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Diverticulosis and Diverticulitis

  • Joseph D. Feuerstein
    Correspondence
    Correspondence: Address to Joseph D. Feuerstein, MD, Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA 02215.
    Affiliations
    Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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  • Kenneth R. Falchuk
    Affiliations
    Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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      Abstract

      Diverticular disease is a common condition that is associated with variable presentations. For this review article, we performed a review of articles in PubMed through February 1, 2016, by using the following MeSH terms: colon diverticula, colonic diverticulitis, colonic diverticulosis, colonic diverticulum, colonic diverticula, and diverticula. Diverticula are structural alterations within the colonic wall that classically form “pockets” referred to as diverticula. Diverticula form from herniation of the colonic mucosa and submucosa through defects in the circular muscle layers within the colonic wall. Often this is at the sites of penetrating blood vessels in the colon. Diverticular disease is extremely common, which resulted in 2,682,168 outpatient visits and 283,355 hospitalization discharges for diverticulitis or diverticulosis in 2009. Diverticulosis is one of the most common detected conditions found incidentally on colonoscopy. Risk factors for the development of diverticulitis include obesity, smoking, nonsteroidal anti-inflammatory drugs, corticosteroids, and opiates. In contrast, fiber may be protective, but recent studies have questioned the role of fiber in developing diverticular disease. Most patients with diverticulosis will be asymptomatic, but a subset of patients may develop nonspecific abdominal pain (isolated or recurrent), diverticulitis, or segmental colitis associated with diverticulosis. Classically, the treatment of diverticulitis has included antibiotics for all patients. More recent evidence indicates that in mild to even moderate uncomplicated diverticulitis, antibiotics may not be as necessary as initially believed. In more complicated diverticulitis, intravenous antibiotics and surgery may be necessary. Once a patient has had an attack of diverticulitis, increasing fiber may help prevent future attacks. Other modalities such as 5-aminosalicylate products, antibiotics, and probiotics are still of unclear benefit in preventing future episodes of diverticulitis. Similarly, even when patients develop recurrent episodes of diverticulitis, surgery may not be necessary as a prophylactic treatment.

      Abbreviations and Acronyms:

      AGA (American Gastroenterological Association), 5-ASA (5-aminosalicylate), CT (computed tomography), IBD (inflammatory bowel disease), RR (relative risk), SCAD (segmental colitis associated with diverticulosis), SUDD (symptomatic uncomplicated diverticular disease)
      Article Highlights
      • Diverticular disease is a common condition that is found in approximately 50% of individuals older than 60 years.
      • Diverticular disease is increasingly common in younger patients who often present with a more virulent form and develop more substantial complications.
      • Risk factors for diverticulitis include obesity, smoking, and medications (eg, nonsteroidal anti-inflammatory drugs, corticosteroids, and opiates).
      • Routine use of antibiotics may not be necessary in cases of mild diverticulitis.
      • The optimal timing and need for surgery is unclear and is no longer considered necessary after 2 episodes of diverticulitis.
      • The role of fiber in preventing formation of diverticulitis and preventing further complications of diverticulitis is unclear.
      • Diverticular disease can be associated with more chronic forms of abdominal pain and inflammation even after the acute episode.
      Diverticula are structural alterations within the colonic wall that classically form “pockets” referred to as diverticula. Diverticula form from herniation of the colonic mucosa and submucosa through defects in the circular muscle layers within the colonic wall. Often this is at the sites of penetrating blood vessels in the colon.
      • Slack W.W.
      The anatomy, pathology, and some clinical features of diverticulitis of the colon.
      Diverticular disease is a common condition affecting many patients, with an estimated 2,682,168 outpatient clinic visits in 2009.
      • Peery A.F.
      • Dellon E.S.
      • Lund J.
      • et al.
      Burden of gastrointestinal disease in the United States: 2012 update.
      It was the most common gastrointestinal-related hospitalization discharge code in 2009, accounting for 219,133 persons discharged for diverticulitis and another 64,222 discharged for diverticulosis.
      • Peery A.F.
      • Dellon E.S.
      • Lund J.
      • et al.
      Burden of gastrointestinal disease in the United States: 2012 update.
      Likewise, diverticulosis is the most frequently detected anomaly on colonoscopy.
      • Everhart J.E.
      • Ruhl C.E.
      Burden of digestive diseases in the United States part II: Lower gastrointestinal diseases.
      The disease can be asymptomatic, with diverticulosis noted on colonoscopy, or it can present with bleeding (ie, diverticular bleeding) or inflammation (ie, diverticulitis). The overall rates of complications of bleeding are quite low, and most cases will resolve spontaneously. In contrast, diverticulitis can be associated with infection, sepsis, and perforation. Often antibiotics are used and surgery may be warranted in certain cases. In this article, we review the current literature because it relates to asymptomatic diverticulosis and diverticulitis. For this review, we performed a review of articles in PubMed through February 1, 2016, by using the following MeSH terms: colon diverticula, colonic diverticulitis, colonic diverticulosis, colonic diverticulum, colonic diverticula, and diverticula.

      Epidemiology

      The overall prevalence of diverticulosis increases with age. Approximately 50% of individuals aged 60 years and older will have diverticulosis and by the age of 80, approximately 70% of patients will have diverticulosis.
      • Painter N.S.
      • Burkitt D.P.
      Diverticular disease of the colon, a 20th century problem.
      • Warner E.
      • Crighton E.J.
      • Moineddin R.
      • Mamdani M.
      • Upshur R.
      Fourteen-year study of hospital admissions for diverticular disease in Ontario.
      Western and industrialized countries (eg, United States, Europe, and Australia) have a higher prevalence of diverticular disease than do countries such as Africa and Asia, which have prevalence rates of less than 0.5%.
      • Warner E.
      • Crighton E.J.
      • Moineddin R.
      • Mamdani M.
      • Upshur R.
      Fourteen-year study of hospital admissions for diverticular disease in Ontario.
      The theory behind this finding is the low fiber content in Western diets compared with that in Asian and African diets, which results in the formation of diverticula. Burkitt et al
      • Burkitt D.P.
      • Walker A.R.
      • Painter N.S.
      Effect of dietary fibre on stools and transit-times, and its role in the causation of disease.
      compared fiber in diets in the United Kingdom with that in Uganda. Patients in the United Kingdom had low fiber intake, with a transit time of 80 hours and a mean stool weight of 110 g/d. In contrast, patients in Uganda had increased fiber intake, with a transit time of only 34 hours and a higher mean stool weight of 450 g/d.
      • Burkitt D.P.
      • Walker A.R.
      • Painter N.S.
      Effect of dietary fibre on stools and transit-times, and its role in the causation of disease.
      Similarly, Painter et al
      • Painter N.S.
      • Truelove S.C.
      • Ardran G.M.
      • Tuckey M.
      Segmentation and the localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of colonic diverticula.
      performed motility studies in patients with diverticulosis and noted higher colonic pressures in these patients than in controls. The assumption was that longer stool transit time resulted in the development of diverticular disease from increased wall pressure. As diets change to be more Westernized, this geographic difference has become less evident.
      • Walker A.
      • Segal I.
      Epidemiology of noninfective intestinal diseases in various ethnic groups in South Africa.
      • Ogunbiyi O.
      Diverticular disease of the colon in Ibadan, Nigeria.
      Nonetheless, the actual cause and effect relationship between low fiber and colonic transit time in the development of diverticular disease remains unclear.
      • Manousos O.N.
      • Truelove S.C.
      • Lumsden K.
      Transit times of food in patients with diverticulosis or irritable colon syndrome and normal subjects.
      • Kirwan W.O.
      • Smith A.N.
      Colonic propulsion in diverticular disease, idiopathic constipation, and the irritable colon syndrome.
      There also appears to be sex-related differences in the development of diverticular disease. Using data from the National Inpatient Sample from 2000 to 2010, Wheat and Strate
      • Wheat C.L.
      • Strate L.L.
      Trends in hospitalization for diverticulitis and diverticular bleeding in the United States from 2000 to 2010.
      found that hospitalization for diverticulitis is more common in white women. Most patients are in the age group of 40 to 80 years.
      The location of diverticula differs geographically as well. In Western countries, most diverticular disease is in the sigmoid colon.
      • Etzioni D.A.
      • Mack T.M.
      • Beart Jr., R.W.
      • Kaiser A.M.
      Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment.
      • Painter N.S.
      • Burkitt D.P.
      Diverticular disease of the colon: a deficiency disease of Western civilization.
      • Kang J.Y.
      • Hoare J.
      • Tinto A.
      • et al.
      Diverticular disease of the colon—on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000.
      In contrast, in Asia, right-sided diverticular disease is the predominant.
      • Sugihara K.
      • Muto T.
      • Morioka Y.
      • Asano A.
      • Yamamoto T.
      Diverticular disease of the colon in Japan: a review of 615 cases.
      • Markham N.I.
      • Li A.K.
      Diverticulitis of the right colon—experience from Hong Kong.
      • Ngoi S.S.
      • Chia J.
      • Goh M.Y.
      • Sim E.
      • Rauff A.
      Surgical management of right colon diverticulitis.
      The cause for this geographic variability is unclear. Previous theories about left-sided diverticula being acquired and right-sided diverticula being more congenital have not been substantiated in studies. In addition, despite the Westernization of diets, this difference in geographic location of diverticula remains.
      • Sugihara K.
      • Muto T.
      • Morioka Y.
      • Asano A.
      • Yamamoto T.
      Diverticular disease of the colon in Japan: a review of 615 cases.
      The risk of being hospitalized for diverticulitis is 3 times higher than that associated with diverticular bleeding.
      • Wheat C.L.
      • Strate L.L.
      Trends in hospitalization for diverticulitis and diverticular bleeding in the United States from 2000 to 2010.
      Historically, individuals with diverticulosis have been counseled that 15% to 25% will develop diverticulitis in their lifetime; however, this is not based on population studies and is likely an overestimate of the true risk.
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.
      More recent studies
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.
      • Shahedi K.
      • Fuller G.
      • Bolus R.
      • et al.
      Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy.
      • Shahedi K.
      • Fuller G.
      • Bolus R.
      • et al.
      847 progression from incidental diverticulosis to acute diverticulitis.
      • Kantsø B.
      • Simonsen J.
      • Hoffmann S.
      • Valentiner-Branth P.
      • Petersen A.M.
      • Jess T.
      Inflammatory bowel disease patients are at increased risk of invasive pneumococcal disease: a nationwide Danish cohort study 1977-2013.
      speculate that the true risk is less than 5%, with 1 study indicating that it may be as low as 1% over an 11-year follow-up period. Diverticulitis is more common in patients aged 18 to 80 years than is diverticular bleeding, and it is more prevalent in women than in men (98.6 per 100,000 persons vs 76.3 per 100,000 persons).
      • Wheat C.L.
      • Strate L.L.
      Trends in hospitalization for diverticulitis and diverticular bleeding in the United States from 2000 to 2010.
      However, among patients younger than 50 years, diverticulitis occurs more often in men than in women. Using the data from the National Inpatient Sample, whites were found to have the highest prevalence rate of diverticulitis (61.8±9.0 per 100,000 persons).
      • Wheat C.L.
      • Strate L.L.
      Trends in hospitalization for diverticulitis and diverticular bleeding in the United States from 2000 to 2010.
      The overall prevalence of hospitalization increased from 74.1 per 100,000 persons in 2000 to 91.9 per 100,000 persons in 2010.
      • Wheat C.L.
      • Strate L.L.
      Trends in hospitalization for diverticulitis and diverticular bleeding in the United States from 2000 to 2010.
      This increase is noted in the age group of 17 to 70 years.
      • Wheat C.L.
      • Strate L.L.
      Trends in hospitalization for diverticulitis and diverticular bleeding in the United States from 2000 to 2010.

      Pathophysiology

      Currently, the exact pathological mechanisms by which diverticula occur in the colon are unknown. There are multiple theories including those related to genetics, diet, motility, microbiome, and inflammation.
      One of the leading theories is the development of diverticula from increased pressure in areas of weakened walls. With age, there is degeneration of the mucosal wall as well as increase in the colonic pressure that bulges in areas of insertion of the vasa recta that results in the development of diverticulosis.
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.
      Older theories about the development of diverticulitis stressed food and/or stool lodging in diverticula, which then caused trauma, ischemia, necrosis, and focal perforation. More recent theories have called this into question and instead focus on changes in the microbiome, inflammation, motility, and genetics.
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.

      Genetics

      Genetics play a significant role in the development of diverticular disease. A Swedish Twin Registry comprising 104,452 twins noted diverticular disease in 2296 twins.
      • Granlund J.
      • Svensson T.
      • Olén O.
      • et al.
      The genetic influence on diverticular disease—a twin study.
      The odd ratios for developing diverticular disease was 7.15 (95% CI, 4.82-10.61) when 1 twin was affected and 3.20 (95% CI, 2.21-4.63) for dizygotic twins. The heritability effect is estimated to be 40% and the nonshared environmental effect as 60%.
      • Granlund J.
      • Svensson T.
      • Olén O.
      • et al.
      The genetic influence on diverticular disease—a twin study.
      Specific genes, such as the TNFSF15 SNP rs7848647, have also been implicated in the development of diverticulitis and complications of the disease.
      • Connelly T.M.
      • Berg A.S.
      • Hegarty J.P.
      • et al.
      The TNFSF15 gene single nucleotide polymorphism rs7848647 is associated with surgical diverticulitis.

      Motility

      The motility theory hinges on the neural degradation that occurs with age in the myenteric plexus and in the myenteric glial cells and interstitial cells of cajal.
      • Wedel T.
      • Büsing V.
      • Heinrichs G.
      • et al.
      Diverticular disease is associated with an enteric neuropathy as revealed by morphometric analysis.
      • Bassotti G.
      • Battaglia E.
      • Bellone G.
      • et al.
      Interstitial cells of cajal, enteric nerves, and glial cells in colonic diverticular disease.
      The loss of neurons results in uncoordinated contractions, and subsequent increased pressure may result in the development of diverticular disease.

      Microbiome

      Recently, the changes in the microbiome have been implicated in the development of diverticulitis. Long-standing stasis of feces may result in a chronic microbiome dysbiosis, which may then result in a chronic inflammatory state.
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.
      When comparing patients with diverticulitis with patients without diverticulitis, there was an increase in the Firmicutes/Bacteroidetes ratios as well as overall levels of Proteobacteria.
      • Daniels L.
      • Budding A.E.
      • de Korte N.
      • et al.
      Fecal microbiome analysis as a diagnostic test for diverticulitis.

      Inflammation

      Inflammation is associated with both symptomatic diverticular disease and complications of diverticular disease. In diverticular disease, there is an increase in microscopic inflammation from chronic lymphocytic infiltration and active neutrophilic infiltrate as well as an enhanced expression of tumor necrosis factor α.
      • Tursi A.
      • Brandimarte G.
      • Elisei W.
      • et al.
      Assessment and grading of mucosal inflammation in colonic diverticular disease.
      • Narayan R.
      • Floch M.H.
      Microscopic colitis as part of the natural history of diverticular disease.
      • Tursi A.
      • Elisei W.
      • Brandimarte G.
      • et al.
      Musosal tumour necrosis factor α in diverticular disease of the colon is overexpressed with disease severity.
      Interestingly, ongoing histological inflammation is associated with an increased risk of recurrent diverticulitis.
      • Tursi A.
      • Elisei W.
      • Giorgetti G.M.
      • et al.
      Detection of endoscopic and histological inflammation after an attack of colonic diverticulitis is associated with higher diverticulitis recurrence.
      A more recently subclassified disorder of diverticulitis is segmental colitis associated with diverticulosis (SCAD), which is associated with the macroscopic finding of chronic inflammation in diverticula on colonoscopy.
      • Jani N.
      • Finkelstein S.
      • Blumberg D.
      • Regueiro M.
      Segmental colitis associated with diverticulosis.
      • Sheth A.A.
      • Longo W.
      • Floch M.H.
      Diverticular disease and diverticulitis.

      Terminology

      There are many different terms used to describe diverticulosis and its complications.
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.
      • Weizman A.V.
      • Nguyen G.C.
      Diverticular disease: epidemiology and management.
      • Tursi A.
      • Papa A.
      • Danese S.
      Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon.
      • Diverticulosis: Presence of diverticula.
      • Diverticular disease: Clinically significant and symptomatic diverticulosis.
      • Acute diverticulitis: Active inflammation in diverticula. This can be isolated or recurrent as well as uncomplicated or complicated.
      • Asymptomatic uncomplicated diverticular disease: This refers to the presence of diverticulosis without any symptoms or complications of the disease. Most often this is noted incidentally on colonoscopy or on radiological imaging.
      • Symptomatic uncomplicated diverticular disease (SUDD): Symptoms attributed to diverticulosis in the absence of any visible inflammation or diverticulitis. This refers to episodes of abdominal pain without evidence of inflammation. Classically, the pain will come and go but can also be constant in nature. Symptoms may be relived with flatus or bowel movements. Associated symptoms include abdominal pain, bloating, constipation, and diarrhea. Importantly, this condition does not include a history of acute diverticulitis.
      • Recurrent symptomatic uncomplicated diverticular disease: This refers to the above-mentioned symptoms of SUDD occurring multiple times during the year.
      • Segmental colitis associated with diverticulosis (SCAD): A chronic form of diverticulitis that can mimic inflammatory bowel disease (IBD) and has evidence of macroscopic inflammation in diverticula on colonoscopy. Symptoms are often similar to IBD and include abdominal pain, diarrhea, and bleeding.

      Risk Factors

      Classically, a diet low in fiber has been viewed as a risk factor for the development of diverticular disease. Dietary fiber intake has been shown to be inversely associated with the risk of developing diverticular disease (relative risk [RR], 0.58; 95% CI, 0.41-0.83; P=.01).
      • Aldoori W.H.
      • Giovannucci E.L.
      • Rimm E.B.
      • Wing A.L.
      • Trichopoulos D.V.
      • Willett W.C.
      A prospective study of diet and the risk of symptomatic diverticular disease in men.
      However, more recently, a large cross-sectional study
      • Peery A.F.
      • Barrett P.R.
      • Park D.
      • et al.
      A high-fiber diet does not protect against asymptomatic diverticulosis.
      of dietary risk factors for the development of diverticulosis failed to identify low fiber diets as a risk factor for diverticulosis. The study followed 2014 patients who underwent screening colonoscopy and then had a telephone interview about food frequency, bowel frequency, and physical activity. This study
      • Peery A.F.
      • Barrett P.R.
      • Park D.
      • et al.
      A high-fiber diet does not protect against asymptomatic diverticulosis.
      found that dose-dependent higher fiber diets were actually associated with a higher prevalence of diverticulosis.
      Although fiber does not appear to prevent the formation of diverticulosis, it may have a role in preventing diverticular disease. Crowe et al
      • Crowe F.L.
      • Appleby P.N.
      • Allen N.E.
      • Key T.J.
      Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians.
      studied 47,033 patients and found that adherence to a vegetarian diet reduced the risk of hospitalization and death from diverticular disease. In this study,
      • Crowe F.L.
      • Appleby P.N.
      • Allen N.E.
      • Key T.J.
      Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians.
      those with higher fiber intake were less likely to have complications of diverticular disease. For many years, it was believed that consumption of nuts and seeds may lead to obstruction of diverticula opening, resulting in the development of diverticulitis.
      • Horner J.L.
      Natural history of diverticulosis of the colon.
      • Peery A.F.
      • Sandler R.S.
      Diverticular disease: reconsidering conventional wisdom.
      However, a large study by Strate et al
      • Strate L.L.
      • Liu Y.L.
      • Syngal S.
      • Aldoori W.H.
      • Giovannucci E.L.
      Nut, corn, and popcorn consumption and the incidence of diverticular disease.
      found that nuts, corn, and seeds were not associated with any increase in diverticulitis or diverticular bleeding.
      Other reported risk factors for diverticulosis include diets high in red meat and fat.
      • Aldoori W.H.
      • Giovannucci E.L.
      • Rimm E.B.
      • Wing A.L.
      • Trichopoulos D.V.
      • Willett W.C.
      A prospective study of diet and the risk of symptomatic diverticular disease in men.
      Medications have been associated with a risk of both diverticulitis and diverticular bleeding, including nonsteroidal anti-inflammatory drugs, corticosteroids, and opiates.
      • Strate L.L.
      • Liu Y.L.
      • Huang E.S.
      • Giovannucci E.L.
      • Chan A.T.
      Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding.
      • Morris C.R.
      • Harvey I.M.
      • Stebbings W.S.
      • Speakman C.T.
      • Kennedy H.J.
      • Hart A.R.
      Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease.
      • von Rahden B.H.
      • Kircher S.
      • Thiery S.
      • et al.
      Association of steroid use with complicated sigmoid diverticulitis: potential role of activated CD68+/CD163+ macrophages.
      • Goh H.
      • Bourne R.
      Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study.
      Obesity is associated with a risk of diverticulitis (RR, 1.57; 95% CI, 1.18-2.07),
      • Strate L.L.
      • Liu Y.L.
      • Aldoori W.H.
      • Syngal S.
      • Giovannucci E.L.
      Obesity increases the risks of diverticulitis and diverticular bleeding.
      and relative to nonsmokers, smokers have an increased risk as well (odds ratio, 1.89; 95% CI, 1.15-3.10).
      • Hjern F.
      • Wolk A.
      • Håkansson N.
      Smoking and the risk of diverticular disease in women.
      In contrast, vegetarian diets and increased physical activity appear to be protective of diverticular disease.
      • Strate L.L.
      • Liu Y.L.
      • Aldoori W.H.
      • Giovannucci E.L.
      Physical activity decreases diverticular complications.
      • Williams P.T.
      Incident diverticular disease is inversely related to vigorous physical activity.
      Medications that may have a protective effect are calcium channel blockers and statins. Also, higher vitamin D levels reduce the risk of hospitalization for diverticulitis (RR, 0.49; 95% CI, 0.38-0.62).
      • Strate L.L.
      • Modi R.
      • Cohen E.
      • Spiegel B.M.
      Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights.

      Signs and Symptoms

      Diverticular disease can present in many different ways including asymptomatic disease, infectious complications, and gastrointestinal bleeding.
      Acute diverticulitis can present as mild intermittent pain or as chronic severe unrelenting abdominal pain. Systemic symptoms of fever and a change in bowel habits are common. Constipation is reported in approximately 50% of patients and diarrhea in 25% to 35%.
      • Konvolinka C.W.
      Acute diverticulitis under age forty.
      Other symptoms include nausea, vomiting, and urinary symptoms. In cases of overt peritonitis, abdominal examination may be notable for rigidity, rebound tenderness, and guarding. Laboratory testing is often notable for a leukocytosis and elevated inflammatory markers.

      Diagnosis

      Diverticular disease can be diagnosed clinically with classic presenting symptoms or more frequently with a confirmatory test done radiologically or via colonoscopy.

      Radiological Diagnosis

      Classically, barium enema was used for the diagnosis of diverticular disease.
      • Halligan S.
      • Saunders B.
      Imaging diverticular disease.
      However, currently, computed tomography (CT) has become the standard for diagnosing diverticular disease (Figure 1).
      • Flor N.
      • Rigamonti P.
      • Pisani Ceretti A.
      • et al.
      Diverticular disease severity score based on CT colonography.
      Both CT of the abdomen and pelvis and CT colonography are effective in diagnosing the disease, extent of disease, and complications of disease.
      • Halligan S.
      • Saunders B.
      Imaging diverticular disease.
      • Biondo S.
      • Lopez Borao J.
      • Millan M.
      • Kreisler E.
      • Jaurrieta E.
      Current status of the treatment of acute colonic diverticulitis: a systematic review.
      In the more emergent setting, CT of the abdomen and pelvis is more commonly used. The sensitivity for acute diverticulitis is 94%, with a specificity of 99%.
      • Laméris W.
      • van Randen A.
      • Bipat S.
      • Bossuyt P.M.
      • Boermeester M.A.
      • Stoker J.
      Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy.
      When CT of the abdomen and pelvis is used, the Buckley or Hinchey classification system can be used to assess the severity of diverticulitis (Tables 1 and 2).
      • Hinchey E.J.
      • Schaal P.G.
      • Richards G.K.
      Treatment of perforated diverticular disease of the colon.
      • Buckley O.
      • Geoghegan T.
      • O'Riordain D.S.
      • Lyburn I.D.
      • Torreggiani W.C.
      Computed tomography in the imaging of colonic diverticulitis.
      Figure thumbnail gr1
      Figure 1Sigmoid diverticulitis on computed tomography.
      Table 1Buckley Classification
      • Buckley O.
      • Geoghegan T.
      • O'Riordain D.S.
      • Lyburn I.D.
      • Torreggiani W.C.
      Computed tomography in the imaging of colonic diverticulitis.
      ClassComputed tomographic findings
      Mild diseaseBowel wall thickening

      Fat stranding
      Moderate diseaseBowel wall thickening >3 mm

      Phlegmon/small abscess
      Severe diseaseBowel wall thickening >5 mm

      Perforation with subdiaphragmatic free air

      Abscess >5 mm
      Table 2Hinchey Classification
      • Hinchey E.J.
      • Schaal P.G.
      • Richards G.K.
      Treatment of perforated diverticular disease of the colon.
      ClassComputed tomographic findings
      Stage IPericolic abscess/phlegmon
      Stage IIPelvic, intra-abdominal, or retroperitoneal abscess
      Stage IIIPurulent peritonitis
      Stage IVFecal peritonitis

      Endoscopic Diagnosis

      Colonoscopy is the main diagnostic tool for diagnosing diverticular disease. Asymptomatic diverticular disease is a frequent incidental finding on screening colonoscopy (Figure 2).
      • Everhart J.E.
      • Ruhl C.E.
      Burden of digestive diseases in the United States part II: Lower gastrointestinal diseases.
      However, colonoscopy is not used in the setting of acute diverticulitis. In this setting, there is a concern for possible perforation related to air insufflation. Although diverticulitis can be identified on colonoscopy and is seen in up to 2% of screening colonoscopy,
      • Tursi A.
      • Elisei W.
      • Giorgetti G.
      • Aiello F.
      • Brandimarte G.
      Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease.
      it cannot identify certain disease complications such as abscess.
      Figure thumbnail gr2
      Figure 2Diverticulosis on colonoscopy.

      Differential Diagnosis

      A number of conditions may mimic acute diverticulitis. Both ulcerative colitis and Crohn disease may present with similar findings of abdominal pain and changes in bowel habits. In cases of severe inflammation, both conditions may also present with systemic findings of fever. Ischemic colitis may also present similar to acute diverticulitis. This typically presents in patients who develop transient episodes of hypotension, resulting in decreased blood flow to the colon. This can result in diffuse abdominal pain or localized abdominal pain to the areas of ischemia as well as change in bowel habits and low-grade fever. A key difference, however, is that ischemic colitis is often associated with bloody diarrhea, which is not typically present in cases of diverticulitis. Similarly, both infectious gastroenteritis and acute appendicitis need to be ruled out.

      Diverticulitis

      Diverticulitis can be uncomplicated or complicated.

      Management of Uncomplicated Diverticulitis

      In uncomplicated diverticulitis, patients are typically treated with antibiotics and bowel rest. When there are no signs of systemic toxicity, patients can be safely treated with oral antibiotics in an outpatient setting whereas those with more moderate to severe disease should be hospitalized and treated with intravenous antibiotics and bowel rest.
      • Biondo S.
      • Golda T.
      • Kreisler E.
      • et al.
      Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial).
      Overall, uncomplicated diverticulitis is associated with few complications and rarely necessitates emergent surgery.
      • Buchs N.C.
      • Konrad-Mugnier B.
      • Jannot A.S.
      • Poletti P.A.
      • Ambrosetti P.
      • Gervaz P.
      Assessment of recurrence and complications following uncomplicated diverticulitis.
      Antibiotics should be geared toward treating aerobic and anaerobic gram-negative bacteria. Recent European studies
      • de Korte N.
      • Kuyvenhoven J.P.
      • van der Peet D.L.
      • Felt-Bersma R.J.
      • Cuesta M.A.
      • Stockmann H.B.
      Mild colonic diverticulitis can be treated without antibiotics. a case-control study.
      • Westwood D.A.
      • Eglinton T.W.
      Antibiotics may not improve short-term or long-term outcomes in acute uncomplicated diverticulitis.
      • Andersen J.C.
      • Bundgaard L.
      • Elbrønd H.
      • Laurberg S.
      • Walker L.R.
      • Støvring J.
      Danish Surgical Society
      Danish national guidelines for treatment of diverticular disease.
      have suggested that antibiotics may not even be necessary in cases of mild to even moderate uncomplicated disease. A randomized trial
      • Chabok A.
      • Påhlman L.
      • Hjern F.
      • Haapaniemi S.
      • Smedh K.
      AVOD Study Group
      Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.
      in cases of uncomplicated diverticulitis found no change in complications, hospital stay, or recurrent diverticulitis after 12 months of follow-up. An important goal of antibiotic therapy is the reduction in diverticular complications and risk of recurrence.
      • Chabok A.
      • Påhlman L.
      • Hjern F.
      • Haapaniemi S.
      • Smedh K.
      AVOD Study Group
      Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.
      Given that these risks are quite low in uncomplicated diverticulitis, the most recent American Gastroenterological Association (AGA) guidelines
      • Strate L.L.
      • Peery A.F.
      • Neumann I.
      American Gastroenterological Association Technical Review on Management of Acute Diverticulitis.
      now recommend that antibiotics should be used selectively as opposed to routinely in patients with uncomplicated diverticulitis.

      Management of Complicated Diverticulitis

      In complicated cases, patients may present with a phlegmon, abscess, peritonitis, fistula formation, or obstruction. Typically, the infection spreads locally involving structures adjacent to the area of inflammation (eg, bladder and hip joint) or via the portal circulation that may result in the development of hepatic abscesses. In cases of complicated disease as evident on CT, patients should be hospitalized, treated with intravenous antibiotics, bowel rest, and surgical consultation.
      Diverticular abscess may develop in up to 16% of patients with acute diverticulitis.
      • Bahadursingh A.M.
      • Virgo K.S.
      • Kaminski D.L.
      • Longo W.E.
      Spectrum of disease and outcome of complicated diverticular disease.
      When an abscess is present, definitive therapy with surgery or percutaneous drainage is often necessary. In a systematic review
      • Lamb M.N.
      • Kaiser A.M.
      Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis.
      of patients with diverticulitis and abscess formation, abscesses that were of Hinchey stages IB and II were successfully drained by radiology in approximately 50% of cases. Patients who do not improve with conservative therapy may require urgent surgical resection during hospitalization. Given the ongoing inflammation, most patients will necessitate a 2- to 3-staged surgical procedure with a resection of the diseased area, temporary diverting colostomy, and Hartmann pouch formation. More recent studies,
      • Biondo S.
      • Lopez Borao J.
      • Millan M.
      • Kreisler E.
      • Jaurrieta E.
      Current status of the treatment of acute colonic diverticulitis: a systematic review.
      however, have questioned the need for this diversion in patients without overt fecal peritonitis. Oberkofler et al
      • Oberkofler C.E.
      • Rickenbacher A.
      • Raptis D.A.
      • et al.
      A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis.
      reported on 62 patients with diverticulitis from 4 centers who were randomized to a Hartmann pouch or to a diverting ileostomy. The diverting ileostomy was associated with reduced rates of complications, operating time, hospital stay, and lower inhospital costs.
      • Oberkofler C.E.
      • Rickenbacher A.
      • Raptis D.A.
      • et al.
      A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis.
      A previous study
      • Sheth A.A.
      • Longo W.
      • Floch M.H.
      Diverticular disease and diverticulitis.
      had shown safe and positive results in a single-stage procedure in carefully selected individuals.
      Perforation with peritonitis from diverticulitis with rupture into the peritoneal cavity is rare, occurring only 1% to 2% of the time. However, in these situations, mortality rates approach 20%.
      • Kriwanek S.
      • Armbruster C.
      • Beckerhinn P.
      • Dittrich K.
      Prognostic factors for survival in colonic perforation.
      • Nagorney D.M.
      • Adson M.A.
      • Pemberton J.H.
      Sigmoid diverticulitis with perforation and generalized peritonitis.
      Fistulous tracts form in up to 12% of patients with diverticulitis. Most fistula will form to adjacent organs, most often involving the bladder followed by vaginal, cutaneous, and enterocolic fistulas.
      • Strate L.L.
      • Liu Y.L.
      • Aldoori W.H.
      • Giovannucci E.L.
      Physical activity decreases diverticular complications.
      • Woods R.J.
      • Lavery I.C.
      • Fazio V.W.
      • Jagelman D.G.
      • Weakley F.L.
      Internal fistulas in diverticular disease.
      In both situations, broad-spectrum antibiotics and surgery are necessary.
      Overall, the risk of readmission and need for emergent surgery after the nonoperative management of diverticulitis is low.
      • Li D.
      • de Mestral C.
      • Baxter N.N.
      • et al.
      Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.
      However, those presenting with complicated disease are at high risk of readmission (12% vs 8.2%; P<.001) and need for emergent surgery (4.3% vs 1.4%; P<.001) as compared with those with uncomplicated disease.
      • Li D.
      • de Mestral C.
      • Baxter N.N.
      • et al.
      Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.

      Management of Diverticular-Associated Colitis

      Segmental colitis associated with diverticulosis is an infrequently seen form of chronic colitis involving areas of diverticula (Figure 3).
      • Lamps L.W.
      • Knapple W.L.
      Diverticular disease-associated segmental colitis.
      • Peppercorn M.A.
      Drug-responsive chronic segmental colitis associated with diverticula: a clinical syndrome in the elderly.
      The condition can often be mistaken for IBD, especially Crohn colitis. Typically, diverticula will have erythematous and friable mucosa with exudate. The surrounding mucosa around diverticula may also be involved. Aphthous ulcers are not usually seen, and if found, these should be suggestive of Crohn disease. On histology, the inflammatory reaction shows chronic colitis without granuloma formation and typically the rectum should be spared of any disease as diverticula do not involve the rectum.
      • Jani N.
      • Finkelstein S.
      • Blumberg D.
      • Regueiro M.
      Segmental colitis associated with diverticulosis.
      Patients who have persistent symptoms of abdominal pain, rectal bleeding, or diarrhea may be treated similarly to those with IBD, and often 5-aminosalicylate (5-ASA) compounds are used.
      • Sultan K.
      • Fields S.
      • Panagopoulos G.
      • Korelitz B.I.
      The nature of inflammatory bowel disease in patients with coexistent colonic diverticulosis.
      If symptoms persist, then limited surgical resection of the involved area may be warranted. However, surgery should be done cautiously as there are some data to suggest that SCAD may be a precursor of IBD, and in cases of Crohn disease, surgery is not curative.
      • Pereira M.C.
      Diverticular disease-associated colitis: progression to severe chronic ulcerative colitis after sigmoid surgery.
      Figure thumbnail gr3
      Figure 3Segmental colitis associated with diverticulosis on colonoscopy.

      Complications of Diverticular Disease

      The effect of diverticular disease on patients' quality of life is still being elucidated. Even when asymptomatic, patients with a history of symptomatic diverticular disease experience lower health-related quality of life than did controls in areas related to bowel symptoms and overall emotional function.
      • Tursi A.
      • Elisei W.
      • Giorgetti G.
      • Aiello F.
      • Brandimarte G.
      Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease.
      Although an exact causal relationship has yet to be established, epidemiological studies
      • Humes D.J.
      • Simpson J.
      • Neal K.R.
      • Scholefield J.H.
      • Spiller R.C.
      Psychological and colonic factors in painful diverticulosis.
      • Jung H.K.
      • Choung R.S.
      • Locke III, G.R.
      • Schleck C.D.
      • Zinsmeister A.R.
      • Talley N.J.
      Diarrhea-predominant irritable bowel syndrome is associated with diverticular disease: a population-based study.
      implicate diverticular disease with the development of irritable bowel syndrome. Other delayed long-term complications include depression, anxiety, and chronic abdominal pain.
      • Humes D.J.
      • Simpson J.
      • Neal K.R.
      • Scholefield J.H.
      • Spiller R.C.
      Psychological and colonic factors in painful diverticulosis.
      Given the association of long-term bowel symptoms after attacks of diverticular disease, Spiegel et al
      • Spiegel B.M.
      • Reid M.W.
      • Bolus R.
      • et al.
      Development and validation of a disease-targeted quality of life instrument for chronic diverticular disease: the DV-QOL.
      developed and validated a quality-of-life instrument for chronic diverticular disease. Their study found that diverticular disease has a significant impact on patients' quality of life both during and after diverticular attacks. Patients reported negative psychosocial, social, and physical symptoms attributed to diverticular disease. The emotional consequences attributed to diverticular disease included anticipation anxiety, anger, depression, devitalization, frustration, and social ostracism. Interestingly, these symptoms were present even without active diverticular symptoms, but patients specifically attributed these emotional changes to their diverticular disease.
      • Spiegel B.M.
      • Reid M.W.
      • Bolus R.
      • et al.
      Development and validation of a disease-targeted quality of life instrument for chronic diverticular disease: the DV-QOL.

      Prevention of Diverticular Disease

      Unfortunately, aside from surgical resection, there are no ideal methods to prevent the recurrence of diverticular disease. Multiple treatments have been studied, including fiber, anti-inflammatory drugs, and antibiotics.
      Classically, the risk of recurrent diverticulitis ranged from 7% to 62%.
      • Peery A.F.
      • Sandler R.S.
      Diverticular disease: reconsidering conventional wisdom.
      More recent studies,
      • Anaya D.A.
      • Flum D.R.
      Risk of emergency colectomy and colostomy in patients with diverticular disease.
      • Broderick-Villa G.
      • Burchette R.J.
      • Collins J.C.
      • Abbas M.A.
      • Haigh P.I.
      Hospitalization for acute diverticulitis does not mandate routine elective colectomy.
      however, have reported lower risks of 13% over 9 years and 19% over 16 years of follow-up. In a large study
      • Eglinton T.
      • Nguyen T.
      • Raniga S.
      • Dixon L.
      • Dobbs B.
      • Frizelle F.A.
      Patterns of recurrence in patients with acute diverticulitis.
      of patients in the Kaiser Permanente system, after an initial bout of diverticulitis, 86% remained symptom free over nearly 9 years of follow-up. A single clinical recurrence occurred in 13.3% of patients and only 3.9% had a second recurrence. Only 4.7% have multiple recurrences beyond 2 episodes of diverticulitis.
      • Eglinton T.
      • Nguyen T.
      • Raniga S.
      • Dixon L.
      • Dobbs B.
      • Frizelle F.A.
      Patterns of recurrence in patients with acute diverticulitis.
      The risk of developing complicated disease after an initial uncomplicated episode of diverticulitis was only 5% over 8 years of follow-up.
      • Eglinton T.
      • Nguyen T.
      • Raniga S.
      • Dixon L.
      • Dobbs B.
      • Frizelle F.A.
      Patterns of recurrence in patients with acute diverticulitis.
      The risks of recurrent complicated disease after an initial complicated episode are similar to those of uncomplicated disease.
      • Bharucha A.E.
      • Parthasarathy G.
      • Ditah I.
      • et al.
      Temporal trends in the incidence and natural history of diverticulitis: a population-based study.

      Surgery

      Classically, surgery was recommended after 2 uncomplicated attacks of diverticulitis. Parks
      • Parks T.G.
      Natural history of diverticular disease of the colon: a review of 521 cases.
      in 1969 reported that patients who had recurrent diverticulitis had more severe episodes and were more likely to require emergent surgery. More recently, this has been questioned on the basis of evidence showing a low risk of recurrent disease, and so long as patients have not had complicated diverticulitis, many will defer surgical management to patient preference for risks of recurrent episodes vs surgery.
      • Bharucha A.E.
      • Parthasarathy G.
      • Ditah I.
      • et al.
      Temporal trends in the incidence and natural history of diverticulitis: a population-based study.
      Andeweg et al
      • Andeweg C.S.
      • Groenewoud J.
      • van der Wilt G.J.
      • van Goor H.
      • Bleichrodt R.P.
      A Markov decision model to guide treatment of recurrent colonic diverticulitis.
      further supported this notion of delaying surgery on the basis of a Markov decision model used to evaluate the optimal timing for surgery in diverticulitis vs conservative management on quality-adjusted life years. Only after the third episode of diverticulitis, surgical and conservative management provided similar quality-adjusted life years. Importantly, however, abdominal symptoms were less frequent in those managed medically.
      • Andeweg C.S.
      • Groenewoud J.
      • van der Wilt G.J.
      • van Goor H.
      • Bleichrodt R.P.
      A Markov decision model to guide treatment of recurrent colonic diverticulitis.
      Similarly, a study
      • Adamova Z.
      Comparison of long-term quality of life in patients with diverticular disease: are there any benefits to surgery?.
      of patients with complicated diverticulitis had no difference in quality of life when comparing the surgically and medically managed groups. In contrast, a recent meta-analysis
      • Andeweg C.S.
      • Berg R.
      • Staal J.B.
      • Ten Broek R.P.
      • van Goor H.
      Patient-reported outcomes after conservative or surgical management of recurrent and chronic complaints of diverticulitis: systematic review and meta-analysis.
      indicated that surgery may provide an overall improvement in quality of life and reduction in overall gastrointestinal symptoms. Importantly, though, the authors
      • Andeweg C.S.
      • Berg R.
      • Staal J.B.
      • Ten Broek R.P.
      • van Goor H.
      Patient-reported outcomes after conservative or surgical management of recurrent and chronic complaints of diverticulitis: systematic review and meta-analysis.
      noted that the studies included in the analysis were of low quality. Although the timing of surgical management of older patients with diverticulitis is less clear, younger patients appear to be at a high risk of recurrent diverticulitis and more virulent forms with a 5-fold higher risk of complications and requiring more surgical interventions than do older patients.
      • Schauer P.R.
      • Ramos R.
      • Ghiatas A.A.
      • Sirinek K.R.
      Virulent diverticular disease in young obese men.
      Therefore, prophylactic surgery may be reasonable to consider in younger patients.
      • Peery A.F.
      • Sandler R.S.
      Diverticular disease: reconsidering conventional wisdom.
      • Bharucha A.E.
      • Parthasarathy G.
      • Ditah I.
      • et al.
      Temporal trends in the incidence and natural history of diverticulitis: a population-based study.
      Surgery, however, is not without risk of complications. A meta-analysis

      Haas JM, Singh M, Vakil N. Mortality and complications following surgery for diverticulitis: systematic review and meta-analysis. United Eur Q20 Gastroenterol J. [epub ahead of print; doi:10.1177/2050640615617357].

      reported a mortality point estimate of 10.64% (95% CI, 1.73%-5.32%; P<.001) for emergent surgery compared with only 0.50% (95% CI, 0.46%-0.54%; P<.001) for elective surgery. Similarly, mortality was less when using a laparoscopic approach and when a primary anastomosis was performed than that when open surgery and a Hartmann procedure were performed.

      Haas JM, Singh M, Vakil N. Mortality and complications following surgery for diverticulitis: systematic review and meta-analysis. United Eur Q20 Gastroenterol J. [epub ahead of print; doi:10.1177/2050640615617357].

      The increased morbidity and mortality related to emergent surgery may be more related to patient comorbidities and age.
      • Oomen J.L.
      • Engel A.F.
      • Cuesta M.A.
      Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors.
      Also, complicated diverticulitis had higher rates of postoperative complications than did uncomplicated diverticulitis (19.6% vs 10%).
      • Bhakta A.
      • Tafen M.
      • Glotzer O.
      • et al.
      Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies.
      Overall, laparoscopic elective surgery with primary anastomosis appears to be associated with the fewest complications of wound infection, ileus, and need for blood transfusion.
      • Siddiqui M.R.
      • Sajid M.S.
      • Qureshi S.
      • Cheek E.
      • Baig M.K.
      Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis.

      Fiber

      The evidence supporting low fiber as a cause for diverticular disease is equivocal.
      • Aldoori W.H.
      • Giovannucci E.L.
      • Rimm E.B.
      • Wing A.L.
      • Trichopoulos D.V.
      • Willett W.C.
      A prospective study of diet and the risk of symptomatic diverticular disease in men.
      • Crowe F.L.
      • Appleby P.N.
      • Allen N.E.
      • Key T.J.
      Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians.
      Similarly, the ability to prevent further diverticular disease from increasing fiber supplementation is unclear. The recent AGA guidelines
      • Stollman N.
      • Smalley W.
      • Hirano I.
      AGA Institute Clinical Guidelines Committee
      American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis.
      recommend increasing fiber supplementation after an attack of diverticulitis, but note that the recommendation is a conditional recommendation based on weak evidence.

      Anti-Inflammatory Medications

      Given the finding of chronic inflammation in cases of SCAD as well as histological evidence of inflammation on biopsy, studies have evaluated the use of 5-ASA derivatives as a preventive treatment. In an open-label study
      • Trepsi E.
      • Colla C.
      • Panizza P.
      • et al.
      Therapeutic and prophylactic role of mesalazine (5-ASA) in symptomatic diverticular disease of the large intestine. 4 year follow-up results.
      of 166 patients with acute diverticulitis randomized to placebo or mesalamine, patients had symptomatic relapse 15% of the time when receiving mesalamine for 8 weeks as compared with 46% in those who received placebo. A similar study
      • Tursi A.
      • Brandimarte G.
      • Giorgetti G.M.
      • Elisei W.
      • Aiello F.
      Balsalazide and/or high-potency probiotic mixture (VSL# 3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon.
      noted that the continuous dose of mesalamine was superior in preventing relapse as compared with the cyclical dose of mesalmaine for just 10 d/mo. The current AGA guidelines
      • Stollman N.
      • Smalley W.
      • Hirano I.
      AGA Institute Clinical Guidelines Committee
      American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis.
      indicate that there is no adequate evidence at this time to recommend the use of 5-ASA products after a flare of diverticulitis.

      Antibiotics

      Antibiotics have been evaluated as a preventive measure on the basis of the theory that altered intestinal microbiota may be the trigger for inflammation and resultant symptoms. Rifaximin use has been associated with a reduction in recurrent diverticulitis in patients with SUDD and appears to be more effective when combined with a 5-ASA product.
      • Tursi A.
      • Brandimarte G.
      • Daffinà R.
      Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon.
      • Ornstein M.H.
      Two kinds of diverticular disease.
      A meta-analysis
      • Bianchi M.
      • Festa V.
      • Moretti A.
      • et al.
      Meta-analysis: Long-term Therapy with rifaximin in the management of uncomplicated diverticular disease.
      of rifaximin in diverticular disease found a number needed to treat of only 3 to achieve symptom relief and a number needed to treat of 59 to avoid a diverticular complication. Nonetheless, the AGA guidelines
      • Stollman N.
      • Smalley W.
      • Hirano I.
      AGA Institute Clinical Guidelines Committee
      American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis.
      do not recommend using rifaximin as a preventive drug at this time.

      Probiotics

      Similar to antibiotics, probiotics work to alter the intestinal flora. Studies
      • Lamiki P.
      • Tsuchiya J.
      • Pathak S.
      • et al.
      Probiotics in diverticular disease of the colon: an open label study.
      have indicated a possible role of probiotics in preventing recurrence of SUDD. Tursi et al
      • Tursi A.
      • Brandimarte G.
      • Giorgetti G.M.
      • Elisei W.
      • Aiello F.
      Balsalazide and/or high-potency probiotic mixture (VSL# 3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon.
      evaluated combining VSL#3 with balsalazide (5-ASA) as compared with VSL#3 alone. In this study, there was no difference in remission rates between the groups, but the combination group had better symptom control related to constipation, bloating, and pain.

      Miscellaneous

      Current societal guidelines
      • Stollman N.
      • Smalley W.
      • Hirano I.
      AGA Institute Clinical Guidelines Committee
      American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis.
      • Stollman N.H.
      • Raskin J.B.
      Ad Hoc Practice Parameters Committee of the American College of Gastroenterology
      Diagnosis and management of diverticular disease of the colon in adults.
      recommend colonoscopy 4 to 8 weeks after an episode of diverticulitis. In the first year after diagnosis of diverticular disease, there is an increased risk of colon cancer. One study
      • Granlund J.
      • Svensson T.
      • Granath F.
      • et al.
      Diverticular disease and the risk of colon cancer—a population-based case-control study.
      reported an increased odds ratio of 25 (95% CI, 17-38) for a diagnosis of colon cancer within 6 months of admission for diverticular disease. In a systematic review of imaging confirmed cases of diverticulitis from 2000 to 2010, the rates of missed colon cancer were substantial, with an estimated 1/67 patients with confirmed diverticulitis would have a misdiagnosed colon cancer identified on colonoscopy.
      • Daniels L.
      • Unlü C.
      • de Wijkerslooth T.R.
      • Dekker E.
      • Boermeester M.A.
      Routine colonoscopy after left-sided acute uncomplicated diverticulitis: a systematic review.
      However, if adequate screening colonoscopy was performed recently, then routinely repeating it after an episode of diverticulitis is not necessary.
      • Stollman N.
      • Smalley W.
      • Hirano I.
      AGA Institute Clinical Guidelines Committee
      American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis.

      Conclusion

      Diverticular disease is a common condition. It affects individuals in many different ways. The current recommendations for the management and prevention of diverticulitis is evolving as newer evidence debunks classic beliefs and treatment paradigms. Further studies are still needed to better identify who is at highest risk of future complications and who will benefit most from early antibiotics and prophylactic surgery.

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      Linked Article

      • Misdiagnosis of Diverticulitis in Patients With Irritable Bowel Syndrome
        Mayo Clinic ProceedingsVol. 91Issue 11
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          Two articles published recently in Mayo Clinic Proceedings1,2 are relevant to an important clinical issue: the misdiagnosis of acute colonic diverticulitis in patients with irritable bowel syndrome (IBS). As clearly described in these articles, abdominal pain and disordered bowel habits are common to both disorders, and symptom severity varies in both. Furthermore, patients with either of these disorders typically have tenderness on examination, most often in the lower abdomen. Computed tomography (CT) of the abdomen and pelvis, the most commonly used diagnostic test for diverticulitis,2 is often not urgently available for clinic patients, and some patients with CT-documented diverticulitis have no fever or leukocytosis.
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