only in younger patients (<50 years).

Acute colonic diverticulitis is a common clinical condition. Severity of the disease is based on clinical, laboratory, and radiological investigations and dictates the need for medical or surgical intervention. Recent clinical trials have improved the understanding of the natural history of the disease resulting in new approaches to and better evidence for the management of acute diverticulitis. We searched the Cochrane Library (years 2004-2015), MEDLINE (years 2004-2015), and EMBASE (years 2004-2015) databases. We used the search terms "diverticulitis, colonic" or "acute diverticulitis" or "divertic*" in combination with the terms "management," "antibiotics," "non-operative," or "surgery." Registers for clinical trials (such as the WHO registry and the https://clinicaltrials.gov/ ) were searched for ongoing, recruiting, or closed trials not yet published. Antibiotic treatment can be avoided in simple, non-complicated diverticulitis and outpatient management is safe. The management of complicated disease, ranging from a localized abscess to perforation with diffuse peritonitis, has changed towards either percutaneous or minimally invasive approaches in selected cases. The role of laparoscopic lavage without resection in perforated non-fecal diverticulitis is still debated; however, recent evidence from two randomised controlled trials has found a higher re-intervention in this group of patients. A shift in management has occurred towards conservative management in acute uncomplicated disease. Those with uncomplicated acute diverticulitis may be treated without antibiotics. For complicated diverticulitis with purulent peritonitis, the use of peritoneal lavage appears to be non-superior to resection.

This Month in Gastroenterology

BackgroundRoutine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT‐proven acute diverticulitis.MethodsPubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT‐proven left‐sided acute diverticulitis. The prevalence was pooled using a random‐effects model and, if possible, compared with that among asymptomatic controls.ResultsSeventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent.ConclusionRoutine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.

Background: The usefulness of inflammatory indices in assessment of the severity of acute diverticulitis remains unestablished. The aim of this study was to determine whether inflammatory indices and hematological ratios could be utilised to differentiate between uncomplicated and complicated diverticulitis. Methods: Hematological and inflammatory indices were recorded for each admission with CT confirmed acute diverticulitis (101 complicated, 127 uncomplicated). Cases were divided into training (n = 57) and test sets (n = 171). A classification and regression tree (CART) analysis was employed in the training set to identify optimal inflammatory marker cut-off points associated with complicated diverticulitis. Samples (test set) were then categorized as (A) greater than and (B) less than CART identified cut-off points. The predictive properties of inflammatory marker cut-off points in distinguishing severity of diverticulitis were assessed using a univariate logistic regression analysis, summary receiver operating characteristic curves and confusion matrix generation. Results: C-reactive protein >109 mg/ml (OR 3.07, 95% CI 1.43-6.61, p = 0.004, area under the curve; AUC = 0.64) and white cell lymphocyte ratio (WLR) >17.72 (OR 4.23, 95% CI 1.95-9.17, p < 0.001, AUC = 0.64) were the most accurate parameters in distinguishing complicated and uncomplicated disease. WCC >21 × 10⁹/l (p = 0.02, AUC = 0.60) and lymphocyte count >0.55 × 10⁹/l (p = 0.009, AUC = 0.60) were less accurate. Conclusion: Widely used inflammatory indices are useful in the depiction of complicated diverticulitis. The indices cut-off points highlighted in this study should be considered at the time of diagnosis in combination with radiological features of complicated diverticulitis.

Introduction Acute diverticulitis is one of the most common causes for surgical emergency hospital admissions in the UK. The guidelines for endoscopic follow-up for patients with diverticulitis has changed over the last few years. This study aimed to assess the local follow-up of patients who present with diverticulitis. The objective was to identify the outcome of patients with diverticulitis and establish the new local guidelines for endoscopic follow-up. Methods A single-centre retrospective study was done for all patients who had CT proven diverticulitis at the Royal Shrewsbury Hospital in 2022. Data was collected about the patient demographics, vital statistics on presentation, Hinchey Classification, mode of management, previous admissions with diverticulitis, readmissions in one year, surgery in one year, and their follow-up results. Results There were 193 patients in the study with a median age of 61 (IQR: 51-73) and 37.8% were male. Follow-up endoscopy was done in 45.6% (87/193) of the patients, amongst which 85.1% (74) had uncomplicated diverticulitis. There was one cancer detected in colonoscopy and one in flexible sigmoidoscopy both of which were suspicious on the initial CT scan. 13 patients had a follow-up CT scan within 1 year, of which 2 confirmed cancer. Median time for endoscopy and CT scan was 10 and 26 weeks from discharge, respectively. Conclusion Diagnosis of cancer on an isolated follow-up colonoscopy or flexible sigmoidoscopy after uncomplicated diverticulitis is rare. These investigations should be reserved for patients with complicated diverticulitis or suspicious features of cancer on the initial CT scan.

Although acute diverticulitis and its recurrence are well studied, little is known about the period after these attacks have passed. Many patients appear to be affected by persistent symptoms that impair quality of life. The few published studies on this topic are mostly limited by the lack of CT confirmation of the acute diverticulitis diagnosis, low numbers of patients, or cross-sectional design. This study longitudinally evaluated quality of life and symptoms after antibiotic or observational treatment of uncomplicated acute diverticulitis. This was an observational study of randomized clinical trial data. This study was conducted at a single tertiary care center. Patients with CT-proven, primary, left-sided, uncomplicated acute diverticulitis were randomly assigned to observational or antibiotic treatment. Quality of life was assessed using questionnaires (EuroQol 5D, Short Form-36, and Gastrointestinal Quality of Life Index) at baseline and 3, 6, 12, and 24 months after random assignment. Patients were considered to have persistent symptoms when specific quality-of-life scores at the 12- and 24-month follow-ups were among the lowest 16% of scores measured in a healthy reference group. A total of 528 patients were included. No difference was detected between the observational and antibiotic groups in any quality-of-life score during follow-up. Overall, 32.2% to 38.2% of patients had persistent symptoms after 1 or 2 years, depending on which questionnaire (sub)score was assessed. Risk factors for persistent symptoms based on to the Gastrointestinal Quality of Life index GI symptoms score included a mean pain score ≥3.75 (OR = 2.77 (95% CI, 1.60-4.80)) during the first 10 days of disease and prolonged (≥28 d) time to recovery (OR = 2.25 (95% CI, 1.31-3.88)). Flatulence, rumblings, bloating, fullness, and many stools were the top 5 complaints at the 12- and 24-month follow-ups. The study was limited by possible selection bias of patients included in a randomized controlled trial. More than one third of patients experience persistent symptoms after an episode of acute uncomplicated diverticulitis. Long-term quality of life is comparable after initial antibiotic or observational treatment. See Video Abstract at http://links.lww.com/DCR/A916.

Objectives: Most diverticulitis patients (80%) who are referred to secondary care have uncomplicated diverticulitis (UD) which is a self-limiting disease and can be treated at home. The aim of this study is to develop a diagnostic model that can safely rule out complicated diverticulitis (CD) based on clinical and laboratory parameters to reduce unnecessary referrals.Methods: A retrospective cross-sectional study was performed including all patients who presented at the emergency department with CT-proven diverticulitis. Patient characteristics, clinical signs and laboratory parameters were collected. CD was defined as > Hinchey 1A. Multivariable logistic regression analyses were used to quantify which (combination of) variables were independently related to the presence or absence of CD. A diagnostic prediction model was developed and validated to rule out CD.Results: A total of 943 patients were included of whom 172 (18%) had CD. The dataset was randomly split into a derivation and validation set. The derivation dataset contained 475 patients of whom 82 (18%) patients had CD. Age, vomiting, generalized abdominal pain, change in bowel habit, abdominal guarding, C-reactive protein and leucocytosis were univariably related to CD. The final validated diagnostic model included abdominal guarding, C-reactive protein and leucocytosis (AUC 0.79 (95% CI 0.73–0.84)). At a CD risk threshold of ≤7.5% this model had a negative predictive value of 96%.Conclusion: This proposed prediction model can safely rule out complicated diverticulitis. Clinical practitioners could cautiously use this model to aid them in the decision whether or not to subject patients to further secondary care diagnostics or treatment.

Surgical evaluation and treatment is commonly required for the treatment of diverticulitis in both the acute and elective situations. This chapter discusses the surgical treatment of the clinically important manifestations of diverticular disease. Different options for surgical treatment are described for patients in both the urgent and elective settings, including technical aspects of these options. Current controversies are reviewed, including resection versus laparoscopic lavage for the treatment of purulent peritonitis, the use of gastrointestinal diversion in the surgical treatment of acute diverticulitis, and timing of operation for recurrent diverticulitis. This review contains 8 figures, 4 tables, and 67 references. Key Words: acute diverticulitis, complicated diverticulitis, diverticular disease, diverticulitis, diverticulosis, Hartmann procedure, laparoscopic lavage, sigmoid resection with primary anastomosis, uncomplicated diverticulitis

Diverticulitis is common and increasing in incidence. The risk of malignancy in those with uncomplicated diverticulitis is estimated to be 0.7%, compared with 10% in complicated diverticulitis. Newer guidelines suggest colonic investigation in patients with complicated diverticulitis only. We aim to investigate which patients in Northland undergo colonic investigation following an episode of diverticulitis, define malignancy detection rate and aid in the formulation of local guidelines. A retrospective review of adults admitted to Whangārei Hospital with diverticulitis between 2015 and 2019. Patients were classified as complicated or uncomplicated based on the Hinchey classification radiologically or intra-operatively. Patients were followed up to a minimum of 24 months. Three hundred and forty-nine patients were included. One hundred and eighty-two (48%) patients underwent colonic investigation following admission with diverticulitis; 50 with complicated and 132 with uncomplicated disease. The rate of colonic investigation between the groups was similar, at 53% and 47% respectively. Two patients (1.1%) were found to have a colonic malignancy, both in the uncomplicated group. The performance of a colonic investigation was not associated with complicated disease, ethnicity, gender or age on univariate or multivariate analysis. Colonic investigation following an admission for acute diverticulitis in Northland is not aligned with recently published guidelines. The rate of colonic malignancy found was low. Larger local studies are needed to guide clinicians and maximise efficiency of resource utilisation.

Comorbidity is a major determinant of severity in acute diverticulitis

Acute diverticulitis is a condition that can be divided into left-sided diverticulitis and right-sided diverticulitis. Left-sided diverticulitis is seen in the sigmoid colon and accounts for most cases of diverticulitis in the West. Right-sided diverticulitis is seen in the ascending colon and is predominantly seen in Asia. It can be divided into uncomplicated and complicated diverticulitis. The surgical management of left-sided complicated diverticulitis involves Hartmann’s procedure or sigmoid resection with anastomosis. Laparoscopic lavage is a bridging procedure that is used to stabilize some patients with complicated diverticulitis. Right-sided complicated diverticulitis is treated with right hemicolectomy or ileocecal resection. In this review, we will look at the surgical management of complicated right and left-sided diverticulitis.

Right-sided colonic diverticulitis is commonly seen in younger and predominantly Asian patients, and it presents with pain over the right lower abdomen. The diagnosis is usually confirmed by imaging modalities like computerized tomography. It is divided into complicated or uncomplicated diverticulitis, with uncomplicated diverticulitis being managed with non-operative treatment. Complicated diverticulitis is managed with surgical resection, with either a right hemicolectomy or an ileocecal resection being performed. In this article, we will look at the management of right-sided colonic diverticulitis, especially the role of non-operative management and surgical resection.