Management of diverticulitis in younger patients

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Timing of laparoscopic elective surgery for acute left colonic diverticulitis. Retrospective analysis of 332 patients

PURPOSE

The optimal time to perform elective surgery remains to be determined. We analyzed the impact of time interval to surgery on short-terme outcome parameters in patients undergoing elective laparoscopic left colonic resection for diverticulitis.

MATERIALS AND METHODS

Retrospective analysis of two series of case-matched patients according to the timing of operation after the last episode of diverticulitis: group A (within 90 days) and group B (beyond 90 days).

RESULTS

332 patients had left colonic resection for diverticulitis. 117 patients were included in group A vs 114 patients in group B. Overall abdominal morbidity in Group A was 21% vs 5% in group B (p = 0.02). Mean hospital stay was 7.7 days in group A vs 5 days in group B (p = 0.08). Residual inflammation was significantly increased in group A (31%) as compared to group B (11%) (p = 0.01).

CONCLUSIONS

Laparoscopic left colonic resection for acute diverticulitis is best performed beyond the third month after the last acute episode.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

[Treatment of the acute diverticulitis: A systematic review]

Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Colonic diverticulitis with comorbid diseases may require elective colectomy

AIM: To investigate the comorbid disease could be the predictors for the elective colectomy in colonic diverticulitis.

METHODS: A retrospective chart review of 246 patients with colonic diverticulitis admitted between 2000 and 2008 was conducted, and 19 patients received emergent operation were identified and analyzed. Data were collected with regard to age, sex, albumin level on admission, left or right inflammation site, the history of recurrent diverticulitis, preoperative comorbidity, smoking habits, medication, treatment policy, morbidity, and mortality. Preoperative comorbid diseases included cardiovascular disease, diabetes, pulmonary disease, peptic ulcer disease, gouty arthritis, and uremia. Medications in use included non-steroidal anti-inflammatory drugs, acetylsalicylic acid (Aspirin), and corticosteroids. Univariate and multivariate logistic regression analyses were performed to identify the relevant risk factors correlating to colectomy.

RESULTS: The mean age of the 246 patients was 69.5 years (range, 24-94 years). Most diverticulitis could be managed with conservative treatment (n = 227, 92.3%), and urgent colectomy was performed in 19 patients (7.7%). There were three deaths in the surgical group and four deaths in the nonsurgical group. The overall mortality rate in the study was 1.7% among patients with conservative treatment and 15.7% among patients undergoing urgent colectomy. Multiple logistic regression analysis indicated that comorbidities were risk factors for urgent colectomy for diverticulitis.

CONCLUSION: To avoid high mortality and morbidity related to urgent colectomy, we suggest that patients with colonic diverticulitis and comorbid diseases may require elective colectomy.

Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis

BACKGROUND

The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed.

METHODS

A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities.

RESULTS

The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy.

CONCLUSION

Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.

Routine screening for colon cancer after conservative treatment of diverticulitis

BACKGROUND AND AIMS

It is generally advised to perform colonoscopy after conservatively treated diverticulitis because colon cancer may present itself with similar symptoms, laboratory and radiological results. With this study we investigated in what percentage of patients a malignancy was found by performing routine colonoscopy or radiologic imaging after a conservatively treated episode of diverticulitis, and whether this follow-up programme could be reserved for a selected group of patients.

METHODS

In our hospital, routine colonoscopy or, as a second choice, radiologic imaging has been standard practice over the last decade. We collected all colonoscopy and radiologic imaging results that were conducted of all 516 patients who were diagnosed with diverticulitis in this period.

RESULTS

Of those 516 patients, 378 had undergone colonoscopy, 45 radiologic imaging and 93 did not undergo any additional investigation. Eight cases of malignant neoplasia were found in those patients (2.1%), and an additional number of 40 adenomatous polyps (9.5%). Six out of 8 patients with colon cancer reported rectal blood loss, significant weight loss or persisting abdominal pain after being treated for diverticulitis.

CONCLUSIONS

In patients who were conservatively treated with routine colonoscopy or radiologic imaging for apparent diverticulitis, a malignant tumour was found in the colon in 2.1% of them. If only performed in patients reporting alarm symptoms, a case of colon cancer would be missed in only 0.5% of patients conservatively treated for diverticulitis. Therefore, screening for colon cancer after conservative treatment of diverticulitis is only indicated in symptomatic patients.

Sigmoid diverticulitis in 2011: many questions; few answers

AIM

Patients were studied after a first episode of acute left-colonic diverticulitis for the initial and later evolution of the disease with the aim of defining evidence-based indications for elective surgery.

METHOD

Relevant data from prospective studies were retrieved from a MEDLINE search of English language articles.

RESULTS

Young male patients (≤ 50 years of age) had a higher risk of CT-graded severe diverticulitis. After medical treatment of the first episode, the incidence of complications was highest for young patients with CT-graded severe diverticulitis and lowest for older patients with CT-graded moderate diverticulitis. Recurrence in the form of diffuse peritonitis was rare. CT grading of initial diverticulitis seemed to be a predictor of recurrence, whereas the role of age was less clear. A family history of diverticulitis might be predictive of recurrence.

CONCLUSION

CT grading of acute diverticulitis helps to predict poor outcome after medical treatment of a first episode. Elective surgical resection should be proposed to patients with residual symptoms who do not respond to conservative treatment. Additional research is needed to clarify the role of a genetic predisposition in the development of diverticulitis in young adults.

Value of CT for acute left-colonic diverticulitis: the surgeon's view

AIM

To determine the immediate and later role(s) of initial CT in patients presenting with their first episode of acute left-colonic diverticulitis.

METHODS

Prospective inclusion of 542 patients hospitalized in the University Hospital of Geneva between 1986 and 1997. 465 (86%) patients had a CT. CT grading of diverticulitis was divided between moderate diverticulitis (no sign of colonic perforation) and severe diverticulitis (signs of colonic perforation).

RESULTS

During the index hospitalization, surgical treatment of the first episode of acute diverticulitis was needed in 26% of patients with CT-severe diverticulitis compared to 4% for patients with CT-moderate diverticulitis. At 5 years of follow-up after medical treatment of the first episode, incidence of remote complications was the highest (49%) for patients with CT-severe diverticulitis and the lowest (22%) for patients with CT-moderate diverticulitis. Finally, we found that the location of the diseased segment, which is important to guide the type of resection in case of elective surgery, varies in 35% of patients who had 2 episodes of acute diverticulitis.

CONCLUSION

CT is the indispensable tool both to confirm the suspected diagnosis of acute diverticulitis and to appreciate the risk of surgical treatment during the initial acute episode. Moreover, CT grading of diverticulitis is a statistically significant prognostic parameter of the chance of secondary complicated outcome after a first acute diverticulitis episode successfully treated medically. Finally, CT gives the exact location of diverticulitis. In case of elective surgery this colonic segment should be removed.

[Perforation risk and patient age. Risk analysis in acute sigmoid diverticulitis]

INTRODUCTION

It is often postulated that younger patients with acute sigmoid diverticulitis (SD) have an increased risk of perforation which constitutes an indication for early surgery. The aim of this study was to correlate the severity of sigmoid diverticulitis with patient age in order to check the surgical indication in younger patients.

PATIENTS AND METHODS

Patients with acute SD from January 1998 to June 2009 were included. Two age groups were distinguished: group I (GI) ≤40 years in age and group II (GII) >40 years. The perforation risk associated with first episode SD was determined by multivariate analysis. SD was classified according to Hansen and Stock (H/S).

RESULTS

In the total cohort of 959 patients, including 86 in GI (8.9%) and 873 in GII (91.1%) 468 had a first episode, with 64 in GI (13.7%) and 404 in GII (86.3%). The proportion of first episodes was 74.4% in GI and 46.3% in GII (p<0.001). The perforation risk did not differ (H/S IIb: 29.7% in GI vs. 29.2% in GII, p=0.938; H/S IIc: 25% in GI vs. 25% in GII, p=1). Treatment regimes were (GI vs. GII) emergency operations 25% vs. 25% (p=1), elective operations 17.2% vs. 10% (p=0.096) and conservative treatment 57.8% vs. 64.9% (p=0.276).

CONCLUSION

First episodes of SD were more frequent in younger patients (≤40) and did not involve a higher risk of perforation. The indication for treatment of acute SD should not be based on age but on the severity of inflammation and the individual situation of patients.

Sigmoid diverticulitis in young patients--a more aggressive disease than in older patients?

INTRODUCTION

There is controversy over whether sigmoid diverticulitis (SD) is more aggressive with a higher risk of perforation in younger than in older patients. The aim of this study was to assess the clinical presentation and outcome of patients ≤40 and >40 years old with acute diverticulitis.

PATIENTS AND METHODS

Consecutive admissions of all patients with acute SD were prospectively recruited from January 1998 to June 2010.

RESULTS

A total of 1,019 patients were included: 513 (69 ≤40 years and 444 >40 years) presented with their first episode, while 506 (20 ≤40 years, 486 >40 years) had a prior history of SD. The percentage of patients with severe SD did not differ between the two age groups either for the first (covered perforation, 30.4% vs. 29.5%, p = 0.875; free perforation, 26.1% vs. 23.9%, p = 0.69) or for the recurrent episode (covered perforation, 15% vs. 8.2%, p = 0.287; free perforation, 5% vs. 4.1%, p = 0.846). Furthermore, the rate of emergency surgery did not differ between both age groups either for the first (26.1% vs. 23.9%, p = 0.690) or the recurrent episode (5% vs. 4.1%, p = 0.846). No differences in the rate of Hartmann's procedure (52.6% vs. 68.3%, p = 0.180) and failure of conservative treatment (3.4% vs. 4.9%, p = 0.607) were observed between younger and older patients.

CONCLUSION

Acute SD in younger patients is not more aggressive and has no higher risk of perforation or need for emergency surgery compared to older patients.

Acute diverticulitis in younger patients: Any rationale for a different approach?

AIM: To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently.

METHODS: This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B > 50 years (n = 126). Mean patient follow-up was 15 mo.

RESULTS: The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence.

CONCLUSION: Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.

Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy

BACKGROUND

This study was designed to asses the predictive factors of postoperative complications in patients who underwent a laparoscopic elective approach for recurrent diverticulitis and to determine the relationship between the number of acute episodes and surgical morbidity.

METHODS

A retrospective analysis was performed on patients with colonic diverticular disease treated by an elective laparoscopic approach between July 2000 and November 2007. The variables studied were age, sex, BMI, ASA, number of previous acute episodes, local severity, abdominal surgery history, comorbidity, and laparoscopic training of the surgeon. Logistic regression analysis was used to establish significant results.

RESULTS

A total of 137 patients were analyzed; 87 (63.5%) were men with a mean age of 56.7 (range, 27-89) years. Intraoperative and postoperative complications occurred in 2.9% (n = 4) and 12.4% (n = 17) of the patients respectively. Conversion rate was 9.4% (n = 13). Local severity (odds ratio (OR), 16.34; 95% confidence interval (CI), 4.1-64.5, p = 0.00007), history of abdominal surgery (OR, 3.02; 95% CI, 0.8-11.5; p = 0.02), and the training of the operating surgeon (OR, 4.8; 95% CI, 1.02-22.7; p = 0.001) were significant risk factors related to surgery conversion. A history of three or more acute episodes was significantly associated with a high severity of local process and was a risk factor related to conversion (OR, 2.6; 95% CI, 0.5-12.3; p = 0.22). The severity of the local process seems to be a risk factor for perioperative complications. A significant association (chi2, 4.45; p = 0.03) between conversion and postoperative complications also was observed (OR: 3.79, 95% CI, 1.02-14.07; p = 0.04).

CONCLUSIONS

A history of three or more acute episodes of diverticulitis with conservative treatment is associated with a high severity of the local process during laparoscopic sigmoidectomy and increases the rate of conversion and perioperative complications.

Management of right-sided diverticulitis: A retrospective review from a hospital in Japan

PURPOSE

Right-sided diverticulitis is a rare clinical entity in Western countries; however, in some Asian countries diverticulitis affects the right side of the colon more often than the left side. This study aims to establish some guidelines for patients with right-sided diverticulitis because at present, there are only guidelines for those with acute left-sided diverticulitis.

METHODS

A review was conducted of the medical records of patients with acute right-sided diverticulitis admitted to Okinawa Prefectural Chubu Hospital, a teaching hospital in Japan, between 1994 and 2005.

RESULTS

Right-sided diverticulitis was identified in 110 patients. The mean age of these patients was significantly lower than that of those with left-sided diverticulitis (43.4 +/- 14.8 years vs 54.8 +/- 17.4 years, respectively). Emergency laparotomy was performed for suspected acute appendicitis in 10 patients. Initial conservative therapy did not fail in any of the remaining 100 patients, although 5 underwent subsequent elective surgery, and 8 (8.4%) of the remaining 95 suffered recurrent right-sided diverticulitis, which was treated successfully with conservative therapy.

CONCLUSION

Patients with acute right-sided diverticulitis seldom require emergency surgery unless acute appendicitis is misdiagnosed preoperatively. Most cases of uncomplicated right-sided diverticulitis, even if it is recurrent, can be treated conservatively.

Presentation and treatment outcome of diverticulitis in younger adults: a different disease than in older patients?

PURPOSE

The severity and most appropriate treatment of diverticulitis in young patients are still controversial. The aim of this study is to compare young patients (<or=50 years) with older patients (>50 years) regarding clinical and radiologic parameters of acute left colonic diverticulitis and to determine whether differences exist in presentation and treatment.

METHODS

We reviewed medical records of 271 consecutive patients with left colonic acute diverticulitis admitted to our institution from 2001 through 2004: 71 patients were aged 50 years or younger and 200 patients were older than 50. Clinical and radiologic parameters were analyzed. Conservative treatment was standardized, and included antibiotic therapy and bowel rest. Criteria for emergency surgical treatment were diffuse peritonitis, pneumoperitoneum, and septic shock.

RESULTS

Conservative treatment alone was successful in 64 patients (90.1%) in the younger group and in 152 patients (76%) in the older group (P = .017). The percentage of patients requiring surgery at admission or during the hospital stay was significantly lower in younger than in older patients (5.6% vs 20.5%, P = .007), and the percentage of patients requiring emergency end colostomy was higher (although not significantly) in the older group (1.4% vs 9.0%, P = .059). No differences in rate of successful conservative treatment were observed between patients with a first episode and those with recurrence in either age group (P = .941 in the younger group; P = .227 in the older group).

CONCLUSION

Young age is not a predictive factor of poor outcome in the management of first or recurrent episodes of acute diverticulitis. Patients older than 50 years more frequently need emergency surgical treatment.

Current indications and role of surgery in the management of sigmoid diverticulitis

Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.

The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature

Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age <or= 50 years). Much of the older literature suggests that young patients experience a more virulent course with diverticulitis. Previous studies have shown misclassification and selection bias. As a result leading to a bias for more severe cases to be recognized mild cases may not be included. Young patients appear more likely to undergo operations to resolve an uncertain diagnosis. Recent studies have raised doubts about a virulent course with diverticulitis suggesting that recurrence may be associated with disease severity on CT scan, and supporting a conservative approach to diverticular disease. The diagnosis of diverticulitis is often delayed in younger patients because it is not considered, resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated. There is a lack of evidence to support the hypothesis that elective surgery should follow a single attack of diverticulitis. Any increased risk appears be a chronologic rather than pathologic phenomenon. Most patients will not have further episodes of diverticulitis.

Clinical outcomes of complicated diverticulitis managed nonoperatively

BACKGROUND

Surgical resection is typically recommended for patients with computed tomography (CT)-confirmed complicated diverticulitis. This study was designed to assess outcomes of patients with complicated diverticulitis managed nonoperatively.

METHODS

A retrospective study covering 14 years evaluated patients with complicated diverticulitis diagnosed by CT scan. Patient outcomes, including recurrence and need for operations, were reviewed.

RESULTS

Of 256 patients identified, 99 were managed nonoperatively. Forty-six of the 99 patients had a recurrent episode of diverticulitis. Of these 46 patients, 20 underwent a sigmoid colon resection, with only 1 patient requiring a colostomy for obstruction. None of these recurrences resulted in the need for emergency resection.

CONCLUSIONS

Surgical treatment should play an important role in the management of patients with complicated diverticulitis because of the high risk of recurrence. However, nonoperative management may be appropriate in a select population if age or medical comorbidities preclude a safe operation since the need for emergency operation is unlikely.

Outcome of younger patients with acute diverticulitis

BACKGROUND

There is controversy over whether patients presenting with a primary attack of acute diverticulitis at a younger age are more prone to complications and recurrence than older patients.

METHODS

A review, including postal questionnaires, was undertaken of 234 patients who had a primary episode of acute diverticulitis. The diagnosis was confirmed by computed tomography (CT) and/or pathology report. The mean length of follow-up was 30 (range 16-45) months.

RESULTS

In 58 patients aged 50 years or less no differences in fever or white blood cell count were found in comparison with findings in 176 patients aged above 50 years. The rate of severe diverticulitis observed with CT was lower in the younger patients (2 versus 11.9 per cent; P = 0.025). Surgical management during the first admission was undertaken less commonly in younger patients (2 versus 6.8 per cent; P = 0.271). Rates of subsequent events (recurrent diverticulitis and/or further surgery) during follow-up were higher in younger patients (25 versus 19.5 per cent), but this was not significant (P = 0.423). A type II error cannot be excluded.

CONCLUSION

First episodes of acute diverticulitis were not more aggressive in patients aged 50 years or less. Recurrence rates were slightly higher than in older patients.

Review article: Management of diverticulitis

BACKGROUND AND AIM

The incidence and therefore complications of (sigmoid) diverticular disease are increasing.

METHODS

Review of current literature.

RESULTS

From all patients, 15% will develop diverticulitis, 5% complications and 5% diverticular bleeding. Diagnosis is established with computerised tomography. Colonoscopy is needed to rule out malignancy. NSAIDs increase the risk of perforation; steroids, diabetes, collagen vascular disease and immune compromised are associated with complicated disease and death. In mild diverticulitis, antibiotics are recommended. In complicated disease with abscesses, <5 cm antibiotics are sufficient. Larger abscesses are drained under computerised tomography-guidance. Peritonitis forms an indication for surgery. Diverticulitis recurrence rate is around 30%, most are uncomplicated. Recurrence after surgery is around 10%. Elective surgery is reserved for fistula closure and obstruction. The need for elective surgery to prevent recurrence has diminished because of new insights. Important is to identify risk groups. New issues are the possible relationship between diverticulitis and cancer, segmental colitis associated with diverticulitis, and treatment of diverticulitis with mesalazine and probiotics.

CONCLUSIONS

Uncomplicated diverticulitis is treated medically. Complicated diverticulitis with small abscesses is treated with antibiotics while larger abscesses are drained with computerised tomography-guided puncture. Emergency surgery is reserved for peritonitis, elective surgery for fistula/stenosis. Surgery to prevent recurrence is indicated only in selected cases (e.g. immune compromised).