Skip to main content

Advertisement

SpringerLink
Log in

Management of Acute Diverticulitis and its Complications

  • Original Article
  • Published:
Indian Journal of Surgery Aims and scope Submit manuscript

Abstract

Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann’s procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications—such as fistulating disease, strictures or recurrent diverticular bleeding—and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Unlu C, de Korte N, Daniels L, Consten ECJ, Cuesta MA, Gerhards MF, van Geloven AAW, van der Zaag ES, van der Hoeven JAB, Klicks R, Cense HA, Roumen RMH, Eijsbouts QAJ, Lange JF, Fockens P, de Borgie CAJM, Bemelman WA, Reitsma JB, Stockmann HBAC, Vrouenraets BC, Boermeester MA (2010) A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial). BMC Surg 10:23

    Article  PubMed Central  PubMed  Google Scholar 

  2. Biondo S, Golda T, Kreisler E, Espin E, Vallribera F, Oteiza F, Codina-Cazador A, Pujadas M, Flor B (2013) Outpatient versus hospitalization management for uncomplicated diverticulitis. Ann Surg 00:1–7

    Google Scholar 

  3. Szojda MM, Cuesta MA, Mulder CM, Felt-Bersma RJF (2007) Review article: management of diverticulitis. Aliment Pharmacol Ther 26(Suppl 2):67–76

    Article  PubMed  Google Scholar 

  4. Tan KK, Wong J, Yan Z, Chong CS, Liu JZ, Sim R (2013) Colonic diverticulitis in young Asians: a predominantly mild and right-sided disease. ANZ J Surg doi: 10.1111/ans.12273

  5. Simpson J, Scholefield JH, Spiller RC (2002) Pathogenesis of colonic diverticula. Br J Surg 89:546–554

    Article  CAS  PubMed  Google Scholar 

  6. Fozard JBJ, Armitage NC, Schofield JB, Jones OM (2011) ACPBGI position statement on elective resection for diverticulitis. Color Dis 13(Suppl 3):1–11

    Article  Google Scholar 

  7. Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109. In: Phillips RKS (ed) Colorectal Surgery, 4th Edn. Saunders Ltd, pp107-123

  8. Toorenvliet BR, Bakker RFR, Breslau PJ, Merkus JWS, Hamming JF (2009) Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Color Dis 12:179–187

    Article  Google Scholar 

  9. Ambrosetti P, Gervaz P, Fossung-Wiblishauser A (2012) Sigmoid diverticulitis in 2011: many questions; few answers. Color Dis 14:e439–e446

    Article  CAS  Google Scholar 

  10. Ambrosetti P, Jenny A, Becker C, Terrier F, Morel P (2000) Acute left colonic diverticulitis-compared performance of computed tomography and water-soluble contrast enema. Dis Colon Rectum 43:1363–1367

    Article  CAS  PubMed  Google Scholar 

  11. Ambrosetti P, Becker C, Terrier F (2002) Colonic diverticulitis: impact of imaging on surgical management—a prospective study of 542 patients. Eur Radiol 12:1145–1149

    Article  CAS  PubMed  Google Scholar 

  12. Ambrosetti P, Grossholz M, Becker C, Terrier F, Morel P (1997) Computed tomography in acute left colonic diverticulitis. Br J Surg 84:532–534

    Article  CAS  PubMed  Google Scholar 

  13. Shaikh S, Krukowski ZH (2007) Outcome of a conservative policy for managing acute sigmoid diverticulitis. Br J Surg 94:876–879

    Article  CAS  PubMed  Google Scholar 

  14. Hjern F, Josephson T, Altman D, Holmström B, Johansson C (2008) Outcome of younger patients with acute diverticulitis. Br J Surg 95:758–764

    Article  CAS  PubMed  Google Scholar 

  15. Shabanzadeh DM, Wille-Jorgensen P (2012) Antibiotics for uncomplicated diverticulitis. Cochrane Database of Systematic Reviews Issue 11. Art. No.: CD009092. doi: 10.1002/14651858.CD009092.pub2

  16. Ridgway PF, Latif A, Shabbir J, Ofriokuma F, Hurley MJ, Evoy D, O’Mahony JB, Mealy K (2009) Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Color Dis 11:941–946

    Article  CAS  Google Scholar 

  17. Ribas Y, Bombardó J, Aguilar F, Jovell E, Alcantara-Moral M, Campillo F, Lleonart X, Serra-Aracil X (2010) Prospective randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicillin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Color Dis 25:1363–1370

    Article  Google Scholar 

  18. Hjern F, Josephson T, Altman D, Holmström B, Mellgren A, Pollack J, Johansson C (2007) Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory? Scand J Gastroenterol 42:41–47

    Article  PubMed  Google Scholar 

  19. de Korte N, Kuyvenhoven JP, van der Peet DL, Felt-Bersma RJ, Cuesta MA, Stockmann HBAC (2011) Mild colonic diverticulitis can be treated without antibiotics. A case–control study. Color Dis 14:325–330

    Article  Google Scholar 

  20. Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K (2012) Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 99:532–539

    Article  CAS  PubMed  Google Scholar 

  21. Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F (2005) Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 48:787–791

    Article  PubMed  Google Scholar 

  22. Durmishi Y, Gervaz P, Brandt D, Bucher P, Platon A, Morel P, Poletti PA (2006) Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan. Surg Endosc 20:1129–1133

    Article  CAS  PubMed  Google Scholar 

  23. Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA (2006) Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case–control study. Dis Colon Rectum 49:1533–1538

    Article  CAS  PubMed  Google Scholar 

  24. Biondo S, Pares D, Ragué JM, Kreisler E, Fraccalvieri D, Jaurrieta E (2002) Acute colonic diverticulitis in patients under 50 years of age. Br J Surg 89:1137–1141

    Article  CAS  PubMed  Google Scholar 

  25. Anaya DA, Flum DR (2005) Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 140:681–685

    Article  PubMed  Google Scholar 

  26. Broderick-Villa G, Burchette RJ, Collins C, Abbas MA, Haigh PI (2005) Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 140:576–583

    Article  PubMed  Google Scholar 

  27. Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA (2010) Indications for elective sigmoid resection in diverticular disease. Ann Surg 251:670–674

    Article  PubMed  Google Scholar 

  28. Krukowski ZH (2009) Diverticular disease. In: Phillips RKS (ed) Colorectal Surgery, 4th Edn. Saunders Ltd, pp107-123

  29. Shaikh S, Krukowski ZH, O’Kelly T (2006) Conservative management of pneumo-peritoneum secondary to complicated sigmoid diverticulitis: a prospective observational study. Color Dis 8(Suppl 4):17–18

    Google Scholar 

  30. Krukowski ZH, Matheson NA (1984) Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 71:921–927

    Article  CAS  PubMed  Google Scholar 

  31. Zeitoun G, Laurent A, Rouffet F, Hay JM, Fingerhut A, Paquet JC, Peillon C (2000) Multicentre, randomized clinical trial of primary versus secondary sigmoid resection in generalized peritonitis complicating sigmoid diverticulitis. Br J Surg 87:1366–1374

    Article  CAS  PubMed  Google Scholar 

  32. Tadlock MD, Karamanos E, Skiada D, Inaba K, Talving P, Senagore A, Demetriades D (2013) Emergency surgery for acute diverticulitis: which operation? A National Surgical Quality Improvement Program study. J Trauma Acute Care Surg 74:1385–1391

    Article  PubMed  Google Scholar 

  33. Myers E, Winter DC (2010) Adieu to Henri Hartmann? Color Dis 12:849–850

    Article  CAS  Google Scholar 

  34. Biondo S, Jaurrieta E, Ragué JM, Ramos E, Deiros M, Moreno P, Farran L (2000) Role of resection and primary anastomosis of the left colon in the presence of peritonitis. Br J Surg 87:1580–1584

    Article  CAS  PubMed  Google Scholar 

  35. Biondo S, Perea MT, Ragué JM, Pares D, Jaurrieta E (2001) One-stage procedure in non-elective surgery for diverticular disease complications. Color Dis 3:42–45

    Article  CAS  Google Scholar 

  36. Schilling MK, Maurer CA, Kollmar O, Buchler MW (2001) Primary vs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysis. Dis Colon Rectum 44:699–703

    Article  CAS  PubMed  Google Scholar 

  37. Zorcolo L, Covotta L, Carlomagno N, Bartolo DCC (2003) Safety of primary anastomosis in emergency colo-rectal surgery. Color Dis 5:262–269

    Article  CAS  Google Scholar 

  38. Regenet N, Pessaux P, Hennekinne S, Lermite E, Tuech JJ, Brehant O, Arnaud JP (2003) Primary anastomosis after intraoperative colonic lavage vs. Hartmann’s procedure in generalized peritonitis complicating diverticular disease of the colon. Int J Color Dis 18:503–507

    Article  CAS  Google Scholar 

  39. Abbas S (2007) Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Color Dis 22:351–357

    Article  Google Scholar 

  40. Constantinides VA, Heriot A, Remzi F, Darzi A, Senapati A, Fazio VW, Tekkis PP (2007) Operative strategies for diverticular peritonitis. A decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg 245:94–103

    Article  PubMed Central  PubMed  Google Scholar 

  41. Trenti L, Biondo S, Golda T, Monica M, Kreisler E, Fraccalvieri D, Frago R, Jaurrieta E (2011) Generalized peritonitis due to perforated diverticulitis: Hartmann’s procedure or primary anastomosis? Int J Color Dis 26:377–384

    Article  Google Scholar 

  42. Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH, Fazio VW, Aydin N, Darzi A, Senapati A (2006) Primary resection with anastomosis vs. Hartmann’s procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 49:966–981

    Article  PubMed  Google Scholar 

  43. Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C, Grieder F, Gelpke H, Decurtins M, Tempia-Caliera AA, Demartines N, Hahnloser D, Clavien PA, Breitenstein S (2012) A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforate left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 256:819–827

    Article  PubMed  Google Scholar 

  44. Binda GA, Karas JR, Serventi A, Sokmen S, Amato A, Hydo L, Bergamaschi R (2012) Primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a prematurely terminated randomized controlled trial. Color Dis 14:1403–1410

    Article  CAS  Google Scholar 

  45. Mueller MH, Karpitschka M, Renz B, Kleespies A, Kasparek MS, Jauch KW, Kreis ME (2011) Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis. Int J Color Dis 26:227–234

    Article  Google Scholar 

  46. Salem L, Veenstra DL, Sullivan SD, Flum DR (2004) The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 199:904–912

    Article  PubMed  Google Scholar 

  47. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A (1996) Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 171:432–434

    Article  PubMed  Google Scholar 

  48. Faranda C, Barrat C, Catheline JM, Champault GG (2000) Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases. Surg Laparosc Endosc Percutan Tech 10:135–138

    CAS  PubMed  Google Scholar 

  49. Mutter D, Bouras G, Forgione A, Vix M, Leroy J, Marescaux J (2006) Two-stage totally minimally invasive approach for acute complicated diverticulitis. Color Dis 8:501–505

    Article  CAS  Google Scholar 

  50. Taylor CJ, Layani L, Ghusn MA, White SI (2006) Perforated diverticulitis managed by laparoscopic lavage. ANZ J Surg 76:962–965

    Article  PubMed  Google Scholar 

  51. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan L (2008) Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures. J Am Coll Surg 206:654–657

    Article  PubMed  Google Scholar 

  52. Franklin ME, Portillo G, Treviño JM, Gonzalez JJ, Glass JL (2008) Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 32:1507–1511

    Article  PubMed  Google Scholar 

  53. Favuzza J, Friel JC, Kelly JJ, Perugini R, Counihan TC (2009) Benefits of laparoscopic peritoneal lavage for complicated sigmoid diverticulitis. Int J Color Dis 24:797–801

    Article  Google Scholar 

  54. Karoui M, Champault A, Pautrat K, Valleur P, Cherqui D, Champault G (2009) Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study. Dis Colon Rectum 52:609–615

    Article  PubMed  Google Scholar 

  55. White SI, Frenkiel B, Martin PJ (2010) A ten-year audit of perforated sigmoid diverticulitis: highlighting the outcomes of laparoscopic lavage. Dis Colon Rectum 53:1537–1541

    Article  PubMed  Google Scholar 

  56. Myers E, Hurley M, O’Sullivan GC, Kavanagh D, Wilson I, Winter DC (2008) Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 95:97–101

    Article  CAS  PubMed  Google Scholar 

  57. Alamili M, Gögenur I, Rosenberg J (2009) Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum 52:1345–1349

    Article  PubMed  Google Scholar 

  58. Toorenvliet BR, Swank H, Schoones JW, Hamming JF, Bemelman WA (2010) Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Color Dis 12:862–867

    Article  CAS  Google Scholar 

  59. Afshar S, Kurer MA (2011) Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis. Color Dis 14:135–142

    Article  Google Scholar 

  60. Swank HA, Mulder IM, Hoofwijk AGM, Nienhuijs SW, Lange JF, Bemelman WA (2013) Early experience with laparoscopic lavage for perforated diverticulitis. Br J Surg 100:704–710

    Article  CAS  PubMed  Google Scholar 

  61. Mäkelä J, Vuolio S, Kiviniemi H, Laitinen S (1998) Natural history of diverticular disease. When to operate? Dis Colon Rectum 41:1523–1528

    Article  PubMed  Google Scholar 

  62. Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P, Soravia C (2002) Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Dis Colon Rectum 45:962–966

    Article  CAS  PubMed  Google Scholar 

  63. Janes S, Meagher A, Frizelle FA (2005) Elective surgery after acute diverticulitis. Br J Surg 92:133–143

    Article  CAS  PubMed  Google Scholar 

  64. Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, Kreis ME (2005) Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol 17:649–654

    Article  CAS  PubMed  Google Scholar 

  65. Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA (2010) Patterns of recurrence in patients with acute diverticulitis. Br J Surg 97:952–957

    Article  CAS  PubMed  Google Scholar 

  66. Buchs NC, Konrad-Mugnier B, Jannot A-S, Poletti P-A, Ambrosetti P, Gervaz P (2013) Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg 100:976–979

    Article  CAS  PubMed  Google Scholar 

  67. Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, Larson D (2005) Complicated diverticulitis. Is it time to rethink the rules? Ann Surg 242:576–583

    PubMed Central  PubMed  Google Scholar 

  68. Katz LH, Guy DD, Lahat A, Gafter-Gvili A, Bar-Meir S (2013) Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis. J Gastroenterol Hepatol. doi: 10.1111/jgh.12274

Download references

Author information

Authors and Affiliations

  1. Academic Surgical Unit, Castle Hill Hospital, Castle Road, Cottingham, HU16 5JQ, UK

    Hannah L. Welbourn & John E. Hartley

Authors
  1. Hannah L. Welbourn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. John E. Hartley
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hannah L. Welbourn.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Welbourn, H.L., Hartley, J.E. Management of Acute Diverticulitis and its Complications. Indian J Surg 76, 429–435 (2014). https://doi.org/10.1007/s12262-014-1086-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12262-014-1086-6

Keywords

Search

Navigation