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Treatment of acute diverticulitis


Diverticulitis is an acute inflammation of the diverticular bearing portion of colon, caused by microscopic or macroscopic perforation of one or more diverticula. An inflammatory reaction develops primarily involving the colonic wall and surrounding pericolonic tissue. For patients with a microperforation or uncomplicated diverticulitis, the inflammatory reaction is self-limited and confined, and without the development of an abscess or peritonitis. For patients with a macroperforation or complicated diverticulitis, complications of the inflammatory reaction can include fecal and/or purulent peritonitis, abscess, enteric fistula, and/or stricture formation.

This topic review will focus on the management of patients with acute diverticulitis. Epidemiology, pathophysiology, and clinical manifestations are reviewed elsewhere:

(See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis".)

(See "Clinical manifestations and diagnosis of acute diverticulitis in adults".)

(See "Diverticular colitis".)


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Literature review current through: Mar 2014. | This topic last updated: Feb 10, 2014.
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  1. Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49:939.
  2. Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000; 43:290.
  3. Surgical treatment of diverticulitis. Patient Care Committee of the Society for Surgery of the Alimentary Tract (SSAT). J Gastrointest Surg 1999; 3:212.
  4. Stollman NH, Raskin JB. Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999; 94:3110.
  5. Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13:430.
  6. Fozard JB, Armitage NC, Schofield JB, et al. ACPGBI position statement on elective resection for diverticulitis. Colorectal Dis 2011; 13 Suppl 3:1.
  7. Thompson WG, Patel DG. Clinical picture of diverticular disease of the colon. Clin Gastroenterol 1986; 15:903.
  8. Cheskin LJ, Bohlman M, Schuster MM. Diverticular disease in the elderly. Gastroenterol Clin North Am 1990; 19:391.
  9. Detry R, Jamez J, Kartheuser A, et al. Acute localized diverticulitis: optimum management requires accurate staging. Int J Colorectal Dis 1992; 7:38.
  10. Hachigian MP, Honickman S, Eisenstat TE, et al. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992; 35:1123.
  11. Kellum JM, Sugerman HJ, Coppa GF, et al. Randomized, prospective comparison of cefoxitin and gentamicin-clindamycin in the treatment of acute colonic diverticulitis. Clin Ther 1992; 14:376.
  12. Larson DM, Masters SS, Spiro HM. Medical and surgical therapy in diverticular disease: a comparative study. Gastroenterology 1976; 71:734.
  13. Biondo S, Parés D, Martí Ragué J, et al. Acute colonic diverticulitis in patients under 50 years of age. Br J Surg 2002; 89:1137.
  14. Young-Fadok TM, Roberts PL, Spencer MP, Wolff BG. Colonic diverticular disease. Curr Probl Surg 2000; 37:457.
  15. Dharmarajan S, Hunt SR, Birnbaum EH, et al. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum 2011; 54:663.
  16. Buchs NC, Konrad-Mugnier B, Jannot AS, et al. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg 2013; 100:976.
  17. Biondo S, Golda T, Kreisler E, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg 2014; 259:38.
  18. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999; 42:470.
  19. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment. Am Fam Physician 2005; 72:1229.
  20. Chabok A, Påhlman L, Hjern F, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99:532.
  21. Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev 2012; 11:CD009092.
  22. Painter NS. Diverticular disease of the colon. The first of the Western diseases shown to be due to a deficiency of dietary fibre. S Afr Med J 1982; 61:1016.
  23. Aldoori WH, Giovannucci EL, Rockett HR, et al. A prospective study of dietary fiber types and symptomatic diverticular disease in men. J Nutr 1998; 128:714.
  24. Brodribb AJ. Treatment of symptomatic diverticular disease with a high-fibre diet. Lancet 1977; 1:664.
  25. Ornstein MH, Littlewood ER, Baird IM, et al. Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J (Clin Res Ed) 1981; 282:1353.
  26. Strate LL, Liu YL, Syngal S, et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008; 300:907.
  27. Lau KC, Spilsbury K, Farooque Y, et al. Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? Dis Colon Rectum 2011; 54:1265.
  28. Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011; 54:283.
  29. Binda GA, Arezzo A, Serventi A, et al. Multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg 2012; 99:276.
  30. Mäkelä JT, Kiviniemi HO, Laitinen ST. Spectrum of disease and outcome among patients with acute diverticulitis. Dig Surg 2010; 27:190.
  31. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975; 4:53.
  32. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease. Ann R Coll Surg Engl 1994; 76:117.
  33. Imbembo AL, Bailey RW. Diverticular disease of the colon. In: Textbook of Surgery, 14th ed, Sabiston DC Jr (Ed), Churchill Livingstone, 1992. p.910.
  34. Chautems R, Ambrosetti P, Ludwig A. Long-term follow-up after first acute episode of sigmoid diverticulitis: Is surgery mandatory. Dis Colon Rectum 2001; 44:A5.
  35. Kaiser AM. Complicated diverticulitis: it is not yet time to rethink the rules! Ann Surg 2006; 243:707.
  36. Wolff BG, Ready RL, MacCarty RL, et al. Influence of sigmoid resection on progression of diverticular disease of the colon. Dis Colon Rectum 1984; 27:645.
  37. Corman, ML. Colon and Rectal Surgery, 3rd edition, JB Lippincott, Philadelphia 1993. p.817.
  38. Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151:269.
  39. Horgan AF, McConnell EJ, Wolff BG, et al. Atypical diverticular disease: surgical results. Dis Colon Rectum 2001; 44:1315.
  40. Boostrom SY, Wolff BG, Cima RR, et al. Uncomplicated diverticulitis, more complicated than we thought. J Gastrointest Surg 2012; 16:1744.
  41. Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol 2006; 12:3225.
  42. Sheth AA, Longo W, Floch MH. Diverticular disease and diverticulitis. Am J Gastroenterol 2008; 103:1550.
  43. Stollman N, Magowan S, Shanahan F, et al. A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial. J Clin Gastroenterol 2013; 47:621.
  44. Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 1985; 28:71.
  45. Krobot K, Yin D, Zhang Q, et al. Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery. Eur J Clin Microbiol Infect Dis 2004; 23:682.
  46. Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis 1994; 9:158.
  47. Ambrosetti P, Robert J, Witzig JA, et al. Prognostic factors from computed tomography in acute left colonic diverticulitis. Br J Surg 1992; 79:117.
  48. Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984; 200:466.
  49. Doringer E. Computerized tomography of colonic diverticulitis. Crit Rev Diagn Imaging 1992; 33:421.
  50. Neff CC, vanSonnenberg E, Casola G, et al. Diverticular abscesses: percutaneous drainage. Radiology 1987; 163:15.
  51. Schechter S, Eisenstat TE, Oliver GC, et al. Computerized tomographic scan-guided drainage of intra-abdominal abscesses. Preoperative and postoperative modalities in colon and rectal surgery. Dis Colon Rectum 1994; 37:984.
  52. Kuligowska E, Keller E, Ferrucci JT. Treatment of pelvic abscesses: value of one-step sonographically guided transrectal needle aspiration and lavage. AJR Am J Roentgenol 1995; 164:201.
  53. Schiller VL, Schreiber L, Seaton C, Sarti DA. Transvaginal sonographic diagnosis of sigmoid diverticulitis. Abdom Imaging 1995; 20:253.
  54. Siewert B, Tye G, Kruskal J, et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol 2006; 186:680.
  55. Brandt D, Gervaz P, Durmishi Y, et al. Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum 2006; 49:1533.
  56. Gaertner WB, Willis DJ, Madoff RD, et al. Percutaneous drainage of colonic diverticular abscess: is colon resection necessary? Dis Colon Rectum 2013; 56:622.
  57. Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA 2014; 311:287.
  58. Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for diverticulitis in the 21st century: a systematic review. JAMA Surg 2014; 149:292.
  59. Stollman NH, Raskin JB. Diverticular disease of the colon. J Clin Gastroenterol 1999; 29:241.
  60. Chappuis CW, Cohn I Jr. Acute colonic diverticulitis. Surg Clin North Am 1988; 68:301.
  61. Janes S, Meagher A, Frizelle FA. Elective surgery after acute diverticulitis. Br J Surg 2005; 92:133.
  62. Chapman JR, Dozois EJ, Wolff BG, et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg 2006; 243:876.
  63. Klarenbeek BR, Samuels M, van der Wal MA, et al. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010; 251:670.
  64. Constantinides VA, Tekkis PP, Senapati A, Association of Coloproctology of Great Britain Ireland. Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 2006; 93:1503.
  65. Köckerling F, Schneider C, Reymond MA, et al. Laparoscopic resection of sigmoid diverticulitis. Results of a multicenter study. Laparoscopic Colorectal Surgery Study Group. Surg Endosc 1999; 13:567.
  66. Franklin ME Jr, Dorman JP, Jacobs M, Plasencia G. Is laparoscopic surgery applicable to complicated colonic diverticular disease? Surg Endosc 1997; 11:1021.
  67. Stevenson AR, Stitz RW, Lumley JW, Fielding GA. Laparoscopically assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients. Ann Surg 1998; 227:335.
  68. Eijsbouts QA, Cuesta MA, de Brauw LM, Sietses C. Elective laparoscopic-assisted sigmoid resection for diverticular disease. Surg Endosc 1997; 11:750.
  69. Dwivedi A, Chahin F, Agrawal S, et al. Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease. Dis Colon Rectum 2002; 45:1309.
  70. Scheidbach H, Schneider C, Rose J, et al. Laparoscopic approach to treatment of sigmoid diverticulitis: changes in the spectrum of indications and results of a prospective, multicenter study on 1,545 patients. Dis Colon Rectum 2004; 47:1883.
  71. Alves A, Panis Y, Slim K, et al. French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease. Br J Surg 2005; 92:1520.
  72. Purkayastha S, Constantinides VA, Tekkis PP, et al. Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum 2006; 49:446.
  73. Larson DW, Batdorf NJ, Touzios JG, et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg 2010; 211:485.
  74. Klarenbeek BR, Veenhof AA, Bergamaschi R, et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 2009; 249:39.
  75. Siddiqui MR, Sajid MS, Qureshi S, et al. Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis. Am J Surg 2010; 200:144.
  76. Jones OM, Stevenson AR, Clark D, et al. Laparoscopic resection for diverticular disease: follow-up of 500 consecutive patients. Ann Surg 2008; 248:1092.
  77. Pendlimari R, Touzios JG, Azodo IA, et al. Short-term outcomes after elective minimally invasive colectomy for diverticulitis. Br J Surg 2011; 98:431.
  78. Gervaz P, Inan I, Perneger T, et al. A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 2010; 252:3.
  79. Raue W, Paolucci V, Asperger W, et al. Laparoscopic sigmoid resection for diverticular disease has no advantages over open approach: midterm results of a randomized controlled trial. Langenbecks Arch Surg 2011; 396:973.
  80. Champagne BJ, Papaconstantinou HT, Parmar SS, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg 2012; 255:66.
  81. Vestweber B, Galetin T, Lammerting K, et al. Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS. Surg Endosc 2013; 27:434.
  82. O'Sullivan GC, Murphy D, O'Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996; 171:432.
  83. Myers E, Hurley M, O'Sullivan GC, et al. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95:97.
  84. Franklin ME Jr, Portillo G, Treviño JM, et al. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 2008; 32:1507.
  85. Toorenvliet BR, Swank H, Schoones JW, et al. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 2010; 12:862.
  86. Swank HA, Vermeulen J, Lange JF, et al. The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 2010; 10:29.
  87. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12:85.
  88. Rothenberger DA, Wiltz O. Surgery for complicated diverticulitis. Surg Clin North Am 1993; 73:975.
  89. Constantinides VA, Tekkis PP, Athanasiou T, 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.
  90. Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg 1989; 26:133.
  91. Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012; 256:819.
  92. Lee EC, Murray JJ, Coller JA, et al. Intraoperative colonic lavage in nonelective surgery for diverticular disease. Dis Colon Rectum 1997; 40:669.
  93. Roberts P, Abel M, Rosen L, et al. Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1995; 38:125.
  94. Morris CR, Harvey IM, Stebbings WS, Hart AR. Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008; 95:876.
  95. Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007; 22:351.
  96. Salem L, Flum DR. Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47:1953.
  97. Gooszen AW, Tollenaar RA, Geelkerken RH, et al. Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 2001; 88:693.
  98. Maggard MA, Zingmond D, O'Connell JB, Ko CY. What proportion of patients with an ostomy (for diverticulitis) get reversed? Am Surg 2004; 70:928.
  99. Vermeulen J, Coene PP, Van Hout NM, et al. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009; 11:619.
  100. Banerjee S, Leather AJ, Rennie JA, et al. Feasibility and morbidity of reversal of Hartmann's. Colorectal Dis 2005; 7:454.
  101. Vermeulen J, Gosselink MP, Busschbach JJ, Lange JF. Avoiding or reversing Hartmann's procedure provides improved quality of life after perforated diverticulitis. J Gastrointest Surg 2010; 14:651.
  102. Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis in young patients. J Am Coll Surg 1994; 179:156.
  103. Schauer PR, Ramos R, Ghiatas AA, Sirinek KR. Virulent diverticular disease in young obese men. Am J Surg 1992; 164:443.
  104. Acosta JA, Grebenc ML, Doberneck RC, et al. Colonic diverticular disease in patients 40 years old or younger. Am Surg 1992; 58:605.
  105. Freischlag J, Bennion RS, Thompson JE Jr. Complications of diverticular disease of the colon in young people. Dis Colon Rectum 1986; 29:639.
  106. Pautrat K, Bretagnol F, Huten N, de Calan L. Acute diverticulitis in very young patients: a frequent surgical management. Dis Colon Rectum 2007; 50:472.
  107. Ritz JP, Lehmann KS, Stroux A, et al. Sigmoid diverticulitis in young patients--a more aggressive disease than in older patients? J Gastrointest Surg 2011; 15:667.
  108. Chodak GW, Rangel DM, Passaro E Jr. Colonic diverticulitis in patients under age 40: need for earlier diagnosis. Am J Surg 1981; 141:699.
  109. Ouriel K, Schwartz SI. Diverticular disease in the young patient. Surg Gynecol Obstet 1983; 156:1.
  110. Chautems RC, Ambrosetti P, Ludwig A, 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.
  111. Vignati PV, Welch JP, Cohen JL. Long-term management of diverticulitis in young patients. Dis Colon Rectum 1995; 38:627.
  112. Simonowitz D, Paloyan D. Diverticular disease of the colon in patients under 40 years of age. Am J Gastroenterol 1977; 67:69.
  113. Cunningham MA, Davis JW, Kaups KL. Medical versus surgical management of diverticulitis in patients under age 40. Am J Surg 1997; 174:733.
  114. Mpofu S, Mpofu CM, Hutchinson D, et al. Steroids, non-steroidal anti-inflammatory drugs, and sigmoid diverticular abscess perforation in rheumatic conditions. Ann Rheum Dis 2004; 63:588.
  115. Young-Fadok T, Sgambati S, Wolff B. Increased morbidity and mortality after colectomy in patients with lupus: A case-matched series (abstract). Dis Colon Rectum 2000; 43:A57.
  116. Perkins JD, Shield CF 3rd, Chang FC, Farha GJ. Acute diverticulitis. Comparison of treatment in immunocompromised and nonimmunocompromised patients. Am J Surg 1984; 148:745.
  117. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969; 10:336.
  118. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984; 27:454.
  119. Ngoi SS, Chia J, Goh MY, et al. Surgical management of right colon diverticulitis. Dis Colon Rectum 1992; 35:799.
  120. Sugihara K, Muto T, Morioka Y, et al. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum 1984; 27:531.
  121. Markham NI, Li AK. Diverticulitis of the right colon--experience from Hong Kong. Gut 1992; 33:547.
  122. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996; 171:244.
  123. Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diverticulitis: US and CT findings--new insights about frequency and natural history. Radiology 1998; 208:611.