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Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, Rafferty JF. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94
[Free full-text American Society of Colon and Rectal Surgeons Practice Parameters PDF | PubMed® abstract | National Guideline Clearinghouse version]
[EXCERPTS]
Major Recommendations
Initial Evaluation of Acute Diverticulitis
1. The initial evaluation of a patient with suspected acute diverticulitis should include a problem-specific history and physical examination; a complete blood count, urinalysis, and abdominal radiographs in selected clinical scenarios. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
Urinalysis and plain abdominal radiographs are helpful in excluding diagnoses in the differential including urinary tract infections, kidney stones, and bowel obstruction. Other diagnoses that can mimic the presentation of acute diverticulitis include irritable bowel syndrome, appendicitis, irritable bowel disease (IBD), ischemic bowel, neoplasia, and gynecologic disorders. In an effort to reduce the misdiagnosis rate among patients with diverticulitis, clinical scoring systems have been proposed that rely on history, physical examination, and blood work.
2. Computed tomography (CT) scan of the abdomen and pelvis is the most appropriate imaging modality in the assessment of suspected diverticulitis. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
In the appropriate setting, multi-slice CT imaging with intravenous and luminal contrast has excellent sensitivity and specificity, reported as high as 98% and 99%. Importantly, cross-sectional imaging can accurately diagnose other disease processes that may mimic the presentation of diverticulitis. The utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT correlates with the risk of failure of nonoperative management in the short-term and with long-term complications such as recurrence, the persistence of symptoms, and the development of colonic stricture and fistula.
3. Ultrasound and magnetic resonance imaging (MRI) can be useful alternatives in the initial evaluation of a patient with suspected acute diverticulitis. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
Medical Treatment of Acute Diverticulitis
1. Nonoperative treatment typically includes oral or intravenous antibiotics and diet modification. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
The vast majority of patients diagnosed with diverticulitis who are treated with oral antibiotics are successfully treated as outpatients. Patients with complicated disease (i.e., free perforation, larger abscesses, fistula, or stricture), who cannot tolerate oral hydration, with relevant comorbidities, or who do not have adequate support at home, require hospital admission and, typically, intravenous antibiotics and bowel rest. Antibiotics should cover Gram-negatives and anaerobes. Multidisciplinary, nonoperative management of inpatients with acute diverticulitis is successful in as many as 91% of patients.
2. Image-guided percutaneous drainage is usually the most appropriate treatment for stable patients with large diverticular abscesses. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
Evaluation After Recovery from Acute Diverticulitis
1. After resolution of an episode of acute diverticulitis, the colon should typically be endoscopically evaluated to confirm the diagnosis, if this is a first episode or recent colonoscopy has not been performed. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
The purpose of the investigation is to exclude diagnoses other than diverticulitis, because patients with simple thickening on imaging may be found to have ischemia, IBD, or neoplasia. Patients with presumed diverticulitis who have not had a recent colon evaluation should undergo colonoscopy, typically within 6 to 8 weeks following resolution of the acute episode (although data supporting this time interval is lacking). The absence of neoplasia on colonoscopy may confirm the diagnosis of diverticulitis suspected on CT. Alternatively, CT colonography may be used in this setting.
Elective Surgery for Acute Diverticulitis
1. The decision to recommend elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be individualized. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
Despite previous emphasis on the number of attacks dictating the need for surgery, the literature demonstrates that patients with more than 2 episodes are not at an increased risk for morbidity and mortality in comparison with patients who have had fewer episodes, signifying that diverticulitis is not a progressive disease.
2. Elective colectomy should typically be considered after the patient recovers from an episode of complicated diverticulitis. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
Complicated diverticulitis includes those episodes associated with free perforation, abscess, fistula, obstruction, or stricture. Free perforation resulting in generalized peritonitis requires urgent operative intervention and is reviewed elsewhere (see the section "Emergency Surgery for Acute Diverticulitis," recommendation 1, below). Neither phlegmon nor extraluminal gas alone seen on imaging is considered complicated disease, and these findings should not dictate a specific therapy. Rather, the clinician should consider these findings together with the clinical scenario, physiologic status, physical examination, and response to ongoing therapy when deciding on operative intervention.
3. Routine elective resection based on young age (<50 years) is no longer recommended. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
Diverticulitis among young patients has historically been associated with worse clinical outcomes, and young age has therefore been used as an indication for elective surgery following recovery after an acute episode of even uncomplicated diverticulitis. Conflicting data remain regarding the risks for recurrence or complications for younger (age <50 years) versus older patients, although more recent data suggest that age <50 years does not increase the risk for worse clinical outcomes.
Emergency Surgery for Acute Diverticulitis
1. Urgent sigmoid colectomy is required for patients with diffuse peritonitis or for those in whom nonoperative management of acute diverticulitis fails. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
2. Following resection, the decision to restore bowel continuity must incorporate patient factors, intraoperative factors, and surgeon preference.Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
3. In patients with purulent or feculent peritonitis, operative therapy without resection is generally not an appropriate alternative to colectomy.Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C.
[Definitions of Levels of Evidence- available online]
[Free full-text American Society of Colon and Rectal Surgeons Practice Parameters PDF | PubMed® abstract | National Guideline Clearinghouse version]
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