4. After 50 years of age
Colonic diverticulosis is the most commonly reported
finding reported on colonoscopy usually performed for
colon cancer screening
6. Edward John Hinchey: Father of Modern Age of Acute
Complicated Diverticulitis of the Colon
7. Hinchey Classification*
Modified Hinchey Classification**
*Hinchey, E.J., Schaal, P.G. and Richard, G.K. Treatment of perforated diverticular disease of the colon. Advances in Surgery 12:85-
109, 1978
** Sher ME, Agachan F, Bortul M, et al. Laparoscopic surgery for diverticulitis. Surg Endosc. 1997;11:264–267.
8. Hinchey classification Modified Hinchey classification by Sher et al.
I
Pericolic abscess or
phlegmon
I Pericolic abscess
II
Pelvic,
intraabdominal, or
retroperitoneal
abscess
IIa
Distant abscess
amendable to
percutaneous
drainage
IIb
Complex abscess
associated with
fistula
III
Generalized purulent
peritonitis
III
Generalized purulent
peritonitis
IV
Generalized faecal
peritonitis
IV Faecal peritonitis
10. CRP
A useful biomarker of inflammation
A predictor of the clinical severity
A cut-off value of 170 mg/L significantly discriminated
severe from mild diverticulitis (P < 0.00001).
Kechagias A, Rautio T, Kechagias G, Mäkelä J. The role of C-reactive protein in the prediction of the
clinical severity of acute diverticulitis. Am Surg. 2014;80:391–5
12. Trials
AVOD study - Antibiotika Vid Okomplicerad
Divertikulit
DIVER trial - Hospitalization or Ambulatory
Treatment of Acute Uncomplicated Diverticulitis
LADIES trial - Laparoscopic peritoneal lavage or
resection for purulent peritonitis and Hartmann's
procedure or resection with primary anastomosis for
purulent or faecal peritonitis in perforated
diverticulitis
13. Majority of Acute Diverticulitis ?
Uncomplicated?
Complicated?
Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular
disease. Arch Surg. 2005;140:681–5
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute
diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005;140:576–81
15% present as complications.
14. Generally the first episode is the most severe.
1st Recurrence 13.3% of patients
2nd Recurrence 3.9%.
Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular
disease. Arch Surg. 2005;140:681–5
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute
diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005;140:576–81
15. 80.6% of patients non-operative treatment
Emergency colectomy was performed in 19.4%.
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does
not mandate routine elective colectomy. Arch Surg. 2005;140:576–81
16. Antibiotics are mandatory in the treatment of Acute
Diverticulitis?
17. Newer hypotheses
“Acute Diverticulitis may be an inflammatory
rather than an infectious condition”
Rezapour M, Ali S, Stollman N. Diverticular disease: an update on pathogenesis and management. Gut Liver. 2017
May 12
18. “An observational approach to acute uncomplicated
diverticulitis is not inferior to antibiotic treatment and
does not result in increased complication or recurrence
rates.”
“No differences about the median time to recovery were
found.”
AVOD Trial
Daniels L, et al. Dutch DD(3D) Collaborative Study Group. Randomized clinical trial of observational versus
antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg.
2017;104:52–61
Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst
Rev. 2012;11:CD009092
19. DIVER Trial
Hospitalization or Ambulatory Treatment of Acute
Diverticulitis
Outpatient treatment is safe and effective in selected
patients with uncomplicated acute diverticulitis
23. Recruitment terminated early after interim analysis of
results demonstrated poorer outcomes in the
laparoscopy group: At 30 days, the combined primary
outcome was 39% in the laparoscopic lavage group
compared with 19% in the sigmoid colectomy group
25. ACPGBI Position Statement on Elective Resection
for Diverticulitis
The Association of Coloproctologists of Great Britain
and Ireland clearly reject the need for universal
elective resection
“The decision regarding whether to offer resection
should be made on an individual basis and the surgeon
should involve the radiologists and pathologists in this
decision, in addition to the patients themselves...”
27. Dietary Fibres
European guidelines support the use of a high-
fibre diet for the prevention of acute diverticulitis
Sánchez-Velázquez P, Grande L, Pera M. Outpatient treatment of uncomplicated diverticulitis: a systematic review. Eur
J Gastroenterol Hepatol. 2016;28:622–7
Kruis W, Germer CT, Leifeld L German Society for Gastroenterology, Digestive and Metabolic Diseases and The
German Society for General and Visceral Surgery. Diverticular disease: guidelines of the German society for
gastroenterology, digestive and metabolic diseases and the German society for general and visceral surgery. Digestion.
2014;90:190–207
Pietrzak A, Bartnik W, Szczepkowski M, Krokowicz P, Dziki A, Reguła J, Wallner G. Polish interdisciplinary consensus
on diagnostics and treatment of colonic diverticulosis. Pol Przegl Chir. 2015;87:203–20
Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi
G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and
diverticular disease. United European Gastroenterol J. 2014;2:413–42
28. Rifaximin
Rifaximin may reduce the risk of
occurrence when associated with fibre intake
recurrence of diverticulitis
29. Mesalazine
No clear evidence that mesalazine reduces episodes
Most European guidelines do not recommend
Diverticulum: outpocket of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall
Diverticulosis: asymptomatic presence of diverticula
Diverticular Disease: Symptomatic diverticula
Diverticulitis:
Diverticular disease most common gastrointestinal disorders
Some lifestyle factors such as smoking, physical activity, dietary habits and especially fibre consumption have been associated to the development of diverticulitis
Hinchey Classification is used to describe perforations of the colon due to diverticulitis.
ACPGBI states CT or ultrasound should be undertaken during the acute presentation of diverticulitis. This helps to confirm the diagnosis, guide management of the acute attack and occasionally will demonstrate other pathologies. Investigation of the colonic lumen by endoscopic means or barium enema after the acute attack is mandatory
multicentre study evaluating the accuracy of US compared with CT in unselected patients referred for acute abdominal pain to the emergency department, showed that CT have higher sensitivity compared to US in detecting AD (81 vs 61%; p=0.048) - van Randen A, et al, OPTIMA Study Group. A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol. 2011;21:1535–45
A CRP cutoff value of 170 mg/L significantly discriminated severe from mild diverticulitis (87.5 % sensitivity, 91.1 % specificity, area under the curve 0.942, P < 0.00001. Those with higher CRP values have a greater probability of undergoing surgery or radiological drainage
15% presenting complications as abscesses, fistulas, obstructions and perforations
In this cohort, non-operative treatment was used in 80.6% of patients, whereas emergency colectomy was performed in 19.4%
Recent strong data showed that antibiotics can be used selectively, rather than routinely, in uncomplicated AD
The most recent multicentric RCT, study compared with antibiotic treatment for a first episode of CT-proven uncomplicated Acute diverticulitis, no differences about the median time to recovery were found: 14 days for the observational and 12 days for the antibiotic treatment
Cochrane review evaluating the antibiotic use in uncomplicated AD, found no significant difference between antibiotics compared with no antibiotics in the treatment of uncomplicated diverticulitis
Diver Randomized Trial Compared Two Treatment Strategies for Acute Diverticulitis; Hospitalization or Ambulatory Antibiotic Treatment
Result: Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis
Recent systemic review also observed that The outpatient (Ambulatory) treatment of uncomplicated Acute Diverticulitis is safe, effective and economically efficient.
This LADIES Multicentre RCT Trial is Dutch study investigating the acute surgical management of diverticulitis.
The objective of this LADIES trial is to determine whether LaparOscopic LAvage and drainage is a safe and effective treatment for patients with purulent peritonitis (LOLA-arm) and to determine the optimal resectional strategy in patients with a purulent or faecal peritonitis (DIVA-arm: perforated DIVerticulitis: sigmoidresection with or without Anastomosis).
For LOLA The primary outcome was a composite endpoint of major morbidity and mortality within 12 months.
Recruitment terminated early for LOLA after interim analysis of results demonstrated poorer outcomes in the laparoscopy group: At 30 days, the combined primary outcome was 39% in the laparoscopic lavage group compared with 19% in the sigmoid colectomy group.
Surgical re-interventions accounted for most of these adverse events.
Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis.
Laparoscopic lavage does not reduce serious complication rates and has poorer secondary outcomes
Rifaximin is a poorly absorbable oral antibiotic
Danish, Polish and Italian studies concur that cyclic rifaximin plus fibre supplementation should be used for SUDD patients for symptom relief.
5-aminosalicylic acid (mesalazine) is an anti-inflammatory drug
available data do not allow conclusions to be made. Italian guidelines do not support because of insufficient evidence
This topic remains dynamic
Symptomatic diverticular disease is becoming increasingly prevalent and this challenges clinicians to consistently provide the highest level of care
An individualised approach to each patient depending on the specifics of presentation is required.