Benign Colon: Diverticular Disease

Abstract

The term “diverticular disease” of the colon represents a continuum of anatomic and pathophysiologic change within the colon related to the presence of diverticula. These changes most often occur in the sigmoid colon. It can refer to an asymptomatic state (diverticulosis) or any one of a number of diverse combinations of inflammatory symptoms, changes, and complications (diverticulitis). Symptoms may variably result from simple physiologic changes in colonic motility related to altered neuromuscular activity in the sigmoid colon, varying degrees of localized inflammatory response, or complex inflammatory interactions leading to diffuse peritonitis and septic shock. These more complex symptoms and resulting complications arise from breaches in the integrity of the wall of one or more diverticula. Diverticula may be true, containing all layers of the bowel wall (congenital), or false, lacking the muscular layer (acquired or pulsion diverticula).

Appendix:Practice Parameters for the Treatment of Sigmoid Diverticulitis

Prepared by The Standards Task Force, The American Society of Colon and Rectal Surgeons.

The initial evaluation of a new patient with suspected acute diverticulitis should include a problem-specific history and physical examination; a complete blood count, urinalysis, and plain abdominal radiographs may be useful in selected clinical scenarios. Computerized tomography scan of the abdomen and pelvis is usually the most appropriate imaging modality in the assessment of suspected diverticulitis. Contrast enema x-ray, cystography, ultrasound, and endoscopy are sometimes useful in the initial evaluation of a patient with suspected acute diverticulitis.

Nonoperative treatment typically includes dietary modification and oral or intravenous antibiotics. Radiologically guided percutaneous drainage is usually the most appropriate treatment for patients with a large diverticular abscess.

After resolution of an initial episode of acute diverticulitis, the colon should be adequately evaluated to confirm the diagnosis. Colonoscopy or contrast enema x-ray (probably with flexible sigmoidoscopy) is appropriate to exclude other diagnoses, primarily cancer, ischemia, and inflammatory bowel disease.

Urgent sigmoid colectomy is required for patients with diffuse peritonitis or for those who fail nonoperative management of acute diverticulitis. The decision to recommend elective sigmoid colectomy after recovery from acute diverticulitis should be made on a case-by-case basis. Elective colon resection should typically be advised if an episode of complicated diverticulitis is treated nonoperatively. The resection should be carried proximally to compliant bowel and extend distally to the upper rectum. When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patients.

Reprinted from Dis Colon Rectum 2006; 49: 939–944. Copyright © 2006. All rights reserved. American Society of Colon and Rectal Surgeons.