Diverticulitis: Current Concepts and Management

Educational Objectives

The goal of this program is to improve treatment of diverticulitis. After hearing and assimilating this program, the clinician will be better able to:

1. Summarize the risk factors for diverticular disease.
2. Compare antibiotic use with observation in management of uncomplicated acute diverticulitis.
3. Explain outcomes using laparoscopic lavage in patients with purulent peritonitis.

Summary

Diverticular disease (DD): attributed to consumption of processed food instead of whole grains; DD primarily occurs in the sigmoid colon where the wall is perforated by blood vessels; propulsion of low caliber stool generates high pressure, resulting in bulges (diverticula); diverticula are not composed of all the layers of the wall (pseudodiverticula); stasis and ulceration lead to diverticular bleed, microperforation, and acute infection

Risk factors: include genetics, low fiber intake, less physical activity, obesity, use of nonsteroidal anti-inflammatory drugs, and smoking; alcohol is equivocal; misconceptions abound in social media about DD; study (Strate et al [2008]) prospectively followed a cohort of men for 20 yrs (follow-up, 90%) and concluded that nut, corn, and popcorn consumption do not increase the risk for diverticulosis or diverticular complications; nut and popcorn consumption is inversely associated with risk for diverticulitis

Clinical practice guidelines (CPG): have evolved over the years; the 2000 guidelines suggested that fiber intake is an important component of DD; the 2020 guidelines evaluated the role of lifestyle and medications in DD

Medical management: data do not support the use of mesalamine, rifaximin, or probiotics; antibiotics — Chabok et al (2012) randomized patients with computed tomography (CT)-confirmed uncomplicated diverticulitis (UD) to antibiotics vs intravenous fluids and found no significant difference between the 2 groups for pain, fever, progression to complicated disease, length of hospital stay, or recurrence at l yr; the DIABOLO trial (Daniels et al [2017]) randomized patients with CT-confirmed UD (included Hinchey stage Ib disease with abscesses <5 cm) to observation (most as outpatients) or antibiotics (10 days); the primary outcome was time to recovery (follow-up, 6 mo); noninferiority analysis; secondary end points included readmission, recurrence or persistence, incidence of complicated disease, and the need for colectomy or percutaneous intervention; no difference was found between the observation group and antibiotic group; no difference in the incidence of complicated diverticulitis ≤6 mo or recurrence ≤6 mo

CPG (2020): selected patients with UD can be treated without antibiotics; nonoperative treatment of diverticulitis may include antibiotics

Complicated Disease

Necessity for surgery: in a study (Garfinkle et al [2016]), ≈50% of patients with CT-confirmed diverticular abscess (DA) were managed with nonoperative intent, of whom 40% of patients visited the emergency room for recurrence, a few developed free perforation, and 10% received elective resection; of the total patients, ≈50% avoided surgery; female sex had a trend toward higher risk for surgery; previous episodes of uncomplicated disease were associated with recurrence; in a population-based study (Aquina et al [2019]) of outcomes following an initial acute DA, ≈33% of the cohort failed initial nonoperative management (NOM), 16% opted for elective colectomy ≤6 mo of discharge, and >50% continued NOM; in the NOM cohort, ≈25% had recurrence, 13% developed complicated recurrence, 8% received nonelective colectomy, and 5% received stoma; diverticulitis-related death rate was 1.9%; elective colectomy had a higher inpatient cost (3-fold), inpatient days (2-fold), and stoma rate (2-fold) compared with NOM

Recurrence: in a study, recurrence after medical management was common (antibiotics alone, 25%; percutaneous drain, 15%); data indicate that recurrence after medical management of abscess is 4- to 5-fold higher; a substantial number of patients with DA will not recur after successful NOM; surgery is effective for persistent symptoms

CPG (2020): after successful NOM of a DA, elective resection should be typically considered

Uncomplicated Disease

After UD: most emergency colectomies are performed after the first episode; the first episode is usually severe compared with subsequent episodes; necessity for emergency surgery for recurrence is low; the risk for emergency stoma formation is 1 in 2000 patient-follow-up years; the 2014 guidelines recommended avoidance of routine elective colectomy after the first episode

DIRECT trial: van de Wall et al (2017) randomized patients with recurrent UD (3 episodes) or persistent symptoms to NOM or surgery; anastomotic leak rate was 15% in the surgery group (SG); gastrointestinal quality of life index (GIQLI) scores were higher in the SG; ≈25% of patients in the NOM group required colectomy later

LASER trial: in a randomized trial, Santos et al (2021) found that patients in the SG had higher GIQLI scores compared with patients in the NOM group; however, patient satisfaction with the assigned treatment was not different between the groups

Recommendation: the decision to recommend elective sigmoid colectomy after recovery from acute UD should be individualized; patient autonomy and quality of life play a major role

Acute Presentations

Laparoscopic lavage (LL): the LADIES trial (Vennix et al [2015]) compared LL with sigmoid resection; the short-term serious event rate was higher in the LL group (2-fold); in the SCANDIV trial (Schultz et al [2015]), the reoperation rate was higher in the LL group (20% vs 6%), with no major difference in QOL

Clinical practice guidelines (2020): LL is not recommended in patients with feculent peritonitis; in patients with purulent peritonitis, colectomy is preferred over LL; LL is associated with higher rates of intervention compared with colectomy

Purulent and feculent peritonitis: Hartmann procedure (HP) is associated with significant morbidity (wound infection, 24%) and mortality (18%); 35% of patients who underwent HP do not undergo reversal; Oberkofler et al (2012) randomized patients with diverticulitis (Hinchey stages III and IV disease) to primary anastomosis with diverting ileostomy (PADI) or HP at the time of anesthesia; the rates of stoma reversal were much higher for PADI (90% vs 57%); the rates of serious complications and the duration of hospital stay were lower for PADI

CPG (2020): following resection, the decision to restore bowel continuity should incorporate patient factors, intraoperative factors, and surgeon preference

Take-home points: decision to proceed with elective surgery following uncomplicated or complicated presentation should be individualized; evidence supports watch and wait approach; LL has been abandoned; DA can be managed nonoperatively, but recurrence is high; PA with or without ileostomy has a role in the management of Hinchey stages III and IV diverticulitis

Readings

Aquina CT, Becerra AZ, Xu Z, et al. Population-based study of outcomes following an initial acute diverticular abscess. Br J Surg. 2019;106(4):467-476. doi:10.1002/bjs.10982; Chabok A, Påhlman L, Hjern F, et al; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99(4):532-539. doi:10.1002/bjs.8688; Daniels L, Ünlü Ç, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52-61. doi:10.1002/bjs.10309; Garfinkle R, Kugler A, Pelsser V, et al. Diverticular abscess managed with long-term definitive nonoperative intent is safe. Dis Colon Rectum. 2016;59(7):648-655. doi:10.1097/DCR.0000000000000624; Gregersen R, Mortensen LQ, Burcharth J, et al. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg. 2016;35:201-208. doi:10.1016/j.ijsu.2016.10.006; Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020;63(6):728-747. doi:10.1097/DCR.0000000000001679; Isacson D, Smedh K, Nikberg M, et al. Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis. Br J Surg. 2019;106(11):1542-1548. doi:10.1002/bjs.11239; Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg. 2012;256(5):819-826; discussion 826-827. doi:10.1097/SLA.0b013e31827324ba; Santos A, Mentula P, Pinta T, et al. Comparing laparoscopic elective sigmoid resection with conservative treatment in improving quality of life of patients with diverticulitis: The Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) randomized clinical trial. JAMA Surg. 2021;156(2):129-136. doi:10.1001/jamasurg.2020.5151; Schultz JK, Yaqub S, Wallon C, et al. Laparoscopic lavage vs primary resection for acute perforated diverticulitis: The SCANDIV randomized clinical trial. JAMA. 2015;314(13):1364-1375. doi:10.1001/jama.2015.12076; Søreide K, Boermeester MA, Humes DJ, et al. Acute colonic diverticulitis: modern understanding of pathomechanisms, risk factors, disease burden and severity. Scand J Gastroenterol. 2016;51(12):1416-1422. doi:10.1080/00365521.2016.1218536; Strate LL, Liu YL, Syngal S, et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907-914. doi:10.1001/jama.300.8.907; van de Wall BJM, Stam MAW, Draaisma WA, et al. Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol. 2017;2(1):13-22. doi:10.1016/S2468-1253(16)30109-1; Vennix S, Musters GD, Mulder IM, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet. 2015;386(10000):1269-1277. doi:10.1016/S0140-6736(15)61168-0.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Bleier is a consultant for Medtronic. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Bleier was recorded at the 2024 Combined Arizona Chapter of the American College of Surgeons Annual Meeting/Phoenix Surgical Symposium, held February 8-10, 2024, in Scottsdale, AZ, and presented by The Phoenix Surgical Society and Banner Health. For more information about upcoming CME activities from this presenter, please visit http://www.phoenixsurgicalsociety.com/conference-information/. Audio Digest thanks Dr. Bleier and the Phoenix Surgical Society and Banner Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

GS710902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.