Colonic diverticulosis is among the most common diseases in developed Western countries. In the United States, diverticulosis occurs in approximately one third of the population older than age 45 and in up to two thirds of the population older than 85 years,1,2 and it also affects a significant proportion of younger adults.
Definition and causesA diverticulum is a saclike protrusion in the colonic wall that develops as a result of herniation of the mucosa and submucosa through points of weakness in the muscular wall of the colon. The colonic diverticulum is a false or pulsion diverticulum-that is, it does not contain all layers of the colonic wall. Diverticulosis indicates the presence of multiple diverticula and generally implies an absence of symptoms (Fig. 1). Diverticular disease implies any clinical state caused by diverticula, including hemorrhage, inflammation, or their complications. Diverticulitis describes the presence of an inflammatory process associated with diverticula. Its pathogenesis is attributed to genetic and environmental factors (Box 1).
|Environmental factors |
|Epidemiologic factors |
Medical TreatmentComplicated diverticulitis refers to acute diverticulitis accompanied by abscess, fistula, obstruction, or free
intra-abdominal perforation. In the absence of complications and systemic signs and symptoms, patients with mild abdominal tenderness may be treated conservatively. Conservative treatment typically includes dietary modification and oral or IV antibiotics. This has been shown to be successful in 70% to 100% of patients.37,38,40
Uncomplicated diverticulitis may be managed in the outpatient setting with dietary modification and oral antibiotics for those without fever, excessive vomiting, or marked peritonitis, as long as there is the opportunity for follow-up. If these conditions are not met or the patient fails to improve with outpatient therapy, hospital admission is required.
Antibiotic selection should be based on appropriate coverage for gram-negative rods and anaerobic bacteria.41 Conservative treatment will resolve acute diverticulitis in 85% of patients, but approximately one third will have a recurrent attack, often within a year.5,42,43
After recovery from the first episode, use of fiber prevents recurrence in more than 70% of patients.44,45 Immunosuppressed or immunocompromised patients are more likely to present with perforation and fail medical treatment.41,42,46
Approximately 15% of patients develop pericolonic or intramesenteric abscess.47,48 Abscesses smaller than 2 cm in diameter may resolve with antibiotic treatment without any further intervention, whereas larger abscesses may require percutaneous drainage. This may prevent an emergency operation and multistaged surgeries involving the creation and closure of stoma.42,48,49
Surgical TreatmentSurgical treatment of the disease can be evaluated emergently or electively, based on the stage of the disease and clinical presentation. Emergent sigmoid colectomy is required for patients with the following:
40,42 Factors affecting decision making for elective surgery include the following:
55,56 and cost and outcome are comparable with those of open resection.57
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PreventionPrevention can be achieved by elimination of the factors involved in the pathogenesis of this disease (see Box 1). Increasing the proportion of fiber in the diet, along with an increase in fluid intake, will help keep more diverticula from forming and also will help keep the existing condition from worsening. Additionally, alteration of lifestyle by weight reduction and exercise can limit the contribution of other causative factors.
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Special circumstancesThere are special circumstances in which the general recommendations for the diagnostic workup and treatment of diverticulitis may not apply. These are closely associated with the presence of factors such as manifestation of the disease, patient's response to the disease, and treatment.