J Gastrointest Surg

DOI 10.1007/s11605-017-3404-3

EVIDENCE BASED CURRENT SURGICAL PRACTICE

Management of Diverticulitis in 2017

Sarah E. Deery 1 & Richard A. Hodin 1

Received: 14 January 2017 / Accepted: 12 March 2017

# 2017 The Society for Surgery of the Alimentary Tract

Abstract Diverticulitis has become increasingly more common in the 20th century and is now one of the most frequent
indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical presentation can vary widely from mild,
uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically,
all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or
emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid BHartmann’s^ stump. However, the
treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting
the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore,
the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and
complicated left-sided diverticulitis in 2017.

Keywords Diverticulitis . Colectomy . Hartmann Introduction

SED and RAH meet all four authorship criteria. Although diverticular disease was first described in the late
1700s by Alexis Littre, diverticulitis was not considered a
CME questions for this article available to SSAT members at http://ssat. 1,2

com/jogscme/.
Disclosure Information: Authors: Sarah E. Deery, M.D. has nothing to
disclose; Richard A. Hodin, M.D. has nothing to disclose. Editor-in-
Chief: Jeffrey B. Matthews, M.D., has nothing to disclose. CME
Overseers:Arbiter: Jeffrey B. Matthews, M.D., has nothing to disclose;
Vice-Arbiter: Melanie Morris, M.D., has nothing to disclose; Question
Reviewers: Abdulrahim Alawashez, M.D. has nothing to disclose;
Matthias Stelzner, M.D., has nothing to disclose.
Learning Objectives:
1. Describe the role of antibiotics in uncomplicated diverticulitis
clinical problem until the early twentieth century. The inci-
dence of diverticular disease then rose dramatically over the
next century, likely due in part to the decrease of dietary fiber
in the Western diet, as first described by Painter and Burkitt in
3
their landmark 1971 article. Diverticulosis is now quite com-
mon in the USA and has been found in as many as 10% of
4,5
people >40 years and 70% of those >80 years. Diverticulitis,
defined as inflammation and infection related to diverticula,
6
occurs in 20% of patients with diverticulosis and results in
7,8

2. Critically compare management strategies for complicated over 200,000 yearly hospitalizations in the USA.
diverticulitis The pathogenesis of diverticular disease is multifactorial and
3. Explain the role of laparoscopic lavage for diverticulitis with peritonitis is thought to be related to low-grade inflammation, alterations
4. Review the management of diverticulitis in the immunocompromised in colonic microbiota, and immune, enteric nerve, and muscu-
patient
lar system dysfunction. Patients with diverticulitis have higher
9
numbers of mast cells present in all layers of the colonic wall,
* Richard A. Hodin
rhodin@mgh.harvard.edu and also have significant lymphocytic and neutrophilic infil-
10–12
trates, depending on the severity of disease. Part of this
1
Department of Surgery, Massachusetts General Hospital, Harvard chronic inflammatory process may result from imbalance in
13
Medical School, 15 Parkman St, WAC 4-460, Boston, MA 02114, the normal colonic flora .Gut microbiota in patients on low-
14
USA versus high-fiber diets vary dramatically, and DNA

sequencing confirms that the colonic microbiota vary accord-
15,16
ing to consumption of dietary fiber. Finally, colonic
dysmotility can also be associated with diverticular disease.
Patients with diverticulosis have been shown to have increased
duration of lower frequency contractile activity of the involved
17
colon and reduced density of interstitial cells of Cajal.
Additionally, sigmoid colon specimens with diverticular dis-
ease have higher in vitro sensitivity to acetylcholine, lower
smooth muscle choline acetyltransferase activity, and upregu-
lation of smooth muscle muscarinic M3 receptors, all of which
suggest alterations in the enteric nervous and muscular
18
systems.
Colonic diverticula tend to arise in areas of weakness
of the colonic wall, most frequently occurring between
the mesenteric and anti-mesenteric teniae where the vasa
recta penetrate the muscle. Microscopic studies show
muscular atrophy at these sites, making them particular-
ly susceptible to herniation of the mucosa in the setting
of increased intraluminal pressure. With obstruction of a
diverticula and resulting venous congestion, inflamma-
tion and ultimately microperforation can occur. The ex-
tent of the perforation determines the clinical nature of
the disease, which then dictates its management.
In 1942, Reginald Smithwick reported his series of over
300 patients at the Massachusetts General Hospital, and
showed that the 10% who underwent colonic resection had
superior outcomes, stimulating a shift towards operative
19
management. Henri Hartmann developed his eponymous
two-stage sigmoid resection with end colostomy and
20
oversewn rectosigmoid stump for cancer in 1923, but this
was later modified by Boyden and Nelsen for use in acute
21,22
diverticulitis in the 1950s. Surgical resection for the man-
agement of diverticulitis thus gained popularity over the sub-
sequent decades. However, the treatment paradigm has now
shifted, with recent literature suggesting that many patients
would benefit from less aggressive, frequently nonoperative,
management. The purpose of this review is to summarize our
approach to managing diverticulitis based on the continuously
evolving literature. While diverticulitis can affect any location
of the colon, this review will focus on the management of the
most common entity, left-sided diverticular disease.
Symptoms
The clinical presentation of diverticular disease varies widely,
with many patients having merely asymptomatic diverticulo-
sis with no adverse sequelae. In patients with left-sided diver-
ticulitis, the most common presenting complaint is left lower
quadrant abdominal pain, which is usually accompanied by
fever and leukocytosis. Patients may also present with nausea,
5
vomiting, changes in bowel function, and dysuria. Other
symptoms may be present in the setting of other
J Gastrointest Surg
complications, such as hematochezia with diverticular bleed-
ing or fecaluria, pneumaturia, and/or pyuria with a colovesical
fistula. Generalized peritonitis may be elicited in severe cases
of acute diverticulitis with free perforation.
Diagnosis
The initial evaluation of a patient with suspected acute diver-
ticulitis should begin with a complete history and physical
exam, and, in some clear-cut cases of recurrent disease, the
diagnosis can be made without further imaging studies. When
the diagnosis is in question, or the patient has severe symp-
toms and possibly complicated diverticulitis, computed to-
mography (CT) axial imaging should be performed. CT can
distinguish diverticulitis from other conditions, including irri-
table bowel disease, gastroenteritis, or gynecologic disease.
While the presence of sigmoid inflammation and diverticulo-
sis can be identified by CT imaging, inflammation secondary
to diverticulitis versus colon cancer or other etiologies cannot
be reliably differentiated by imaging, so all patients with a
first-time episode should be followed with a colonoscopy to
23
rule out malignancy. The colonoscopy should be done in a
delayed (4 to 6 weeks) fashion to minimize the risks of perfo-
ration from over-distension.
In addition to being used for diagnostic purposes, CT scans
can stratify patients by disease severity and identify patients
with complications of diverticulitis, such as abscess, stricture,
or pneumoperitoneum (Fig. 1). Mild diverticulitis is usually
associated with thickening of the colon wall and peri-colonic
inflammatory changes such as fat stranding. In cases of com-
plicated diverticulitis, the commonly used Hinchey classifica-
tion can be applied (Table 1). Those with type I disease have
only localized para-colonic abscesses, type II includes disease
with distant or pelvic abscesses, and types III and IV have
24
generalized purulent and feculent peritonitis, respectively.
An additional classification system from the European
Association for Endoscopic Surgeons is based only on clinical,
rather than radiographic, findings (Table 2), with three grades of
disease ranging from symptomatic and uncomplicated (grade I)
to recurrent uncomplicated (grade II) to complicated disease
(grade III), which can include hemorrhage, abscess, phlegmon,
25
perforation, peritonitis, stricture, fistula, or obstruction.
Prevention
It is widely believed that low intake of dietary fiber predisposes
people on Western diets to elevated colonic pressures and the
3
development of diverticulosis. A recent prospective cohort
study of nearly 50,000 men with no known history of divertic-
ulosis showed that diets high in red meat were associated with
higher incidence of diverticulitis over nearly three decades of
J Gastrointest Surg
Fig. 1 Computed tomographic imaging from a patient presenting with
uncomplicated sigmoid diverticulitis (a), and another patient presenting
with complicated diverticulitis with a complex pelvic abscess (b)
follow-up, whereas diets high in fiber were associated with
26
decreased incidence of diverticulitis. Unfortunately, despite
the strong epidemiologic association between fiber intake and
the eventual development of diverticulosis, no study to date has
been able to show a reversal of the process or a reduction in
27
episodes of diverticulitis with the adoption of a high-fiber diet.
Furthermore, there are limited data regarding the role of
pharmacologic intervention, including mesalamine,
rifaxamine, and probiotics, to prevent diverticulitis. A recent
meta-analysis of six randomized controlled trials of over 1000
total patients comparing mesalamine to placebo found that the
incidence of diverticulitis was lower amongst patients receiv-
28
ing mesalamine. While fewer patients on mesalamine
Table 1 Hinchey classification
of complicated diverticulitis Stage Description
24
(adapted from Hinchey et al. )
I Localized pericolic abscess
II Distant (retroperitoneal or pelvic) abscess
III Generalized purulent peritonitis, caused by rupture of a pericolic or pelvic abscess, noncommunicating
with bowel lumen
IV Generalized feculent peritonitis, caused by free perforation of a diverticulum, communicating with
bowel lumen
developed diverticulitis than those on other therapies, includ-
ing a high-fiber diet and low-dose rifaxamine, these results
were not statistically significant. Multiple studies have
attempted to study the role of probiotics in the prevention
and treatment of diverticular disease, but a recent systemic
review concluded that the quality of evidence was too poor
29
to make any conclusions.
Treatment
Management of diverticulitis depends on the presentation. The
most important distinction is to first determine if the patient has
complicated or uncomplicated diverticulitis (Fig. 2). Of those
patients with uncomplicated diverticulitis, initial management
is generally nonoperative, although elective resection can be
considered in select patients, including some of those with re-
current episodes. Conversely, complicated diverticulitis often
results in intervention, either electively or emergently, although
emergent surgery is mostly reserved for patients with Hinchey
type III or IV diverticulitis with peritonitis.
Uncomplicated Diverticulitis
Even amongst patients with uncomplicated diverticulitis, the
spectrum of symptoms can vary widely. In those with minimal
symptoms, outpatient management with or without oral anti-
biotics to cover colonic flora (including gram negative rods
and anaerobes) is often sufficient. However, in patients with
fever, systemic symptoms, or intolerance to oral intake, inpa-
tient treatment with intravenous antibiotics and perhaps a
short period of bowel rest may be appropriate. In these pa-
tients, clinical improvement can be monitored with serial ab-
dominal examinations as well as temperature and white blood
cell count. After resolution of the acute symptoms, patients
with a first-time episode of diverticulitis should be referred for
colonoscopy to rule out mucosal disease (such as cancer or
inflammatory bowel disease) as the underlying etiology, as
23
these cannot be reliably ruled out based on CT imaging.
While antibiotics have been the standard of care for uncom-
plicated diverticulitis for many years, recent studies have sug-
gested that antibiotics may not always be necessary. In 2014,
Chabok et al. conducted a randomized, controlled trial in
 J Gastrointest Surg

Table 2 The clinical

classification of diverticulitis
from the European Association
for Endoscopic Surgeons
25
(adapted from Kohler et al. )
Grade Definition
I Symptomatic uncomplicated disease, initial
II Symptomatic uncomplicated disease, recurrent
III Complicated disease (initial or recurrent), to include any of the following:
abscess, phlegmon, hemorrhage, fistula, stricture, obstruction, perforation, and/or peritonitis

Sweden of 623 patients with CT-confirmed uncomplicated di-
30
verticulitis, randomized to either antibiotics or no antibiotics.
They found no difference in abdominal pain, abdominal tender-
ness, or temperature curves between the two groups (Fig. 3).
Diverticulitis-related complications, such as perforation or ab-
scess formation, only occurred in 1.9% of those not on antibi-
otics and 1.0% of those on antibiotics (P = 0.302), and there
were no differences in rates of sigmoid resection, hospital length
of stay, or recurrent diverticulitis at 1-year follow-up.
A similar Dutch trial randomized 528 patients with CT-
proven uncomplicated diverticulitis to observation or
31
antibiotics. The median recovery time was 14 versus 12 days
in the observation and antibiotics groups, respectively (P = 0.15).
They found no statistically significant differences in secondary
endpoints, including episodes of complicated diverticulitis (ob-
servation 3.8% vs. antibiotics 2.6%, P = 0.38), ongoing diver-
ticulitis (7.3 vs. 4.1%, P = 0.18), recurrent disease (3.4 vs. 3.0%,
P = 0.49), sigmoid resection (3.8 vs. 2.3%, P = 0.32), readmis-
sion (18 vs. 12%, P = 0.15), adverse events (49 vs. 55%,
P = 0.22), or mortality (1.1 vs 0.4%, P = 0.43). Notably, hospital
stay was shorter in the observation group (2 vs. 3 days, P < 0.01).
These two large, well-designed trials support the notion that
uncomplicated diverticulitis may be more of an inflammatory
rather than infectious condition, and that antibiotics may not be
necessary to hasten recovery and prevent recurrent episodes or
complications of diverticulitis, and that observation alone should
be considered in select patients.
While the literature is clear that nonoperative management
is the appropriate first strategy for the treatment of uncompli-
cated diverticulitis, patients with smoldering disease that is
poorly or unresponsive to medical management often need
escalation of care. Boostrom et al. evaluated 684 patients with
uncomplicated diverticulitis undergoing sigmoid resection at
the Mayo Clinic and found that 10% of those had disease that
32
they characterized as smoldering or chronic. These patients
all had at least 3 months of continuous symptoms, with a
medium of three completed courses of antibiotics (range 2–
11). All patients underwent resection with primary anastomo-
sis and only 5 of 66 were temporarily diverted. Only 2% of
patients had major complications, and 90% of patients had
complete resolution of all symptoms. Therefore, our practice
is to offer surgical resection with primary anastomosis to pa-
tients with chronic, smoldering disease.
Recurrent, Uncomplicated Diverticulitis
While there is consensus that the acute management of uncom-
plicated diverticulitis does not involve surgical intervention, the
role of elective colectomy to prevent recurrent diverticulitis is
less well defined. Previously, elective colectomy was recom-
mended following the second episode of uncomplicated or first
episode of complicated diverticulitis, given concern that these
patients were more likely to have recurrent disease. However,

Fig. 2 Management of
diverticulitis depends first upon
whether a patient has
uncomplicated or complicated
disease, and treatment can then be
approached in a variety of ways
J Gastrointest Surg
Fig. 3 In a randomized, controlled trial of antibiotics versus no antibiotics, there were no differences in abdominal pain (a), temperature (b), or
30
abdominal tenderness (c) over time (from Chabok et al. )
these recommendations arose from the era before routine use of
33
CT scans and antibiotics, and they are now in question.
Elective sigmoid colectomy is a prophylactic procedure
designed to prevent recurrent diverticulitis. Therefore, under-
standing the predictors of recurrent disease may help define
which patients would benefit from resection. Hall et al. per-
formed a retrospective review of 672 patients treated
34
nonoperatively for diverticulitis at the Lahey Clinic. Of
these, 36% developed recurrent disease over a median 5 years
of follow-up, but only 3.9% of patients developed complicat-
ed recurrence. Multivariable predictors of any recurrence were
retroperitoneal abscess (hazard ratio [HR] 4.5), family history
(HR 2.2), and involved colonic segment >5 cm (HR 1.7),
whereas right colonic disease was protective compared to
left-sided disease (HR 0.27).
Many clinicians and patients fear that their next episode will
be a more severe episode, even necessitating emergent opera-
tion with temporary colostomy. In past decades, this concern
about a colostomy often led to elective surgery but, as Hall and
his colleagues demonstrated with the <4% rate of recurrent
complicated disease, most patients with an initially uncompli-
34
cated episode will never develop severe complications. To
evaluate which patients do present with perforation, Chapman
et al. retrospectively analyzed 337 patients with complicated
35
diverticulitis between 1990 and 2003. Over half of patients
presented with complicated disease as their first episode
(Fig. 4). Of the most severe cases, in which patients with per-
foration died, 90% had no prior history of diverticulitis.
Other studies have shown even lower rates of diverticulitis
history amongst patients presenting with complications.
Somasekar et al. retrospectively evaluated all patients admitted
36
with complicated diverticulitis. Of these, 84% had perfora-
tions and 9% had fistulas, but only 26% had documented di-
verticulosis, and even fewer, 3%, had had prior acute divertic-
ulitis. Similarly, in a cohort of 100 patients with generalized
peritonitis who underwent laparoscopic lavage, only five had
documented diverticulosis, and none had had a prior episode of
37
diverticulitis. Additionally, using the Washington State
Comprehensive Hospital Abstract Reporting System, Anaya
et al. studied over 25,000 patients hospitalized for a first
38
episode of diverticulitis between 1987 and 2001. Of these,
the recurrence rate of diverticulitis was 27% in patients younger
than 50, but only 17% in those 50 years or older, and only 7.5
and 5.5% of these, respectively, re-presented with perforation.
Reported differently, elective colectomy after an initial episode
of diverticulitis in young patients would have led to 13 unnec-
essary colectomies to prevent one colectomy with colostomy
and even more unnecessary colectomies in patients older than
50 years. Given these data, patients should not be encouraged
to undergo elective colectomy merely to avoid a more serious
recurrence of diverticulitis, as this more serious recurrence is
unlikely to occur. Put another way, for most patients who re-
quire emergency colectomy with colostomy for perforated di-
verticulitis, it is their first episode of the disease.
As this new dogma has become accepted, the rates of elective
39
colectomy for diverticulitis have declined. In an analysis of all
patients admitted to hospitals in Ontario with acute diverticulitis
managed nonoperatively, rates of elective colectomy within
1 year of discharge dropped from 9.6% in 2002 to 3.9% in
2011. Even after adjusting for patient characteristics, the rate
of elective colectomy declined by nearly 1% per year. Of these
elective cases, one-third was performed laparoscopically, and
39
only 7.5% received an ostomy. Importantly, the decline in elec-
tive treatment is not resulting in higher rates of patients present-
ing with complicated diverticulitis. Ricciardi et al. used the
Nationwide Inpatient Sample to identify 680,390 patients with
diverticulitis hospital admissions between 1991 and 2005, and
the rates of free perforation amongst those admitted was con-
40
stant at about 1.5% throughout the entire study period.
Which patients should undergo elective resection? Two re-
cent decision analysis models have suggested that patients
should undergo elective surgery after the third or fourth episode
41,42
of uncomplicated diverticulitis. By waiting for the fourth at-
tack, patients older than 50 years would have 0.5% less deaths,
0.7% less colostomies, and would save $1035 per patient com-
pared to operating after the second episode. In younger patients,
operating after the fourth episode results in 0.1% fewer deaths,
42
2% fewer colostomies, and saves $5429 per patient. A recent
systematic review also suggested that there were no data to
support resection after a second attack of diverticulitis, and that

Fig. 4 Of 337 patients presenting
with complicated disease, the
majority of patients had no prior
history of diverticulitis, and
almost all patients with severe
disease resulting from death
presented after the first episode
35
(adapted from Chapman et al. )
the decision for elective colectomy should instead be based on
patient preference in terms of disease severity and quality of
43
life. Clearly, the decision to proceed with elective sigmoid
colectomy should be individualized to the patient. Those pa-
tients on immunosuppression, who have a more chronic, smol-
dering disease, and who have poor access to medical care,
amongst others, may still benefit from elective resection.
Complicated Diverticulitis without Free Perforation
The proper management of acute complicated diverticulitis
depends on the clinical presentation. In patients without gen-
eralized peritonitis or pneumoperitoneum, treatment should
focus on relieving symptoms and managing complications.
Gregersen et al. performed a systematic review of patients
44
presenting with Hinchey stage Ib or II diverticulitis. These
are patients with defined abscesses, and most are treated ini-
tially with antibiotics and CT-guided percutaneous drainage.
They identified 42 studies with 8766 patients and found that
initial non-operative treatment failed in 20%. Patients with
abscesses less than 3 cm in diameter were sufficiently treated
with antibiotics alone, often as an outpatient. Patients treated
with percutaneous drainage had less recurrence than those
treated with antibiotics alone (16 vs. 22%) but did have a small
rate of procedure-related complications (2.5%).
After resolution of the acute episode, however, recurrence
rates are quite high in patients with history of perforation with
abscess. Another meta-analysis from Lamb and Kaiser found
that 40% of patients developed recurrence while awaiting
45
elective resection after resolution of their initial episode.
Therefore, for a patient with complicated diverticulitis without
free perforation, diffuse peritonitis, or systemic sepsis, we
J Gastrointest Surg
recommend antibiotics for all patients, percutaneous drainage
for abscesses >3 cm in diameter, and planned elective surgery
following the index presentation.
Complicated Diverticulitis with Free Perforation
The traditional approach to the emergent surgical management
of complicated diverticulitis has been the procedure described
by Henri Hartmann, in which an open sigmoid colectomy is
20,22
performed with end colostomy, leaving a rectal stump.
However, even in the emergent setting, recent studies have
suggested that the standard Hartmann’s procedure may not al-
ways be needed. For instance, Myers et al. evaluated 100 pa-
tients who needed emergent operation for pneumoperitoneum
37
and peritonitis (Hinchey III or IV). Of these, only four patients
underwent traditional Hartmann’s procedure, whereas 92
underwent planned laparoscopic peritoneal lavage and drain-
age. The overall operative mortality was low at 3%. With
follow-up between 12 and 84 months, only two of 100 patients
were readmitted with recurrent diverticulitis, and no patients
needed re-intervention for complications or a subsequent co-
lostomy. However, not all series have reported such optimistic
results with laparoscopic lavage. A multicenter randomized
trial from 21 centers in Scandinavia compared laparoscopic
46
lavage to primary resection for acute, perforated diverticulitis.
They randomized all patients with suspected perforated diver-
ticulitis, a clinical indication for emergent surgery and pneumo-
peritoneum on abdominal CT to laparoscopic drainage or open
resection. Notably, all patients found to have Hinchey IV fecal
peritonitis (14% in each group) were treated with colon resec-
tion regardless of treatment allocation. The primary outcome
was severe postoperative complications, as defined by a
J Gastrointest Surg
Clavien-Dindo score > IIIa; no statistically significant differ-
ence was found in rate of the primary outcome (31% in lavage
patients vs. 26%, P = 0.53). There was also no difference in
mortality at 90 days (14 vs. 12%, P = 0.67). However, the
reoperation rate was higher in the laparoscopic lavage group
(20 vs. 5.7%, P = 0.01), and four sigmoid carcinomas were
missed with laparoscopic lavage. Based on these data, the au-
thors concluded that laparoscopic lavage was not indicated for
the treatment of perforated diverticulitis.
A meta-analysis of three randomized trials of 358 patients
comparing laparoscopic lavage to open resection reached a
47
different conclusion. Angenete et al. found that at 12 months,
the relative risk of having a reoperation was actually lower for
patients who underwent laparoscopic lavage compared to
those who underwent colon resection, and there were no dif-
ferences in mortality or major morbidity. Therefore, they felt
that, as Hartmann’s resection was more costly and resulted in
higher rates of reintervention, laparoscopic lavage could be a
valid alternative to surgery with resection in select patients
with purulent diverticulitis. However, given the mixed evi-
dence on the efficacy of laparoscopic lavage, we recommend
against this practice in the routine management of patients
with perforated diverticulitis and peritonitis.
In the patients that do undergo an emergent colon resection
for purulent or feculent peritonitis, new findings suggest an
alternative to the traditional Hartmann’s procedure. A multicen-
ter trial involving 62 patients with perforated Hinchey III or IV
left colonic diverticulitis randomized the patients to either
Hartmann’s procedure or sigmoid colectomy with primary
48
anastomosis and diverting loop ileostomy. Patients in both
groups were to have planned stoma reversals at 3 months.
They found no difference in mortality (Hartmann’s 13% vs.
primary anastomosis 9%) or overall complications (80 vs.
84%), but patients undergoing primary anastomosis were more
likely to undergo stoma reversal (90 vs. 57%), had fewer seri-
ous complications (grades IIIb–IV 0 vs. 20%), had shorter hos-
pital stays (6 vs. 9 days), and had lower hospital costs ($16,717
vs. $24,014). While this was a small study, it is the first ran-
domized, controlled trial to favor primary anastomosis with
diverting ileostomy over Hartmann’s for patients with perforat-
ed diverticulitis, which again suggests that the indiscriminate
use of the more conservative Hartmann’s procedure may not be
necessary and may even be harmful in some circumstances.
Management in Special Populations
Certain populations merit special consideration. Young pa-
tients have often been thought to develop more virulent dis-
ease; because of this, some argue that all patients below the
age of 50 should be offered elective colon resection after the
first attack of uncomplicated diverticulitis. However, more
recent data indicate that this logic is flawed. Vignati et al.
surveyed 40 patients under the age of 50 treated with
intravenous antibiotics and bowel rest and found that at a 5-
to 9-year follow-up, none of these patients required colosto-
mies, and only one-third of them had undergone surgery.
Later, Guzzo et al. showed that patients with uncomplicated
diverticulitis under the age of 50 had the same rates of symp-
tom resolution with antibiotics alone as did similar patients
over the age of 50, and again, only 40% ever underwent op-
49
erative intervention. When stratified by disease severity,
young patients have no difference in recurrence rate compared
50
to their older counterparts. As such, we believe that young
patients should be treated according to the same criteria as
older patients and that there is no justification for routine sur-
5,51
gery after a single episode of uncomplicated diverticulitis.
Conversely, diverticulitis in immunocompromised patients
can be more virulent with a higher incidence of free perfora-
tion and fecal peritonitis. Immunocompromised patients have
a higher likelihood of failure of nonoperative management. In
one small series of 10 immunocompromised patients, despite
presentation with little to no symptoms, they experienced a
100% failure rate of response to antibiotics alone, and more
often underwent urgent surgery with a significantly higher
mortality rate (40 vs. 2% in non-immunocompromised
52 53,54
patients). Subsequent studies of transplant recipients, pa-
55
tients on chronic corticosteroids, and those with human im-
56
munodeficiency virus and CD4 counts <200 cells/microL,
all more frequently developed diverticulitis and, when they
did, they presented with more severe disease, more likely
failed medical management, and had significantly higher rates
of mortality and major complications following surgery.
Although these series are small, we believe that the data are
compelling enough to recommend intervention on immuno-
compromised patients after the first episode of diverticulitis,
usually during the index hospitalization.
Quality and Outcomes
The most recent American Society of Colon and Rectal Surgeons
(ASCRS) guidelines reflect the changing literature, as well as our
current views. Following an episode of complicated diverticulitis,
57
elective colectomy should typically be considered. Urgent sig-
moid colectomy is required for patients with diffuse peritonitis
and for those in whom nonoperative management fails. During
resection, the decision to restore bowel continuity must incorpo-
rate patient factors, intraoperative factors, and surgeon prefer-
ences, but primary anastomosis is feasible even in the acute
setting, with or without a temporary diverting loop ileostomy.
If possible, a laparoscopic approach is preferred, and a leak test
should always be performed after creating an anastomosis. In
light of the conflicting literature, laparoscopic lavage is not cur-
rently recommended and is not a routine part of our practice.
Interestingly, regardless of whether colectomy is performed
electively or emergently, there remains a small cohort of

patients that develop recurrence of diverticulitis after resec-
tion. Andeweg et al. reported on 183 patients who underwent
emergent sigmoid resection and found an 8.7% recurrence rate
58
of diverticulitis over a mean follow-up of 8 years. A similar
analysis of 236 patients who underwent elective resection
59
found a 5% recurrence rate by 6 years. While resection
may prevent most future episodes of diverticulitis, it does
not completely resolve all abdominal complaints. Egger
et al. performed structured postoperative interviews of 129
patients, and many of these patients reported ongoing abdom-
inal symptoms after surgery (constipation in 37%, painful ab-
dominal distension in 23%, abdominal cramps in 23%, and
60
frequent painful diarrhea in 23%). Therefore, surgical resec-
tion is not a definitive cure for diverticulitis and its associated
abdominal complaints and should be reserved for select pa-
tients with specific indications and reasonable expectations.
Conclusions
Diverticulitis is a complex inflammatory condition with a wide
spectrum of clinical presentations. In patients with acute, uncom-
plicated disease, nonoperative management is indicated, and an-
tibiotics may not be necessary. Elective surgery for recurrent,
uncomplicated diverticulitis should be limited to patients with
several recurrences and strong preferences. Patients with compli-
cated disease still warrant elective resection in most cases, al-
though surgery can usually be delayed by initial antibiotics and
percutaneous abscess drainage. In patients with purulent perito-
nitis, laparoscopic lavage may allow you to avoid emergent re-
section, although resection is still indicated in patients with fecal
peritonitis. Even in the acute setting, if resection is indicated, one
can consider a primary anastomosis with temporary loop
ileostomy. Further research may better delineate which patients
may still benefit from a more conservative approach.
Continued Medical Education Questions
1. What proportion of people over the age of 80 in the
United States have diverticulosis?
A. 10%
B. 50%
C. 70%
D. 100%
2. Where are diverticula most likely to occur?
A. Where the blood vessels penetrate the wall
B. Along the teniae
C. In close proximity to colonic polyps
D. In the right colon
J Gastrointest Surg
3. When should colonoscopy be performed for patients with
diverticulitis?
A. Colonoscopy is not necessary
B. During the index admission
C. Four to six weeks after resolution of symptoms
D. At least six months after resolution of symptoms
4. Antibiotics are:
A. Are always required for acute episodes of diverticulitis
B. May not be necessary in some patients with uncom-
plicated disease
C. Are not necessary for patients with intraabdominal
abscess undergoing percutaneous drainage
D. Are chosen to cover gram positive cocci and gram
negative rods.
5. Recent trends in elective colectomy and rates of compli-
cated diverticulitis are as follows:
A. Elective colectomy is decreasing and complicated
diverticulitis has remained stable
B. Elective colectomy is decreasing and complicated di-
verticulitis is increasing
C. Elective colectomy is increasing and complicated di-
verticulitis is decreasing
D. Elective colectomy is increasing and complicated di-
verticulitis has remained stable
6. The typical management of a patient presenting with di-
verticulitis and a localized 5 cm abscess should include:
A. Antibiotics alone
B. Antibiotics, percutaneous CT-guided drainage, and
nonoperative management
C. Antibiotics, percutaneous CT-guided drainage, and
delayed elective colectomy
D. Antibiotics and urgent washout and resection
7. For immunocompromised patients with sigmoid divertic-
ulitis, surgery is usually indicated because:
A. Immunocompromised patients are more likely to
have cancer
B. Antibiotics are least efficacious in immunocompro-
mised patients
C. Immunocompromised patients are more likely to de-
velop an obstruction
D. Immunocompromised patients are at higher risk for a
more virulent clinical course and failure of nonoper-
ative management
8. An appropriate management for Hinchey Stage IV fecu-
lent diverticulitis could be:
A. Antibiotics and percutaneous CT-guided drainage
B. Laparoscopic peritoneal lavage and drainage
J Gastrointest Surg
C. Sigmoidectomy with primary anastomosis without
diversion
D. Hartmann’s procedure
References
1. Finney JMT. Diverticulitis and its surgical treatment. Proc Interstate
Post-Grad Med Assembly North Am 1928;55:57–65.
2. Telling WHM, Gruner OC. Acquired diverticula, diverticulitis, and
peridiverticulitis of the large intestine. Br J Surg 1916;4:468–530.
3. Painter NS, Burkitt DP. Diverticular disease of the colon: a defi-
ciency disease of Western civilization. Br Med J 1971;2:450–4.
4. Welch CE, Allen AW, Donaldson GA. An appraisal of resection of the
colon for diverticulitis of the sigmoid. Ann Surg 1953;138:332–43.
5. Wong WD, Wexner SD, Lowry A, Vernava A, 3rd, Burnstein M,
Denstman F, Fazio V, Kerner B, Moore R, Oliver G, Peters W, Ross
T, Senatore P, Simmang C. 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;43:290–7.
6. Heise CP. Epidemiology and pathogenesis of diverticular disease. J
Gastrointest Surg 2008;12:1309–11.
7. Peery AF, Crockett SD, Barritt AS, Dellon ES, Eluri S, Gangarosa
LM, Jensen ET, Lund JL, Pasricha S, Runge T, Schmidt M,
Shaheen NJ, Sandler RS. Burden of gastrointestinal, liver, and pan-
creatic diseases in the United States. Gastroenterology 2015;149:
1731–1741 e3.
8. Wheat CL, Strate LL. Trends in hospitalization for diverticulitis and
diverticular bleeding in the United States From 2000 to 2010. Clin
Gastroenterol Hepatol 2016;14:96–103 e1.
9. Bassotti G, Villanacci V, Nascimbeni R, Antonelli E, Cadei M,
Manenti S, Lorenzi L, Titi A, Salerni B. The role of colonic mast
cells and myenteric plexitis in patients with diverticular disease. Int
J Colorectal Dis 2013;28:267–72.
10. Cianci R, Iacopini F, Petruzziello L, Cammarota G, Pandolfi F,
Costamagna G. Involvement of central immunity in uncomplicated
diverticular disease. Scand J Gastroenterol 2009;44:108–15.
11. Tursi A, Brandimarte G, Elisei W, Giorgetti GM, Inchingolo CD,
Danese S, Aiello F. Assessment and grading of mucosal inflamma-
tion in colonic diverticular disease. J Clin Gastroenterol 2008;42:
699–703.
12. Tursi A, Elisei W, Brandimarte G, Giorgetti GM, Aiello F.
Predictive value of serologic markers of degree of histologic dam-
age in acute uncomplicated colonic diverticulitis. J Clin
Gastroenterol 2010;44:702–6.
13. Daniels L, Philipszoon LE, Boermeester MA. A hypothesis: impor-
tant role for gut microbiota in the etiopathogenesis of diverticular
disease. Dis Colon Rectum 2014a;57:539–43.
14. Tomkins AM, Bradley AK, Oswald S, Drasar BS. Diet and the
faecal microflora of infants, children and adults in rural Nigeria
and urban U.K. J Hyg (Lond) 1981;86:285–93.
15. Daniels L, Budding AE, de Korte N, Eck A, Bogaards JA,
Stockmann HB, Consten EC, Savelkoul PH, Boermeester MA.
Fecal microbiome analysis as a diagnostic test for diverticulitis.
Eur J Clin Microbiol Infect Dis 2014b;33:1927–36.
16. Hooda S, Boler BM, Serao MC, Brulc JM, Staeger MA, Boileau
TW, Dowd SE, Fahey GC, Jr., Swanson KS. 454 pyrosequencing
reveals a shift in fecal microbiota of healthy adult men consuming
polydextrose or soluble corn fiber. J Nutr 2012;142:1259–65.
17. Bassotti G, Battaglia E, De Roberto G, Morelli A, Tonini M, Villanacci
V. Alterations in colonic motility and relationship to pain in colonic
diverticulosis. Clin Gastroenterol Hepatol 2005;3:248–53.
18. Golder M, Burleigh DE, Belai A, Ghali L, Ashby D, Lunniss PJ,
Navsaria HA, Williams NS. Smooth muscle cholinergic denerva-
tion hypersensitivity in diverticular disease. Lancet 2003;361:
1945–51.
19. Smithwick RH. Experiences with the surgical management of di-
verticulitis of the sigmoid. Ann Surg 1942;115:969–85.
20. Hartmann H. Chirurgie du Rectum. Paris: Masson et Cie; 1931. p.
344–356.
21. Boyden AM. Two-stage resection of the sigmoid. Ann Surg
1961;154:210–4.
22. Boyden AM, Neilson RO. Reappraisal of the surgical treatment of
diverticulitis of the sigmoid colon, with special reference to the
choice of operative procedure. Am J Surg 1960;100:206–16.
23. Baker ME. Imaging and interventional techniques in acute left-
sided diverticulitis. J Gastrointest Surg 2008;12:1314–7.
24. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated
diverticular disease of the colon. Adv Surg 1978;12:85–109.
25. Kohler 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.
26. Strate LL, Keeley BR, Cao Y, Wu K, Giovannucci EL, Chan AT.
Western dietary pattern increases, whereas prudent dietary pattern
decreases, risk of incident diverticulitis in a prospective cohort
study. Gastroenterology 2017
27. Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR, Cox
AG. Are fibre supplements really necessary in diverticular disease
of the colon? A controlled clinical trial. Br Med J (Clin Res Ed)
1981;282:1353–6.
28. Picchio M, Elisei W, Brandimarte G, Di Mario F, Malfertheiner P,
Scarpignato C, Tursi A. Mesalazine for the treatment of symptom-
atic uncomplicated diverticular disease of the colon and for primary
prevention of diverticulitis: a systematic review of randomized clin-
ical trials. J Clin Gastroenterol 2016;50 Suppl 1:S64–9.
29. Lahner E, Bellisario C, Hassan C, Zullo A, Esposito G, Annibale B.
Probiotics in the treatment of diverticular disease. A systematic
review. J Gastrointestin Liver Dis 2016;25:79–86.
30. Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K, Group
AS. Randomized clinical trial of antibiotics in acute uncomplicated
diverticulitis. Br J Surg 2012;99:532–9.
31. Daniels L, Unlu C, de Korte N, van Dieren S, Stockmann HB,
Vrouenraets BC, Consten EC, van der Hoeven JA, Eijsbouts QA,
Faneyte IF, Bemelman WA, Dijkgraaf MG, Boermeester MA,
Dutch diverticular disease collaborative study G. Randomized clin-
ical trial of observational versus antibiotic treatment for a first epi-
sode of CT-proven uncomplicated acute diverticulitis. Br J Surg
2017;104:52–61.
32. Boostrom SY, Wolff BG, Cima RR, Merchea A, Dozois EJ, Larson
DW. Uncomplicated diverticulitis, more complicated than we
thought. J Gastrointest Surg 2012;16:1744–9.
33. Griffen WO, Jr. Management of the acute complications of diver-
ticular disease: acute perforation of colonic diverticula. Dis Colon
rectum 1976;19:293–5.
34. Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C,
Marcello PW, Schoetz DJ. Long-term follow-up after an initial
episode of diverticulitis: what are the predictors of recurrence?
Dis Colon Rectum 2011;54:283–8.
35. Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J,
Larson D. Complicated diverticulitis: is it time to rethink the rules?
Ann Surg 2005;242:576–81; discussion 581-3.
36. Somasekar K, Foster ME, Haray PN. The natural history divertic-
ular disease: is there a role for elective colectomy? J R Coll Surg
Edinb 2002;47:481–2, 484.

37. Myers E, Hurley M, O'Sullivan GC, Kavanagh D, Wilson I, Winter
DC. Laparoscopic peritoneal lavage for generalized peritonitis due
to perforated diverticulitis. Br J Surg 2008;95:97–101.
38. Anaya DA, Flum DR. Risk of emergency colectomy and colostomy
in patients with diverticular disease. Arch Surg 2005;140:681–5.
39. Li D, Baxter NN, McLeod RS, Moineddin R, Nathens AB. The
decline of elective colectomy following diverticulitis: a population-
based analysis. Dis Colon Rectum 2016;59:332–9.
40. Ricciardi R, Baxter NN, Read TE, Marcello PW, Hall J, Roberts PL.
Is the decline in the surgical treatment for diverticulitis associated
with an increase in complicated diverticulitis? Dis Colon Rectum
2009;52:1558–63.
41. Andeweg CS, Groenewoud J, van der Wilt GJ, van Goor H,
Bleichrodt RP. A Markov decision model to guide treatment of
recurrent colonic diverticulitis. Clin Gastroenterol Hepatol
2016;14:87–95 e2.
42. Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elec-
tive colectomy in diverticulitis: a decision analysis. J Am Coll Surg
2004;199:904–12.
43. Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery
for diverticulitis in the 21st century: a systematic review. JAMA
Surg 2014;149:292–303.
44. Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC,
Rosenberg J. Treatment of patients with acute colonic diverticulitis
complicated by abscess formation: a systematic review. Int J Surg
2016;35:201–208.
45. Lamb MN, Kaiser AM. Elective resection versus observation after
nonoperative management of complicated diverticulitis with ab-
scess: a systematic review and meta-analysis. Dis Colon rectum
2014;57:1430–40.
46. Schultz JK, Yaqub S, Wallon C, Blecic L, Forsmo HM, Folkesson J,
Buchwald P, Korner H, Dahl FA, Oresland T, Group SS.
Laparoscopic lavage vs primary resection for acute perforated di-
verticulitis: the SCANDIV randomized clinical trial. JAMA
2015;314:1364–75.
47. Angenete E, Bock D, Rosenberg J, Haglind E. Laparoscopic lavage
is superior to colon resection for perforated purulent diverticulitis-a
meta-analysis. Int J Colorectal Dis 2016
48. Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger
P, Buchli C, Grieder F, Gelpke H, Decurtins M, Tempia-Caliera
AA, Demartines N, Hahnloser D, Clavien PA, Breitenstein S. A
J Gastrointest Surg
multicenter randomized clinical trial of primary anastomosis or
Hartmann’s procedure for perforated left colonic diverticulitis with
purulent or fecal peritonitis. Ann Surg 2012;256:819–26; discus-
sion 826-7.
49. Guzzo J, Hyman N. Diverticulitis in young patients: is resection
after a single attack always warranted? Dis Colon rectum
2004;47:1187–90; discussion 1190-1.
50. Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P,
Soravia C. Long-term follow-up after first acute episode of sigmoid
diverticulitis: is surgery mandatory?: a prospective study of 118
patients. Dis Colon Rectum 2002;45:962–6.
51. Eusebio EB, Eisenberg MM. Natural history of diverticular disease
of the colon in young patients. Am J Surg 1973;125:308–11.
52. Perkins JD, Shield CF, 3rd, Chang FC, Farha GJ. Acute diverticu-
litis. Comparison of treatment in immunocompromised and
nonimmunocompromised patients. Am J Surg 1984;148:745–8.
53. Goldberg HJ, Hertz MI, Ricciardi R, Madoff RD, Baxter NN,
Bullard KM. Colon and rectal complications after heart and lung
transplantation. J Am Coll Surg 2006;202:55–61.
54. Leonardi MJ, Jamil KG, Hiscox B, Ross D, Hiatt JR. Abdominal
surgery after lung transplantation. Am Surg 2010;76:1130–4.
55. Hwang SS, Cannom RR, Abbas MA, Etzioni D. Diverticulitis in
transplant patients and patients on chronic corticosteroid therapy: a
systematic review. Dis Colon Rectum 2010;53:1699–707.
56. Albaran RG, Webber J, Steffes CP. CD4 cell counts as a prognostic
factor of major abdominal surgery in patients infected with the
human immunodeficiency virus. Arch Surg 1998;133:626–31.
57. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD,
Rafferty JF. Practice parameters for the treatment of sigmoid diver-
ticulitis. Dis Colon Rectum 2014;57:284–94.
58. Andeweg C, Peters J, Bleichrodt R, van Goor H. Incidence and risk
factors of recurrence after surgery for pathology-proven diverticular
disease. World J Surg 2008;32:1501–6.
59. Thaler K, Baig MK, Berho M, Weiss EG, Nogueras JJ, Arnaud JP,
Wexner SD, Bergamaschi R. Determinants of recurrence after sig-
moid resection for uncomplicated diverticulitis. Dis Colon Rectum
2003;46:385–8.
60. Egger B, Peter MK, Candinas D. Persistent symptoms after elective
sigmoid resection for diverticulitis. Dis Colon Rectum 2008;51:
1044–8.