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Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis

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Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

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Author Contributions

KS and MB planned the review. All authors (MB, DH, GV, KS) drafted sections and performed literature searches. All authors contributed to several revisions of the manuscript sections towards the final version and approved the submitted manuscript.

Funding

DJH is funded by a National Institute for Health Research Post-Doctoral Fellowship.

Author information

Authors and Affiliations

  1. Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

    Marja A. Boermeester

  2. Division of Epidemiology and Public Health, School of Community Health Sciences, City Hospital, University of Nottingham, Clinical Sciences Building 2, Nottingham, UK

    David J. Humes

  3. Division of Trauma Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    George C. Velmahos

  4. Department of Gastrointestinal Surgery, Stavanger University Hospital, P. O. Box 8100, 4068, Stavanger, Norway

    Kjetil Søreide

  5. Department of Clinical Medicine, University of Bergen, Bergen, Norway

    Kjetil Søreide

  6. Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals, University of Nottingham, Nottingham, NG7 2UH, UK

    David J. Humes

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  1. Marja A. Boermeester
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Corresponding author

Correspondence to David J. Humes.

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Conflict of interest

MB has received grants for diverticulitis research from the Dutch Health Care and Efficacy Research (ZonMW), the Dutch Digestive Diseases Foundation (MLDS), and non-diverticulitis-related grants from Baxter, Abbott, Ipsen, LifeCell/Acelity, and GSK. She has spoken at a Dr Falk Pharmaceuticals Symposium as an invited speaker on diverticulitis. DH has received research funding from the Royal College of Surgeons of England, Research into Ageing, and the BUPA foundation for research on diverticular disease. He has spoken at a Dr Falk Pharmaceuticals Symposium as an invited speaker on diverticular disease. GV none. KS none.

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Boermeester, M.A., Humes, D.J., Velmahos, G.C. et al. Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis. World J Surg 40, 2537–2545 (2016). https://doi.org/10.1007/s00268-016-3560-8

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  • DOI: https://doi.org/10.1007/s00268-016-3560-8

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