Management of Acute Diverticulitis: Current Practices

In this SOC we review the general recommendations of both the American and the European Societies’ Guidelines regarding the management of acute colonic diverticulitis.

None of the existing classifications for left-sided colonic diverticulitis has proved superiority. The most used one is Hinchey’s modified classification. The World Society of Emergency Surgery (WSES) proposes a new one, which divides acute diverticulitis into uncomplicated and complicated. The European Society of Coloproctology (ESCP) defines diverticulosis and divides diverticular disease into 3 entities: Symptomatic Uncomplicated Diverticular Disease (SUDS), diverticulitis (acute or chronic, complicated or uncomplicated) and diverticular bleeding.

Prevalence of diverticulitis is hard to estimate. However, it is clear that is increasing throughout the world, even in younger patients. Its pathogenesis is multifactorial.

This disease can sometimes be difficult to differentiate from colorectal cancer. Because of this, it is accepted to make a control colonoscopy in complicated cases.

For diagnosis, a Contrast-enhanced CT scan is generally recommended. Ultrasound can also be a correct image test, although it has some limitations.

Regarding treatment, uncomplicated diverticulitis can be treated in a conservative way, with antibiotics, or even without using them in non-septic patients. These patients can also be treated as outpatients. Management of abscesses depends on their size; when larger than 4-5cm, percutaneous drainage should be considered. Urgent surgery is performed in patients with generalized sepsis and clinical peritonitis, extraluminal air in imaging tests or free fluid. When there is fecal peritonitis, surgical resection must be performed. When peritonitis is purulent, laparoscopic lavage can be an option, although this is still a matter of controversy. There are no significant differences regarding morbimortality between Hartmann’s procedure and primary anastomosis. 

Elective surgery is only justified to improve quality of life or if there are  persistent abscesses or fistulas. There is no evidence of differences between laparoscopic and open surgery.  If the source control has been adequate, a 4-day postoperative antibiotic therapy is recommended.