Controversies in the Diagnosis and Management of Diverticulitis Coli

Abstract

Background

: Diverticulitis is a common disease, especially in the developed world. The treatment has evolved substantially as our understanding of the pathophysiologic process has improved, and the tools available for diagnosis and treatment have advanced.

Methods

: Review and synthesis of the pertinent international literature.

Results

: A number of controversies exist with regard to therapy for diverticulitis. Recent evidence has highlighted the indications for elective surgical intervention, and stressed that the major indication is relief of symptoms, not reduction in morbidity. Laparoscopic surgery, in trained hands, is as effective and safe as open surgery. For surgical therapy of Hinchey Grade III and IV diverticulitis, primary resection and anastomosis may be safer for most patient populations, with lower morbidity, than resection with end-sigmoid colostomy and a Hartmann pouch. Laparoscopic lavage may be useful for temporizing selected patients; however, more work is needed to define more precisely the patient groups in which this approach is appropriate. Finally, short courses of antibiotics and oral antibiotic therapy are effective for appropriate patients with uncomplicated diverticulitis.

Conclusions

: Medical and surgical therapy of diverticulitis both offer several options that must be tailored to the circumstances of the individual patient.

Diverticulitis coli is a common disease, affecting many patients, with major implications for physicians treating surgical infections. The treatment of diverticulitis is evolving as our understanding improves of the associated inflammatory process.

Diverticulitis was first described by Maximillian Stoll in 1787 in de Rationis Medendi. In 1904, Beer described 18 cases of inflammatory disease of the small bowel, and in 1907, William Mayo reported surgical treatment of diverticulitis with a colostomy. A quotation from the collected papers by the staff of St. Mary's Hospital in Rochester, MN, at about the same time notes: “Surgeons have at times explored the abdomen, and finding what seemed to be an unresectable carcinoma of the sigmoid, have sewn up, expecting a progressive downhill course. To their surprise, a marked improvement has followed … .” Treatment of diverticulitis has evolved substantially over the last 30 years, with the modern era of surgical therapy ushered in with the description by Krukowski and Matheson in 1980 of two-stage therapy for perforated diverticulitis [1].

In the U.S., diverticulitis is increasing in incidence, particularly in younger patient populations. Hospital admissions and elective surgery for this disorder in young adults (18–44 years of age) have nearly doubled over the last decade [2]. Therapy for diverticulitis is evolving, with increasing use of resection and primary anastomosis for most cases, excluding those with severe peritonitis (Fig. 1). Diverticulitis is currently staged and treatment options determined using patient criteria aided by the Hinchey classification (Table 1) [3], with most patients having Hinchey Class III or IV diverticulitis requiring urgent surgery.

FIG. 1.

Current guidelines for treatment of diverticulitis. Dz = disease; PA = primary anastomosis; HP = Hartmann procedure.

Table 1.

Hinchey Classification of Diverticulitis

Grade	Definition
I	Diverticulitis with confined paracolic abscess or phlegmon
II	Distant abscesses (pelvic, retroperitoneal)
III	Generalized purulent peritonitis
IV	Generalized fecal peritonitis

A number of current controversies will be addressed in this review. These include the indications for elective surgery, decision-making regarding the type of surgery, and antibiotic therapy.

Indications for Elective Surgery

Recurrent Diverticulitis

A common rationale for elective colon resection for diverticulitis is the prevention of complications associated with recurrent disease (Table 2). This approach is driven by observations reported in 1969 by Parks [4]. In this report of 521 patients with diverticulitis, 25% were admitted with a second episode, and 6% were admitted with three or more episodes. Parks reported that the mortality rate nearly doubled with subsequent episodes necessitating admission (4.7% for the first episode, 8% for further episodes). However, numerous advances in diagnostic techniques, medical therapy, and surgical approaches have changed the outcomes of this disease substantially for the better. Whereas recurrence rates of diverticulitis in modern reports are similar to those reported by Parks (9.4%–51%), the need for operative intervention (as a marker of severity of disease) has been uncommon (1%–28%). Additionally, in these large series, the attributable mortality rate has ranged from 0–3.5%, with the risk of emergency surgery estimated at 1/2,000 patient years [5 –8]. For these reasons, surgery in recurrent diverticulitis should be performed for relief of symptoms, not for prevention of complications.

Table 2.

Complications of Recurrent Diverticulitis in the Last Decade

Series	No. of patients	Mean years of follow-up	Percent recurrence/operative intervention
Moreno and Wille-Jørgensen (2007) [5]	455	6.5	51/8
Chautems et al. (2002) [6]	118	9.5	29/28
Broderick-Villa et al. (2005) [7]	3,165	8.9	9.4/1
Anaya and Flum (2005) [8]	25,058	NA	23/4.2

NA = not available.

Laparoscopic surgery

The first use of laparoscopy to diagnose diverticulitis was described by Jalůvka in 1977 in the context of gynecologic disorders [9]. Over the last 20 years, laparoscopy has been used increasingly for treatment of diverticulitis. More than 400 descriptions exist in the literature on laparoscopy use for diagnosis or treatment of diverticulitis. Recent large series report excellent outcomes using laparoscopic techniques for colon resection [10,11]. Laparoscopic treatment of acute or recurrent diverticulitis by experienced surgeons appears to be appropriate.

Surgical Options

Primary Resection and Anastomosis vs. Sigmoid Colectomy, End-Colostomy, and Hartmann Pouch

For the last 30 years, the standard therapy for Hinchey Grade III or IV diverticulitis has been sigmoid colectomy, end-colostomy, and creation of a Hartmann pouch (HP). However, the HP is associated with substantial risk, including a high reported mortality rate (10–28%), a high risk of postoperative surgical site infection (20%), a risk of fistula formation (7–16%), and cardiovascular complications (25%). Additionally, many people (30–75%) do not undergo reversal, elective or not [12 –14]. Whereas much of this morbidity is likely related to selection bias (more seriously ill patients are more likely to undergo HP), there is likely more morbidity associated with two major operations than with one only (e.g., primary resection and anastomosis [PRA]).

A number of studies have evaluated outcomes in patients with acute complicated diverticulitis treated with either HP or PRA. All extant studies suffer from the retrospective nature of the evaluation; no randomized, controlled trials exist on this topic. One large analysis compared the outcomes of patients undergoing HP reversal vs. PRA at two large colorectal surgery referral centers over a period of 22 years (15). The authors examined data from patients undergoing both elective and emergency procedures and evaluated them for outcomes including death, reoperation rate, and surgical complications. In this series of 731 patients undergoing PRA and 121 patients receiving HP reversal, the authors noted that the latter had a higher incidence of medical co-morbidities, whereas PRA patients carried a higher Hinchey grade and were more likely to undergo emergency surgery. Multivariable analysis demonstrated a higher risk of adverse events in patients undergoing HP reversal (odds ratio [OR] 2.1; 95% confidence interval [CI] 1.3–3.3; p = 0.002).

Constanitinides et al. reported the results from 936 adult patients in their meta-analysis of 15 non-randomized studies evaluating HP reversal vs. PRA in non-elective surgery for diverticulitis [14]. The authors found a significant difference in favor of PRA for mortality rate (OR 0.43; 95% CI 0.21–0.85), a non-significant difference for surgical complications (O.R. 0.51, C.I. 0.2–1.36), and no difference in medical complications (OR 1.16; 95% CI 0.26–5.23) between the groups.

The current literature fails to demonstrate a strong benefit of one procedure over the other for surgical treatment of complicated diverticulitis. In the absence of randomized trials to guide therapy, the choice of which procedure to perform will continue to rest with the individual surgeon. Most patients obviously would prefer one rather than two major operations. For patients who are reasonably healthy, it seems appropriate to perform a PRA. However, it is the practice of this author to favor HP for sicker or immunosuppressed patients, or those with more severe peritoneal soilage.

Laparoscopic lavage

A number of investigators have reported their experience with laparoscopic lavage for the treatment of acute perforated diverticulitis with generalized peritoneal soilage. The concept is that the process that leads to progressive systemic illness is not the colonic inflammation, but the peritonitis. If it is possible to reduce this soilage, it therefore may be possible to avoid major surgery (or to delay surgery until patient factors are more favorable). The approach to this therapy is described by Franklin et al. [16]. Patients with Hinchey Grade III or IV disease receive early antibiotics (in the emergency department if possible), followed by laparoscopy in the operating room. During laparoscopy, purulent fluid is aspirated, and the abdomen is irrigated copiously. Drains are placed around the inflamed colon, and any obvious perforations are closed with a suture or omental patch.

Eight studies using this technique were reviewed recently (there are no randomized trials) [17]. There were 213 patients with a mean age of 59 years. Most were in Hinchey Grade III (n = 162), with 43 patients being Grade II and eight patients Grade IV. The combined mortality rate was 1.4%, with an open-surgery conversion rate of 3%. There was a reported complication rate of 10%, with 38% of patients undergoing elective colon resection afterward (range 0–100%)!

This technique presents a possible alternative to diving into an inflammatory mass with peritonitis, and may allow delay of surgery until a more favorable operative field is obtainable, making the procedure easier for both the patient and the surgeon. Further studies are necessary to determine appropriate patient selection and management.

Antibiotic Therapy

In the treatment of diverticulitis, as in much of medicine, there continues to be a paucity of randomized, appropriately controlled trials to guide the clinician when selecting therapy. This is likewise true when it comes to use of one of the mainstays of therapy, antibiotics. In 2009 a review of antibiotics for diverticulitis, Byrnes and Mazuski wrote (18): “Careful clinical studies are needed … . Until such studies are conducted, we are forced to rely on tradition, in vitro analyses, pharmacokinetic profiling, and indirect evidence … to determine appropriate therapy … .” Said indirect evidence comes from the literature on antibiotic therapy of secondary peritonitis [19].

Oral vs. intravenous antibiotics for uncomplicated diverticulitis

One issue is whether oral antibiotics are effective in the treatment of diverticulitis. This has been studied in a variety of settings. In a recent randomized trial performed over 18 months in Ireland [20], Ridgway et al. treated 80 patients with left iliac fossa pain and tenderness using either intravenous (IV) or oral ciprofloxacin plus metronidazole. Endpoints included the erythrocyte sedimentation rate, white blood cell count, and quantified abdominal tenderness. The demographics were similar in the two groups. Hospital length of stay (5.5 vs. 6.0 days) and readmissions (one in each group) were similar, as were the mean time to resolution of pain (6.5 days) and normalization of inflammatory markers. This study highlights the effectiveness of oral antibiotic therapy for uncomplicated diverticulitis.

In another study of oral antibiotics in computed tomography (CT)-proved diverticulitis [21], Alonso et al. studied two preparations (ciprofloxacin plus metronidazole or amoxicillin/clavulanic acid) given for seven days to patients who did not meet the criteria for admission. Of the nearly 100 patients studied, 70 met the criteria for outpatient therapy and were treated with oral antibiotics. Two patients failed oral therapy and required admission. The authors conclude that outpatient therapy of uncomplicated diverticulitis with oral antibiotics is safe.

Duration of therapy

Another frequent question is the necessary duration of therapy for diverticulitis. Inadequate treatment can be expensive in terms of recurrent symptoms and promotion of resistance, whereas prolonged courses of antibiotics are associated with Clostridium difficile colitis, higher drug cost, and prolonged hospitalization. The appropriate duration of IV antibiotic therapy in patients with Hinchey Grade I/II disease has been studied recently by Shug-Pass et al. [22] at 11 hospitals in Germany, where patients were treated with ertapenem for their acute diverticulitis. If, on day four of therapy, patients were free of pain and other symptoms, they were randomized to have antibiotics discontinued or continue through a seven-day course. Of the 123 patients enrolled, six had persistent symptoms at day four but were not randomized. Eleven other patients were excluded because of surgery or patient request or for other reasons. There were no differences between the four- and seven-day treatment groups with respect to the one-month success rate (94% vs. 96%), one-year recurrence rate (7.5% vs. 10.4%), or the need for elective colon resection (37% vs. 43%). The authors conclude that short courses of IV antibiotic therapy are safe and are as effective as longer courses.

Conclusions

Treatment of diverticulitis has developed substantially over the last decade. Laparoscopic surgery, in trained hands, is as effective and safe as open surgery. For surgical therapy of Hinchey Grade III and IV disease, primary resection and anastomosis may be safer for most patient populations, with lower morbidity, than HP. Laparoscopic lavage may be useful for temporizing selected patients with diverticulitis; however, more work is needed to define further the patient groups in which this approach is appropriate. Finally, in appropriate patients with uncomplicated diverticulitis, short courses of antibiotics and oral therapy are effective.

Footnotes

Author Disclosure Statement

The author has no financial conflicts in relation to this article.

References

Krukowski

, Matheson

. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: A review. Br J Surg, 1984; 71:921–927.

Etzioni

, Mack

, Beart

Jr , Kaiser

. Diverticulitis in the United States: 1998–2005: Changing patterns of disease and treatment. Ann Surg, 2009; 249:210–217.

Hinchey

, Schaal

, Richards

. Treatment of perforated diverticular disease of the colon. Adv Surg, 1978; 12:85–109.

Parks

. Natural history of diverticular disease of the colon: A review of 521 cases. Br Med J, 1969; 4:639–642.

Moreno

, Wille-Jørgensen

. Long-term outcome in 445 patients after diagnosis of diverticular disease. Colorectal Dis, 2007; 9:464–468.

Chautems

, Ambrosetti

, Ludwig

et al. Long-term follow-up after first acute episode of sigmoid diverticulitis: Is surgery mandatory? A prospective study of 118 patients. Dis Colon Rectum, 2002; 45:962–966.

Broderick-Villa

, Burchette

, Collins

et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg, 2005; 140:576–581.

Anaya

, Flum

. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg, 2005; 140:681–685.

Jalůvka

. [Exploratory laparotomies in geriatric-gynaecological patients] (Ger)(author's transl) Geburtshilfe Frauenheilkd, 1977; 37:317–321.

10.

Hassan

, Cima

, Larson

et al. The impact of uncomplicated and complicated diverticulitis on laparoscopic surgery conversion rates and patient outcomes. Surg Endosc, 2007; 21:1690–1694.

11.

Rotholtz

, Montero

, Laporte

et al. Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy. World J Surg, 2009; 33:2444–2447.

12.

Salem

, Flum

. Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum, 2004; 47:1953–1964.

13.

Abbas

. Resection and primary anastomosis in acute complicated diverticulitis: A systematic review of the literature. Int J Colorectal Dis, 2007; 22:351–357.

14.

Constantinides

, Tekkis

, Athanasiou

et al. Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: A systematic review. Dis Colon Rectum, 2006; 49:966–981.

15.

Aydin

, Remzi

, Tekkis

, Fazio

. Hartmann's reversal is associated with high postoperative adverse events. Dis Colon Rectum, 2005; 48:2117–2126.

16.

Franklin

Jr , Portillo

, Treviño

et al. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg, 2008; 32:1507–1511.

17.

Alamili

, Gögenur

, Rosenberg

. Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum, 2009; 52:1345–1349.

18.

Byrnes

, Mazuski

. Antimicrobial therapy for acute colonic diverticulitis. Surg Infect, 2009; 10:143–154.

19.

Solomkin

, Mazusici

, Bradley

et al. Diagnosis and management of complicated intra-abdominal infection in adults and children. Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect, 2010; 11:79–109.

20.

Ridgway

, Latif

, Shabbir

et al. Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis, 2009; 11:941–946.

21.

Alonso

, Pera

, Parés

et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis, 2009Nov 10 [Epub ahead of print]

22.

Schug-Pass

, Geers

, Hügel

et al. Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis, 2010; 25:751–759.