the Management of Diverticular Disease

- Recommendations

Section 1: Risk factors for diverticulosis, diverticulitis and its complications:

·       Modification of dietary habits, lifestyle, body weight and medications are recommended to decrease the development of diverticulosis as they are risk factors, (Strong recommendation, moderate certainty evidence, ⁽⁹⁾).

·       We recommend treatment of the first attack of acute complicated diverticulitis thoroughly as the incidence of complications and mortality is higher, (Strong recommendation, moderate certainty evidence, ⁽⁹⁾).

Section 2: Diagnosis of diverticulitis:

·       We recommend suspecting acute diverticulitis on the basis of problem-specific history and physical examination and appropriate laboratory evaluation, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

·       We recommend against depending solely on the clinical findings to judge the severity of the disease, (Strong recommendation, moderate certainty evidence, ⁽⁹⁾).

·       We recommend CECT scan of the abdomen and pelvis as the most appropriate initial imaging modality in the assessment of suspected diverticulitis, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

·       We advise performing ultrasound and MRI in the initial evaluation of a patient with suspected acute diverticulitis, as a useful alternatives, when CT imaging is contraindicated, (Conditional recommendation, low certainty evidence, ⁽¹⁰⁾).

Section 3: Non-operative  treatment of acute diverticulitis:

·       Tobacco cessation, reduced meat intake, physical activity and weight loss are recommended interventions to potentially reduce the risk of diverticulitis, (Strong recommendation, high certainty evidence, ⁽¹⁰⁾).  

·       We advise against dietary restrictions and bed rest in acute stage of diverticulitis, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       For patients tolerating oral intake, we advise outpatient treatment of uncomplicated diverticulitis in the absence of sepsis, significant comorbidity and immunosuppression, (Conditional recommendation, moderate certainty evidence, ⁽⁹⁾).

·       We advise treatment with antibiotics for patients with radiological signs of complicated diverticulitis, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       Antibiotic treatment should be offered for immunocompromised patients and patients with sepsis, (Strong recommendation, high certainty evidence, ⁽⁹⁾).

·       We recommend against the use of amino salicylate to prevent recurrent AD, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

Section 4: Follow-up after an episode of uncomplicated and complicated diverticulitis:

·       We advise against endoscopic follow-up for patients with symptom-free recovery after a single episode of CT verified uncomplicated diverticulitis, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       For patients treated without resection for acute diverticulitis, we advise follow up with endoscopic examination of the colon at least 6 weeks after the acute episode, if not done within the last 3 years, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

Section 5: Role of percutaneous drainage for patients with a diverticular abscess:

·        Image-guided percutaneous drainage is recommended for stable patients with diverticular abscesses, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

 

Section 6: Indications for abdominal exploration in patients with acute diverticulitis:

·       Immediate surgery is advised in hemodynamically unstable or septic patients, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       Urgent abdominal exploration is recommended for patients with diffuse peritonitis or for those in whom non-operative management of acute diverticulitis fails, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

·       We recommend against elective surgery to prevent complicated disease, irrespective of the number of previous attacks, (Strong recommendation, moderate certainty evidence, ⁽⁹⁾).

·       We advise against colonic resection in symptomatic patients without radiological or endoscopic signs of ongoing inflammation, stenosis or fistula, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

·       After successful non-operative treatment of a diverticular abscess, elective resection should be recommended, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

·       The decision for elective resection after an acute episode of diverticulitis in immunocompromised and younger patients is the same as in other patients, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

Section 7: Surgical treatment of diverticulitis:

·       When expertise is available, a minimally invasive approach to colectomy for diverticulitis is recommended, (Strong recommendation, high certainty evidence, (10)).  

·        In patients with purulent or feculent peritonitis, colectomy, (open or laparoscopic) is recommended over laparoscopic lavage, (Strong recommendation, high certainty evidence, ⁽¹⁰⁾).  

·       The extent of elective resection should include the entire sigmoid colon with margins of healthy colon and rectum, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).

·       In the emergency setting, we advise to focus on the control of sepsis and resecting the perforated segment, (Conditional recommendation, low certainty evidence, ⁽⁹⁾).

Section 8: Surgery of persisting abscesses and fistulas:

·       Elective colectomy, (open or laparoscopic) is recommended for patients with diverticulitis complicated by fistula, persistent abscesses, obstruction, or stricture, (Strong recommendation, moderate certainty evidence, ⁽¹⁰⁾).