39
Diverticular Disease
Jason Hall
Key Concepts
• The optimal diagnostic test to allow for optimal assess-
ment of severity of diverticulitis is CT imaging.
• The majority of patients with acute diverticulitis will
respond to antibiotic therapy.
• CT drainage of localized abscesses in diverticulitis will
often avoid the need for emergency operations, even in
patients who may not initially respond to medical therapy.
• Hartmann’s resection can often be avoided in most
patients requiring surgery for an acute attack. Resection
with primary anastomosis, with or without proximal
diversion (loop ileostomy), can be performed safely in the
absence of physiologic instability.
• The indications for elective resection after an acute attack
of diverticulitis are evolving but should be considered in
patients who remain symptomatic or develop a definite
complication (stricture, fistula, etc.)
Introduction
Colonic diverticula represent saccular outpouchings of the
colonic wall. Most patients with diverticulosis are asymptom-
atic. Symptomatic diverticular disease represents a whole
range of conditions ranging from mild abdominal pain and
bloating to free perforation with peritonitis and sepsis. These
presentations are stratified into complicated or uncomplicated
diverticulitis. Patients with left-sided abdominal pain and
sometimes fever and leukocytosis are considered to have
uncomplicated diverticulitis. Complicated presentations are
defined as episodes of free perforation, obstruction, stricture,
fistula, or hemorrhage. Diverticular hemorrhage is associated
with diverticulosis and not diverticulitis. Because of the wide
range of clinical presentations and potential for significant
morbidity/mortality, management of diverticular disease con-
tinues to represent a major challenge to clinicians. This chap-
ter examines the current pathophysiology, evaluation, and
© Springer International Publishing 2016
S.R. Steele et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, DOI 10.1007/978-3-319-25970-3_39
treatment of left-sided colonic diverticulosis and diverticuli-
tis. The management of diverticula of the foregut and diver-
ticular bleeding is left to other sources for discussion.
Incidence
In the twentieth century, there has been a rising prevalence of
diverticular disease in industrialized nations. Diverticulosis
is rare in patients younger than age 30. The incidence of this
colonic finding rises with age such that over 40% of patients
develop diverticula by the age of 60 years. Over 60% of
patients over 80 years have diverticular disease identified [1, 2].
In almost all cases (95%), diverticula involve the sigmoid
and left colon. In some series, the number of diverticula
increases proportionally with age. They are also found more
proximally as age increases. This may explain why in the
Western societies, right-sided diverticular disease is primar-
ily identified in older patients with pan-diverticulosis [3, 4].
In Asian countries, however, diverticulosis occurs more
commonly on the right side. Some authors estimate that in
Asia, 70% of the diverticula isolated to the right side [5–7].
Ten to twenty-five percent of patients who develop diver-
ticulosis will develop diverticulitis [8–12]. Administrative
data sources suggest that the incidence of diverticulitis is
increasing. According to the Agency for Healthcare Research
and Quality, over 295,000 patient discharges for diverticuli-
tis were reported at the United States hospital in 2006 [13].
One modern analysis of the National Inpatient Sample dem-
onstrated that rates of admission and elective operations rose
in the United States from 1998 to 2005. Rates of admission
and surgical intervention rose 82% and 73%, respectively, in
patients younger than 44 years [14]. Another study examin-
ing the same data source from 1991 to 2005 period noted an
increase diverticulitis discharges from 5.1 cases per 1000
inpatients in 1991 to 7.6 cases per 1000 inpatients in 2005
(p < 0.0001). There also appeared to be conflicting data
regarding the incidence of complicated diverticular disease.
645
646 J. Hall

a 9
8

(cases/1,000 in partients)
Diverticulitis Discharges
7

5
4
3

2
P<0.0001
1
0
1991 1993 1995 1997 1999 2001 2003 2005
Year
b 1.8
Diverticular-Free Perforations

1.6

1.4

1.2
1
0.8

0.6
0.4

0.2
P=NS
0
1991 1993 1995 1997 1999 2001 2003 2005
Year

FIGURE 39-1. (a) Diverticulitis discharges (uncomplicated and com- among all patients with diverticulitis in the Nationwide Inpatient
plicated) in the Nationwide Inpatient Sample from 1991 to 2005. (b) Sample from 1991 to 2005. With permission from Ricciardi et al. Dis
Proportion of patient discharges for free diverticular perforation Colon Rectum. 2009 Sep;52(9):1558–63 © Wolters Kluwer 2009 [15].

The proportion of diverticular abscess discharges increased Pathophysiology, Etiology,

from 5.9% in 1991 to 9.6% in 2005 (p < 0.0001). The propor-
tion of free diverticular perforations, however, remained
unchanged (1.5%) [15] (see Figure 39-1a, b). This increased
incidence has been noted in other industrialized countries. A
recent study from Norway revealed an increase in the inci-
dence of diverticular diseases from 17.9 to 51.1 cases per
100,000 person/years over a 4-year time period [16]. More
recent analysis of the National Inpatient Sample suggested
that diverticulitis admissions peaked in 2008 (96/100,000).
Rates of hospitalization for diverticular bleeding per 100,000
patients have declined from 32.5 to 27.1 (−5.4; 95% confi-
dence interval (CI), −5.1 to −5.7) from 2000 to 2010 [17].
and Epidemiology
Most colonic diverticula are pulsion or false diverticula.
These types of diverticula contain only the mucosal and
muscularis mucosal layers. Diverticula penetrate the
colonic wall where vasa recta penetrate the circular mus-
cle layer in order to provide blood supply for the mucous
membrane (Figure 39-2) [18]. In a non-pathologic situa-
tion, diverticula are soft and compressible, allowing a
free communication between the diverticulum and the
colonic lumen.
39. Diverticular Disease
FIGURE 39-2. Vasa recta penetrate the colonic wall at taenia libera,
omentalis, and mesocolica. This allows herniation of mucosa and
submucosa at these sites.
The exact pathogenesis of progression from diverticulosis to
diverticulitis is not clear. Classic pathophysiology mechanisms
suggested that stasis or obstruction of the diverticulum orifice
leads to bacterial overgrowth, increased intra-diverticular pres-
sure, ischemia, and inflammation. This mechanism is one bor-
rowed from the pathophysiology of appendicitis. Once the
colonic mucosa is ischemic, ulceration can occur leading to a
microperforation in most cases but sometimes formation of a
peridiverticular abscess or free perforation with peritonitis [19].
Histology and Pathology
Many of the microscopic features of diverticulitis include thick-
ening of the lamina propria, mucin depletion, and Paneth cell
hyperplasia. Crypt abscesses and ulceration are also observed in
some cases [20]. Many of the histologic features are similar to
those associated with inflammatory bowel disease [21]. Hinchey
developed pathologic criteria to classify the severity of diverti-
cular disease. This classification has been used and is divided
into Stages I–IV [22]. Stage I are patients with diverticulitis and
a pericolic abscess. Stage II represents patients with distant
abscesses such as a pelvic or retroperitoneal abscess. Stages III
and IV are patients with purulent and feculent peritonitis, respec-
tively (Table 39-1). A number of attempts have been made to
extend the Hinchey criteria to a preoperative staging on CT scan
[23] (Table 39-2). The utility of the system proposed by Hinchey
and by others based on it is limited because purulent and feculent
peritonitis can only usually be determined post hoc.
647
TABLE 39-1. Hinchey classification system
Stage I Pericolic or mesenteric abscess
Stage II Pelvic or retroperitoneal abscess
Stage III Purulent peritonitis
Stage IV Feculent peritonitis
TABLE 39-2. Modified Hinchey classification system
Stage 0 Mild clinical diverticulitis
Stage Ia Confined pericolic inflammation phlegmon
Stage Ib Confined pericolic abscess (within sigmoid
mesocolon)
Stage II Pelvic, distant intra-abdominal or intraperitoneal
abscess
Stage III Generalized purulent peritonitis
Stage IV Fecal peritonitis
Modified from Warsavary et al. [24]
Role of Fiber
A number of authors have postulated that diverticular disease
is related to fiber deficiency [25]. Painter and Burkitt studied
colonic transit times and fiber contents in patients in Uganda
and the United Kingdom. Patients with a higher fiber intake
had more frequent bowel movements, faster colonic transit
times, and larger stool volumes. Specifically, Painter and
Burkitt postulated that a progressively more processed diet
removed a large source of fiber from the Western diet. These
data are confounded by a number of factors including differ-
ing life expectancies in industrialized and nonindustrialized
countries [26]. It is interesting to not that as nonindustrial-
ized societies have adopted a more Western diet; a number of
authors have noted an increasing prevalence of diverticular
disease [27].
A number of studies have examined dietary factors in large
populations of patients with and without diverticular disease
[28, 29]. Both studies demonstrated an inverse association
between diverticular disease incidence and fiber intake. The
relative risks associated with fruit and vegetable fiber intake
were 0.62 [95% CI 0.45–0.86] and 0.55 [95% CI 0.37–0.84]
[28]. Fiber found in fruits and vegetables conferred the most
protective effect (compared with fiber from cereal), and a high
intake of total fat and red meat increased the incidence of diver-
ticular disease. Manousus et al. [29] compared individuals who
ate a predominantly vegetarian diet to those who predominantly
ate meat. The risk of developing diverticular disease was 50-fold
greater in meat eaters. In a more recent cohort (47,228 male
health professionals), popcorn, nut, and seed consumption was
inversely correlated with diverticulosis or diverticular compli-
cations. This study refutes the adage that “nuts, corn, seeds, and
popcorn” cause diverticulitis and should be avoided in patients
who have had an attack of diverticulitis [30].
648
Alternative Pathophysiology Pathways
and Taenia-Specific Elastosis
A number of non-dietary alternative theories regarding the
evolution of diverticular disease have been proposed. Most
of these theories center around the suggestion that the smooth
muscle in the sigmoid colon behaves differently in other
areas of the body. One particularly consistent finding in
patients with diverticular disease is wall thickening often in
the absence of inflammation [31]. Histologic studies have
determined that colonic walls are thickened secondary to
elastin deposition and not muscular hypertrophy or hyper-
plasia. In one study, the concentration of elastin in patients
with diverticular disease was increased over 200% when
compared with controls. The elastin is often laid down in a
contracted form, leading to bunching of the taenia and appar-
ent foreshortening of the bowel [32].
Despite the grossly increased muscle wall thickness,
patients with diverticulosis appear to be more susceptible to
mucosal herniation. In patients with diverticulitis, collagen
fibrils demonstrate increased cross-linking with increased age;
this process seems to increase most dramatically after 40 years
of age, the age at which the incidence of diverticular disease
also appears to increase. This same study demonstrated that
patients with diverticulosis have an abnormally high amount
of collagen cross-linkage in the colon wall. This difference
persists even when patients were compared with age-matched
controls. Increased cross-linkage of collagen fibers likely
causes the tissues to become stiffer and less resistant to stretch-
ing. The loss of compliance of the colonic submucosa, the
layer primarily responsible for tensile strength, may make the
submucosa more susceptible to small tears when subjected to
the higher intraluminal pressures triggered by segmentation.
Any tear in this layer could potentially then lead to mucosal
herniations and the formation of diverticulosis [33].
A possible genetic connective tissue defect has also been
suggested because of reports of diverticular in young patients
with Marfan’s syndrome or Ehlers-Danlos syndrome [34–
36]. It is likely that a number of processes including impaired
motility, low fiber intake, inflammation, and elastin deposi-
tion contribute to the pathogenesis of diverticular disease.
Additional Risk Factors
Age
There has been considerable debate in the medical literature
regarding the role of age in the pathogenesis of diverticulitis.
Diverticular disease tends to affect patients during middle age as
the incidence rises from 5% at age 40 to 80% by age 80 [37].
Traditionally, diverticulitis in younger patients has been described
as more virulent, and young patients were thought to be more
likely to have complicated disease and more likely to require
resection [38, 39]. Young patients have been variably defined as
J. Hall
under 50 years old in some series and under 40 or 45 years old in
other series. Despite variability in what constitutes a “young
patient,” most modern series of younger patients with acute diver-
ticulitis have noted a striking male predominance [40].
Sex
The prevalence of the disease among the sexes is difficult to
ascertain. The prevalence has been estimated to be between 2:3
and 3:1 male-to-female ratio [12, 41]. More recent estimates
suggest that patients with symptomatic diverticular disease
under the age of 65 tend to be male. Some studies have demon-
strated that male patients may present with more severe CT
findings of diverticulitis than female patients [42]. Recent data
suggests that men have a higher incidence of diverticular bleed-
ing, while obstructions are more common among women [43].
Geographic Factors
Diverticulitis is much less common in Asian populations [25].
When diverticulitis does occur, it tends to involve the right-
sided colon in up to 70% of cases [36]. It is unclear if this is an
environmental, dietary, genetic, or geographic factor.
There is a relationship between increasing industrializa-
tion and incidence of this disease. A number of earlier stud-
ies have documented the low prevalence of the disease in
African nations [44–46]. Other authors have noted increased
rates of diverticulitis in Africans with increased penetration
of the Western lifestyle patterns [47]. Reports from both
Japan and Singapore have shown increases in prevalence
approaching 20%. This is thought secondary to the increased
acceptance of the Western diets [48, 49].
Physical Activity
Two studies have examined the effect of exercise on the develop-
ment of diverticular disease [50, 51]. The risk of developing
diverticular disease and levels of physical activity appear to be
inversely related. This difference persisted even when the authors
adjusted differences in dietary fiber intake. A potential drawback
of the study is that the differences may have arisen from the fact
that the ability to exercise might have been impaired or prohib-
ited by symptoms of diverticular disease [50].
Smoking
The potential association between diverticular disease and
smoking is contradictory. One large case-control study dem-
onstrated that smokers had three times the risk of developing
complications from diverticular disease than did nonsmokers
[52]. Another large cohort study of 46,000 men in the United
States failed to show a similar association [51].
39. Diverticular Disease
Nonsteroidal Anti-inflammatory Agents
The use of nonsteroidal anti-inflammatory agents has
been associated with the development of a number of
gastrointestinal complications. Evidence suggests that
chronic NSAID use is almost twice as common in patients
with diverticular disease as healthy controls with no
known colonic disease [53, 54]. While the health profes-
sionals follow-up study showed an increased incidence
of uncomplicated diverticular disease in patients who
used NSAIDs compared with their asymptomatic coun-
terparts, additional studies have noted an increased risk
of complicated diverticulitis with NSAID use [55]. One
retrospective study showed a 23% higher risk of perforat-
ing diverticulitis in patients who took NSAIDs regularly
compared with patients with diverticular disease who did
not take NSAIDs [56]. An additional study of hospital-
ized patients demonstrated chronic NSAID use to be
much higher in patients admitted with diverticular dis-
ease than the population as a whole. In addition these
patients were four times more likely to develop perfo-
rated diverticulitis than patients with no history of
NSAID use [57].
Caffeine Ingestion
Caffeine intake has been investigated as a possible contribut-
ing factor to the development of diverticular disease as it can
affect colonic transit time [58]. No difference in caffeine
consumption was identified in groups of patients with and
without diverticular disease [51].
Obesity
A number of retrospective case series have noted a strik-
ing preponderance of obese patients with diverticulitis,
particularly patients under the age of 40 [39, 59, 60]. In
addition, two prospective cohort studies (the health pro-
fessionals follow-up study and a Swedish study) have
shown an association between body mass index (BMI)
and diverticular disease [51, 61, 62]. The US health pro-
fessionals study has shown an increased risk of diverticu-
litis and diverticular bleeding not only with increasing
BMI but also waist circumference and waist-to-hip ratio
[61]. A recent study from South Korea recently demon-
strated an association between cross-sectional visceral
fat area and complicated diverticulitis [63]. Obesity has
been linked not only to inflammation but also to differ-
ences in the intestinal flora which may be potential
mechanisms for the increased risk of diverticulitis [64–
66]. Although this area of research is new, it may suggest
that a large visceral fat mass may act as an immunologic
or endocrine organ. This mechanism may affect inci-
dence of diverticulitis.
649
Microbiome
Humans exist in a close relationship with a variety of micro-
organisms. Of particular interest are microorganisms which
reside in the gastrointestinal tract. Microbes in the human
gastrointestinal tract contain 1012–1014 genes [67]. The aggre-
gate, multi-organismic, genetic code of those varied microor-
ganisms is referred to as the microbiome. There is little
published clinical evidence suggesting a direct link between
fecal microbiota and diverticular disease. A number of authors
have extrapolated from other known relationships. For exam-
ple, Daniels et al. explore findings of altered microbiota in the
flora of patients with morbid obesity, colon cancer, irritable
bowel syndrome, and inflammatory bowel disease. Based on
these findings, they proposed that altered fecal microbiology
may also have an effect on the pathogenesis of diverticular
disease. While the finding of altered microbiota in various
disease states is intriguing, there is still ample debate as to
whether these changes are causative of disease or simply a
phenotype of the disease process itself. [68].
Clinical Manifestations and Physical
Findings
There are three main clinical presentations of diverticular
disease (Table 39-3). The most common clinical presentation
of diverticulitis is what is termed uncomplicated diverticuli-
tis. This presentation is characterized by left-sided abdomi-
nal pain with or without an associated mass, fever, and
leukocytosis. Patients generally resolve the acute episode
after treatment with antibiotics. Typically most patients can
be treated as outpatients.
Another manifestation is smoldering diverticulitis. This pre-
sentation only partially improves on antibiotics and medical
therapy. Such patients have recurrent symptoms which can
manifest with ongoing low-grade fever and left-sided abdomi-
nal pain. CT scans on such patients generally will demonstrate a
persistent phlegmon, and these patients often require resection
to treat ongoing symptoms. Some of these patients will present
with associated obstruction, abscess, fistula, or perforation.
TABLE 39-3. Typical presentation patterns of diverticulitis
Acute diverticulitis
Typical, relapsing (chronic)
Subacute
Complicated diverticulitis
Obstruction
Mass/abscess
Fistula
Hemorrhage
Perforation
Chronic diverticulitis
Atypical
Atypical site (transverse, ascending)
650
Finally, a small group of patients may have atypical pre-
sentations. Most of these patients have chronic left lower-
quadrant pain. They however lack objective evidence of
diverticulitis such as leukocytosis, fever, or objective find-
ings on CT scan. Many patients with atypical presentations
of diverticulitis may have irritable bowel syndrome.
Surgeons therefore must be facile with telling the difference
between both conditions.
Symptoms
Patients with acute diverticulitis typically present with left-
sided abdominal pain, fever, and leukocytosis. Associated with
abdominal pain will be a physical finding of left lower quadrant
pain and tenderness on examination. Patients with free perfora-
tion will typically present with diffuse peritonitis and signs of
systemic toxicity. An abdominal mass may be palpable or mass
appreciated on rectal or pelvic exam when there is a significant
phlegmon involving the colon. Many patients will present with
abdominal tenderness that is often associated with some degree
of abdominal distension. Right-sided tenderness can be a pre-
sentation in patients that have a redundant sigmoid colon that
extends to the right side of the abdomen. Free perforation is
associated with diffuse abdominal pain, sometimes referred
pain in the shoulder, and shortness of breath.
Many patients often describe changes in their bowel hab-
its such as constipation, diarrhea, or an alternation in stool
caliber. Rectal bleeding rarely occurs as a presentation of
acute diverticulitis. If present, rectal bleeding is more sug-
gestive of ischemic colitis or inflammatory bowel disease. In
complicated presentations, an inflammatory phlegmon can
be associated with a small or large bowel obstruction.
Patients with an obstruction will present with abdominal dis-
tention and sometimes nausea and vomiting.
Patients with fistulas may have minimal abdominal com-
plaints and may present initially to a urologist or gynecolo-
gist. Patients who develop complications of diverticular
disease such as colovesical fistulas may present with pneu-
maturia, pyuria, or fecaluria, while patients with colovaginal
fistulas may present with vaginal discharge, vaginal air, or
stool per vagina.
A number of patients with “chronic” or atypical diverticu-
lar disease will present with pain as their predominant symp-
tom in the absence of other physical findings. The pain is
typically persistent and boring, remaining constant over long
periods of time. It does not tend to be “crampy” in nature as
in patients with irritable bowel syndrome but is difficult to
distinguish from this entity [69].
Diagnostic Evaluation
Most laboratory tests are not terribly helpful in the evalua-
tion of acute diverticulitis. Many patients with acute diver-
ticulitis present with leukocytosis. Patients with a colovesical
J. Hall
fistula may have an abnormal urinalysis and/or a culture with
enteric organisms.
Although a number of different modalities have been used
to evaluate patients with suspected diverticular disease, com-
puted tomography has emerged as the study of choice. Flat
and upright plain films of the abdomen are commonly
obtained in the evaluation of the patient with acute abdomi-
nal pain to exclude obstruction or free intraperitoneal air. In
patients with diverticular disease, the findings of plain films
tend to be nonspecific [70]. Ultrasound has not gained wide
acceptance in the United States. Contrast enemas are seldom
currently used in the evaluation and management of diver-
ticulitis. Water-soluble contrast studies are useful in which
there is a potential need for urgent surgery and a stricture is
suspected.
The most useful test for examination of patients with acute
abdominal pain is the abdominal CT. CT findings associated
with diverticulitis were first described over 30 years ago.
These signs included the presence of diverticula, pericolic
fat stranding, colonic wall thickening more than 4 mm, and
abscess formation [71]. For evaluation of acute diverticulitis,
CT has the ability to stage the severity of disease and adds
the possibility of providing a roadmap for percutaneous
drainage of an associated abscess. CT has the added advan-
tage of detecting other intraperitoneal findings including
hepatic abscesses, pylephlebitis, small bowel obstruction,
colonic strictures/obstruction, and colovesical fistulas.
The first system for classifying the severity of diverticuli-
tis on CT findings to guide clinical management was pro-
posed by Ambrosetti. CT findings consistent with mild
diverticulitis included localized wall thickening (>5 mm)
and inflammation of the pericolic fat. Severe CT findings
were the combination of localized wall thickening and
inflammation of the pericolic fat with abscess, extraluminal
air, or extraluminal contrast (Table 39-4). When the natural
history of patients with diverticulitis was stratified by these
CT criteria, the authors found that patients with severe CT
findings underwent operative intervention more frequently
than those patients with mild findings (33% vs. 15%).
Patients under 50 years of age with severe findings on CT
scan were also more likely to have recurrences or complica-
tions [72]. In prospectively collected dataset, patients with
findings of severe diverticulitis on CT scan were more likely
to have recurrent attacks of diverticulitis after an initial
TABLE 39-4. Ambrosetti CT criteria for diverticulitis severity
Mild diverticulitis Wall thickening (>5 mm)
Pericolic fat stranding
Severe diverticulitis Wall thickening (>5 mm)
Pericolic fat stranding
with
Abscess
Extraluminal air
Extraluminal contrast
Adapted from Ambrosetti et al. [72]
39. Diverticular Disease 651

attack of acute diverticulitis treated with antibiotics when
compared to patients with mild diverticulitis (39% vs. 14%)
[73]. Poletti et al. explored CT and demographic predictors
for nonoperative treatment failure in 312 patients with a first
episode of left-sided diverticulitis and concluded that the
presence of an abscess or extraluminal air >5 mm in diame-
ter were significant predictors of treatment failure [74].
CT findings which are relevant to clinical management
were reclassified into classification system based on the
Hinchey classification system (Table 39-2). In grade 0 there is
colonic wall thickening but not pericolonic fat stranding.
Grade 1a consists of wall thickening and pericolonic fat
stranding, while grade 1b includes a pericolonic or mesocolic
abscess. Patients with grade 2 disease have distant intraab-
dominal or pelvic abscesses. Patients with grade 3 and grade
4 disease have purulent and fecal peritonitis, respectively. CT
is somewhat limited in distinguishing between patients with
grade 3 and grade 4 disease as purulent and fecal peritonitis
often cannot be distinguished on imaging (Figs. 39-3, 39-4,
and 39-5a–d) [75]. Kaiser et al. found that disease severity

FIGURE 39-3. Modified Hinchey Stage Ia Diverticulitis—Arrow

points to pericolic inflammation and phlegmon.

FIGURE 39-4. Modified Hinchey Stage II Diverticulitis—Arrow

points to pelvic abscess.

FIGURE 39-5. (a) Modified

Hinchey Stage III
Diverticulitis—Arrow points to
free fluid. (b) Modified Hinchey
Stage III Diverticulitis—Arrow
points to free air. (c) Modified
Hinchey Stage III
Diverticulitis—Demonstrates
intra-abdominal free fluid. (d)
Modified Hinchey Stage III
Diverticulitis—Arrow points to
pelvic fluid.
652
using the modified CT Hinchey classification system
correlated with postoperative morbidity and mortality. This
group also found that the CT stage correlated with recurrence
when patients were managed nonoperatively. The presence of
a diverticulitis-associated abscess was one particular factor
which was highly associated with high risk of failure of
nonoperative management [76].
Endoscopic Evaluation
Endoscopic evaluation of the colon is recommended follow-
ing an acute episode of diverticulitis. This approach is gener-
ally advocated to exclude the presence of a malignancy or an
alternative diagnosis such as ischemic colitis or inflamma-
tory bowel disease. In actual practice, finding a malignancy
is rare. Bryan et al. evaluated 307 patients with flex sig
(20%) or colonoscopy (80%) following an acute episode of
diverticulitis. Interestingly, they found only 2 patients with
colorectal carcinomas. A significant proportion of patients
had advanced neoplastic lesions (3.4%), hyperplastic polyps
(6.8%), and adenomas (8.8%) [77]. These findings were
mirrored by a study by Lau et al., with 319 patients who
underwent endoscopic surveillance. Overall, 26% of patients
had polyps (9 polyps > 1 cm) and 2.8% were found to have
colorectal cancers [78].
Endoscopic procedures (flexible sigmoidoscopy and colo-
noscopy) are generally not advocated during an acute epi-
sode of diverticulitis. A delay of 6 weeks following resolution
of symptoms is recommended. This approach is encouraged
in order to avoid potential conversion of a sealed microperfo-
ration into a free perforation [79]. This position has been
questioned by other groups who have demonstrated that
colonoscopy during an acute episode of diverticulitis can be
safe. Even when optical examination of the colon is per-
formed in the acute setting, a significant number of the pro-
cedures cannot be completed [79, 80].
Cystoscopy or cystography have been used to identify
suspected colovesical fistulas. In CT scan era, however, the
presence of air in the urinary bladder in the absence of instru-
mentation is considered diagnostic [81].
Differential Diagnosis
The differential diagnosis for suspected diverticular disease
includes appendicitis, bowel obstruction, colorectal cancer,
ischemic colitis, pyelonephritis, gynecologic disease, inflam-
matory bowel disease, and irritable bowel syndrome. Other
diagnoses that should be entertained include endometriosis,
tubo-ovarian abscess, pelvic inflammatory disease, ureteral
calculi volvulus, stercoral ulcer, and ovarian torsion. Modern
cross-sectional imaging is often helpful in diagnosing many
of these clinical entities. The most important diagnosis to
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exclude on initial presentation is colorectal cancer. CT
scanning confirms a diagnosis of diverticular disease, but
often endoscopy is helpful to distinguish between diverticu-
lar disease and colorectal cancer and inflammatory bowel
disease.
Treatment of Acute Diverticulitis
Treatment of Uncomplicated Diverticulitis
Antibiotics
Antibiotic therapy remains the most important component of
the management of patients with acute uncomplicated diver-
ticulitis. Despite the broad application of antibiotics in the
operative and nonoperative therapy of diverticulitis, there have
been few studies examining the optimal dosing and frequency
of administration of these agents [82]. The microflora associ-
ated with diverticular microperforation include flora such as
Gram-negative rods, Gram-positive rods, and anaerobic bacte-
ria. The anaerobic bacteria are far more common and outnum-
ber the aerobic 1000:1 [83]. There are a number of single and
combination antibiotic regimens for the management of acute
diverticulitis. All of the regimens have activity against the
colonic flora; however, little is known about their efficacy [83].
Kellum et al. randomized 51 patients to a regimen of cefoxitin
alone vs. gentamicin/clindamycin. Patients in need of an urgent
operation were excluded. These authors concluded that the
single-agent regimen exhibited similar efficacy to the two-
agent regimen. They recommended the use of cefoxitin as this
was cost-effective [84].
The American College of Gastroenterology guidelines for
the treatment of diverticulitis include cefoxitin or ampicillin/
sulbactam as single agents or a third-generation cephalospo-
rin, aminoglycoside, or monobactam in combination with an
anti-anaerobic agent [84]. The American Society of Colon
and Rectal Surgeons published their practice parameters for
the management of diverticulitis in 2006. They recom-
mended that antibiotic therapy be selected to provide ade-
quate coverage of the most common colonic organisms. The
authors maintained that single and combination regimens
were equally effective. Even with appropriate antibiotic ther-
apy recurrences, approximately one-third of patients will
have a recurrence [8].
The ASCRS guidelines were further revised in 2014 to
suggest that antibiotics were “usually” used in the initial
management of uncomplicated diverticulitis. These guide-
lines take account of new data which suggested that antibi-
otic therapy may be optional and uncomplicated diverticulitis
[85]. de Korte et al. reported on a series of 272 patients who
were studied in a case-control fashion. All patients in their
study had mild diverticulitis and were admitted to one of two
hospitals. In the first hospital, antibiotics were administered,
39. Diverticular Disease
and in the second hospital, Foley IV fluids and bowel rest
were prescribed. The authors found no difference in treat-
ment failure [86]. The AVOD (Antibiotika Vid Okomplicerad
Divertikulit—Swedish for ‘antibiotics in uncomplicated
diverticulitis’) trial and a modest patient with uncomplicated
diverticulitis into an antibiotic therapy and IV fluids vs. IV
fluids the management of uncomplicated diverticulitis. This
study treated 623 patients with CT confirmed uncomplicated
diverticulitis. One group received intravenous fluids, and the
other group received intravenous fluids and antibiotics. The
authors found similar rates of recurrence, time to recovery,
and complications in both groups [87]. A recent Cochrane
Review of the subject examined three randomized trials.
This study did not find a significant difference between anti-
biotic administration and no antibiotic administration in the
management of uncomplicated diverticulitis [88].
Despite this new data, antibiotic therapy continues to be
widely used in the management of all forms of diverticulitis.
Patients with minimal symptoms and mild signs of perito-
neal irritation can typically be treated as outpatients. Patients
who present with fever, systemic symptoms, or inability to
tolerate oral intake are usually hospitalized. Parenteral anti-
biotics are typically administered until the acute symptoms
resolve. Once there is clinical improvement, the antibiotic
route is changed to oral administration.
Diet
A diet that is rich in fiber may increase the bulkiness of
stools, decrease colonic transit time, and therefore decreases
intraluminal pressures [89]. The optimal amount of daily
fiber is unknown; however, 20–30 g is a widely recom-
mended figure. Recent evidence supports the notion that per-
sons with diets high in fiber have decreased rates of
diverticulosis and bear a lower risk of developing diverticuli-
tis [28–30]. Based on this information, a number of dietary
societies have suggested that there is little evidence to sup-
port a change of diet or elimination of specific foods follow-
ing an episode of diverticulitis. The only requirement that is
repeatedly emphasized across the medical literature is the
need to maintain a high-fiber diet [90, 91].
Emerging Medical Therapies
Mesalamaine
As the microperforation pathophysiology of diverticular dis-
ease has come into question, there has been increased inter-
est in the use of immunomodulatory agents in the management
of diverticular disease. 5-ASA products and sulfasalazine
alter DNA synthesis and cell cycle progression in lym-
phocytes. 5-ASA compounds are also thought to suppress
leukotriene and prostaglandin synthesis, thus reducing pro-
inflammatory states [84, 92]. Because a low-grade proin-
flammatory state is the proposed mechanism underlying
653
chronic diverticular disease, a number of small trials have
evaluated the effectiveness of mesalamine-like compounds.
In all of these studies, the outcome of interest was symptom
severity, and none reported any objective analysis of the
actual inflammatory burden (i.e., imaging). In the original
description of the use of mesalamine for the management of
diverticulitis, Trespi et al. demonstrated that patients treated
with antibiotics and mesalamine had decreased symptom-
atology [93].
Another study randomized patients with diverticulitis to a
rifaximin-only arm vs. a rifaximin/mesalamine arm. Patients
in the rifaximin/mesalamine arm demonstrated significantly
improved bowel habits. They also had less recurrent epi-
sodes and demonstrated lower symptom severity [94]. In
another study, mesalamine alone was compared to rifaximin
alone. The authors compared several outcomes including
general illness, nausea, abdominal pain/discomfort, emesis,
dysuria, fever, abdominal tenderness, diarrhea, tenesmus,
and bloating. Patients treated with mesalamine had signifi-
cantly lower global scores than patients treated with rifaxi-
min alone. Therefore this study concluded that mesalamine
is an effective medication for preventing recurrence of diver-
ticulitis and maintaining remission [95].
In a systematic review which included six randomized tri-
als of 5-ASA products in the treatment of diverticulitis,
patients treated with 5-ASA products had better outcomes
than those not treated with 5-ASA. They also concluded,
however, that larger trials which had objective confirmation
of diagnosis by endoscopy are needed for confirmation of the
initial data on this type of treatment [96]. Despite initial
enthusiasm for the use of these products, they have not, at the
time of this manuscript, found significant adoption in the
United States.
Probiotics
Probiotics are marketed as preparations of naturally occurring
colonic microflora which can have a beneficial effect on those
that ingest them. Because patients with diverticular disease are
thought to have altered colonic microflora due to constipation
and stasis of fecal matter, it has been suggested that probiotics
may have a role in the management of this disease [97].
Giaccari et al. examined the administration of rifaximin
and Lactobacillus in patients with diverticular disease. They
reported no complications and adequate symptom control.
They concluded that the combination of rifaximin and
Lactobacillus was an adequate regimen for prophylaxis
against the complications of diverticular disease [98]. In a
smaller study (15 patients), investigators compared adminis-
tration of nonpathogenic E. coli with active coal tablets to
coal tablets alone. These authors concluded that the length of
remission was significantly longer when a probiotic was
administered (14 months vs. 2.4 months) [99]. Although the
initial results are promising, there is only a small amount of
data supporting the use of probiotics.
654
Elective Surgical Management
of Recurrent Uncomplicated
Diverticulitis
For many decades, the indications for surgical management
of diverticulitis were clear. Elective resection was suggested
after two well-documented attacks of uncomplicated diver-
ticulitis requiring hospitalization and/or after one episode of
complicated diverticulitis. In patients under 40 years of age,
elective resection was recommended after the first attack of
complicated or uncomplicated diverticulitis. These guide-
lines were endorsed by a number of societies including the
American Society of Colon and Rectal Surgeons, the Society
for Surgery of the Alimentary Tract, the European
Association for Endoscopic Surgery, and the American
College of Gastroenterology [84, 100–102].
These recommendations have been challenged by new
data. Salem et al. suggested that waiting until the fourth
attack of uncomplicated diverticular disease would be asso-
ciated with fewer intestinal stomas and fewer deaths [103].
Another study concluded that elective resection after the
third attack would be more cost-effective. The guidelines for
surgery were revised by the American Society of Colon and
Rectal Surgeons in 2006 and suggested that the “number of
attacks of uncomplicated diverticulitis is not necessarily an
overriding factor in defining the appropriateness of surgery”
[8]. These recommendations were echoed in the most current
practice parameters. Recommendations should be individu-
alized by the age and medical condition of the patient, by the
severity and frequency of the attacks, and by the presence of
ongoing symptoms [85].
Furthermore, most patients who present with complicated
diverticulitis will have complicated disease on the first
attack; resection after recovery from uncomplicated diver-
ticulitis does not prevent the development of complicated
diverticulitis [68, 104]. Interestingly, the risk of needing a
colostomy following a successfully managed episode of
diverticulitis is small (1/2000). Therefore, the practice of
recommending elective surgery to avoid future stoma forma-
tion should be avoided [85].
Young Patients
Several authors have proposed that patients younger than
40–50 years of age present with a move virulent form of
diverticulitis [104]. Historical recommendations have advo-
cated sigmoid resection for young patients after one well-
established attack of diverticulitis; however, this dictum has
been called into question by recent evidence. Although
younger men are proposed to have severe diverticulitis more
often than older men, they require operative intervention less
frequently [72]. In addition, other authors have pointed
out that younger patients did not have different rates of
J. Hall
conservative management, emergency operation, or mortality
when compared to older patients [103]. Although there is
some evidence that young patients present with a more viru-
lent form of the disease, it is not clear that these patients will
go on to have a recurrence. In a study by Guzzo et al., 1
patient out of 196 young patients (<50 years) had a free per-
foration after medical management of diverticulitis. The
median follow up was 60 months. Recent analysis of a large
administrative dataset suggested that young patients may
indeed have a higher risk of recurrence (27%) but have low
rates of emergency surgical intervention (7.5%) [105]. Given
the current level of evidence, there is no clear mandate to
treat young patients with diverticulitis differently than the
other age groups [106].
Complicated Diverticular Disease
Complicated diverticulitis is defined as diverticulitis associ-
ated with perforation, fistula, abscess, stricture, or obstruc-
tion. Management of complicated diverticular disease is
dependent on the particular presentation of the disease.
Treatment of the complications of diverticulitis may range
from treatment with bowel rest and parenteral antibiotics to
emergent exploratory laparotomy. We will review the treat-
ment options for each of the complications of diverticulitis
separately.
Diverticular Abscess
Diverticular abscess occurs in approximately 10–25% of
patients with acute diverticulitis. Abscesses include perico-
lic, hepatic, pelvic, and retroperitoneal abscesses. In women,
a fistula from the colon to the adenexa may result in tubo-
ovarian abscesses [107]. Traditionally, in patients with diver-
ticulitis and an associated abscess, the goals of care were to
treat the inflammatory process and later to operate on an
elective basis when the risk of infectious complications is
substantially lower. This approach was based on the obser-
vation that over 40% will develop recurrent sepsis [76].
However, reports of patients who have undergone percutane-
ous or operative drainage with no further septic sequelae
have called this practice into question. Franklin and col-
leagues reported on 18 patients who underwent laparoscopic
drainage of Hinchey II abscess, and at a follow-up of 4–34
months, 15 remained asymptomatic without the need to
undergo resection [108].
Cross-sectional imaging of the abdomen is the most effec-
tive way of diagnosing and staging diverticular abscesses.
The initial approach to patients with diverticular abscess
includes bowel rest, antibiotics, and close observation.
Abscesses less than 4 cm in size often resolve with intra-
venous antibiotics alone without the need for further pro-
cedures [8, 109–111]. For those patients with diverticular
39. Diverticular Disease
FIGURE 39-6. Pigtail catheter
in a complex diverticular pelvic
abscess.
abscess who do not improve on initial antibiotic therapy and
continue to have signs of sepsis (fever, abdominal pain, and
leukocytosis), percutaneous drainage is preferred.
A recent review suggested that 20–30% of diverticular
abscesses were amenable to percutaneous drainage and the
failure rate of percutaneous drainage was 20–30% [111]. The
preferred approach for percutaneous drainage is usually by a
transabdominal route (Figure 39-6) [112]. If the abscess is not
accessible by this route, a transgluteal, transperineal, or tran-
srectal routes may be employed. Transabdominal tends to be
better tolerated in terms of patient comfort when compared to
other access routes. In patients with simple unilocular
abscesses, successful drainage is achieved in approximately
80%. Patients with more complex abscesses associated with
loculations and fistula or whose drainage route transverses
normal organs are associated with a higher failure rate [112].
The expertise and skill of the interventional radiologist is also
associated with a higher success rate.
The decision for surgery following successful drainage of
a diverticular abscess should be approached on a case-by-case
basis. Diverticulitis associated with abscess denotes more
severe diverticulitis, and a substantial number of patients
require sigmoid resection. While 40–50% of patients admit-
ted with diverticular abscesses respond to conservative treat-
ment, sigmoid resection is recommended for selected
patients particularly those with more complex or larger
abscesses and those with recurrent or persistent symptoms
such a colocutaneous fistula [113]. Ideally, elective surgery
is performed after initial treatment with antibiotics and/or
percutaneous drainage as indicated.
Perforated Diverticulitis
Approximately 1% of patients with diverticulitis develop
free perforation which may include purulent or fecal perito-
nitis (Figure 39-1b). Free perforation almost exclusively
develops on the first attack of diverticulitis and is generally
not seen in patients who have had multiple attacks of diver-
ticulitis. Similarly, there is general consensus that patients
655
with perforated diverticulitis manifested by purulent
peritonitis or feculent peritonitis require operative interven-
tion. The mainstay of treatment for perforated diverticulitis
over the last several decades has been the Hartmann pro-
cedure which resects the disease and eliminates the septic
focus. A disadvantage of the procedure is the requirement for
a second major surgical procedure to reverse the colostomy
and the attendant morbidity and potential mortality of the
procedure. Data from large administrative databases suggest
that at least one-third of patients may never undergo reversal
[114], and up to 70% of patients, over 77 years may not
undergo reversal [115]. Women are less likely than men to
undergo Hartmann reversal [114, 116].
There has been renewed interest in performing resection
and primary anastomosis in selected patients with Hinchey
III and Hinchey IV diverticulitis. A number of systematic
reviews and meta-analyses have suggested that primary
anastomosis is superior to Hartmann resection for patients
with perforated diverticulitis; however there is considerable
selection bias [103, 117]. In clinical practice, the decision to
perform a primary anastomosis should be done on a case-by-
case basis. A number of technical- and patient-related factors
must be considered by the surgeon to determine if the patient
is a good candidate for a primary anastomosis. Hemodynamic
instability, diffuse peritonitis (either purulent or fecal), isch-
emia or significant edema of the bowel at an intended site of
anastomosis and anemia, malnutrition, and immunocompro-
mised state are general contraindications to a primary anas-
tomosis [118]. Although discussed frequently in the
literature, data from the Nationwide Inpatient Sample has
not shown any evidence that primary anastomosis is being
more commonly used as the preferred procedure for patients
who undergo surgery for acute diverticulitis [14].
Recently, alternatives to resection and definitive treatment
with laparoscopic lavage have been reported. Based on a
small series of successful laparoscopic lavage for treatment
of patients with perforated diverticulitis with purulent perito-
nitis, a prospective multi-institutional study of 100 patients
has been reported [119]. Patients with perforated diverticuli-
tis and generalized peritonitis underwent laparoscopic lavage
656
as definitive treatment. No effort was made to mobilize and
resect the sigmoid colon. The median age was 62.5 years
with a follow-up of 36 months. Eight patients were found to
have fecal peritonitis and converted to an open procedure
and underwent resection. The remaining 92 patients were
successfully treated with laparoscopic lavage with a 4%
morbidity and a 3% mortality. Two patients later required
intervention for a pelvic abscess, and two patients presented
with recurrent diverticulitis in the study period. These data
challenge our conventional surgical teaching and suggest
that selected patients with purulent peritonitis from divertic-
ulitis may be successfully treated with laparoscopic lavage
without resection of the affected segment of colon [119].
A subsequent review of eight studies of 213 patients
with acute complicated diverticulitis managed by laparo-
scopic lavage has noted a 3% conversion rate. Ten percent
of patients had complications, and during a mean follow-
up of 38 months, 38% of patients underwent elective sig-
moid resection with primary anastomosis [120]. Given
these results, it appears that lavage can be appropriate in
selected circumstances. However, in a substantial propor-
tion of patients, it does not effectively eliminate the septic
focus. Based on this the ASCRS clinical practice guide-
lines recommended against its use as alternative to colec-
tomy until more information and longer follow-up is
available [85].
Fistulas
Fistulas occur in 2% of patients with diverticular disease
[121]. The localized inflammatory process develops into an
abscess which then decompresses into adjacent viscera
(Table 39-5). Patients who develop fistulas generally do not
need emergent intervention as the abscess has decompressed;
in fact many patients with fistulas may have few abdominal
signs and symptoms. Colovesical fistulas are the mostly
common (65%), followed by other types of fistulas including
colovaginal, coloenteric, colouterine, and colocutaneous
fistulas [122–125].
TABLE 39-5. Diverticular fistulas
Coloappendiceal
Colocolonic
Colocutaneous
Coloenteric
Colouterine
Colovenous
Cologastric
Coloperineal
Coloperianal
Coloureteral
Colovaginal
Colovesical
Colovesicovaginal
J. Hall
Colovesical Fistulas
Colovesical fistulas are more common in men than in women.
Women affected with a colovesical fistula have usually
undergone a prior hysterectomy. Patients often present with
prominent urinary symptoms including polymicrobial uri-
nary tract infections, pneumaturia, and fecaluria. CT scan-
ning reveals air and/or contrast in the bladder in the absence
of prior instrumentation (Figure 39-7a–c). If performed, cys-
toscopy shows inflammation generally at the dome of the
bladder and, on occasion, vegetable material in the urine.
Colovesical fistulas may also be associated with locally
advanced bladder or primary colon cancer. Cystoscopy and
colonoscopy may be an appropriate test to exclude a malig-
nancy under the appropriate clinical circumstances.
The surgical principles for treatment of colovesical fistu-
las due to diverticular disease include resection of the
affected segment (generally the sigmoid colon). The fistula is
generally small and may be suture repaired. Ureteral stents
are generally not needed. In some cases, the precise site of
the fistula cannot be determined, and pinching it off is suffi-
cient treatment; sutures are not absolutely necessary. A pri-
mary anastomosis can usually be performed safely. Omentum
is used tointerpose between the anastomosis and the bladder.
On occasion, nonoperative management is used for colovesi-
cal fistulas especially if the symptoms are minor and the
patient has medical comorbidities conferring a significant
operative risk. Suppressive antibiotics may be used to ame-
liorate symptoms in such cases [125].
Colovaginal Fistulas
Colovaginal fistulas occur almost exclusively in women who
have undergone a prior hysterectomy (Figure 39-8). Signs
and symptoms include vaginal discharge and passage of air
per vagina. Often, women have seen a gynecologist initially
for evaluation of vaginal discharge. A single-stage sigmoid
resection can generally be performed, pinching off the site of
the fistula and interposing omentum.
Colocutaneous Fistula
Colocutaneous fistulas rarely occur de novo and are gener-
ally seen in patients who have undergone prior colectomy or
percutaneous drainage [125]. Risk factors for the develop-
ment of colocutaneous fistula include unsuspected Crohn’s
disease and anastomosis to the distal sigmoid colon and not
the proximal rectum.
Diverticular Stricture/Obstruction
Repeated attacks of diverticulitis may be associated with the
development of a sigmoid stricture and progressive obstruc-
tive symptoms. Less commonly, complete large bowel
39. Diverticular Disease
FIGURE 39-7. (a) Arrow points to colovesical fistula. (b) Inflamed sigmoid colon adjacent to fistula. (c) Air in non-catheterized bladder
consistent with colovesical fistula.
obstruction associated with diverticular disease develops
(Figure 39-9). The major differential diagnosis is with
obstructing colon cancer. While large bowel obstruction is
most commonly associated with obstructing colon cancer,
approximately 10% of large bowel obstructions are attribut-
able to diverticular disease [126]. Colonic stricturing typi-
cally develops after a number of recurrent attacks leading to
fibrosis with the colonic wall. Small bowel can also become
adherent to a focus of inflamed colonic tissue leading to
associated small bowel obstruction.
The approach to management depends on whether the
obstruction is complete or partial. Patients with a partial
657
obstruction that resolves with bowel rest, intravenous hydra-
tion, and antibiotics may be able to undergo elective resec-
tion. In some patients, treating the acute inflammatory
phlegmon allows for resolution of the obstruction.
Endoscopic or radiologic evaluation can then be performed
and elective resection planned. For patients with complete
obstruction, there are a number of surgical options. In the
past, persistence of obstruction after treatment with antibiot-
ics typically required sigmoid resection, end colostomy, and
Hartmann closure of the rectum because of the concern about
the increased risk of anastomotic leakage in patients who had
dilated and edematous bowel or who were not able to
658
undergo preoperative mechanical bowel preparation. While
the Hartmann resection is still an excellent option in selected
patients, other options include sigmoid resection with pri-
mary anastomosis and diverting proximal stoma (usually a
loop ileostomy), on-table lavage and primary anastomosis,
or colonic stenting placement followed by semi-elective sig-
moid resection.
On-table lavage is a technique which allows for cleansing
of the fecal laden, obstructed colon before potential anasto-
mosis. The technique has been described by Murray et al.
[127] and involves mobilization of the splenic flexure and at
times the hepatic flexure. A Foley catheter attached to warm
irrigation fluid is introduced through the appendix. If surgi-
cally absent, the catheter may be placed through a cecostomy
or ileostomy. Corrugated anesthesia tubing is placed through
the distal colon and secured with umbilical tape. The colon is
lavaged until the returns are clear. The technique may be
used in selected patients who are hemodynamically stable
and in whom there is minimal contamination. While the need
FIGURE 39-8. Colovaginal fistula. Arrow demonstrates vaginal fill-
ing with contrast from pericolonic abscess.
FIGURE 39-9. Large sigmoid
phlegmon causing a large bowel
obstruction. Arrow shows a
retrograde injection of contrast
within the rectum which is
unable to pass the obstruction.
J. Hall
for mechanical bowel preparation has been called into ques-
tion for elective colon resection, this claim has not been criti-
cally evaluated in patients with bowel obstruction [128]. Lee
et al. described the use of on-table lavage and sigmoid resec-
tion with primary anastomosis in 33 patients with diverticu-
lar disease who underwent nonelective resection. There were
no anastomotic leaks in this series, but there was a significant
(18%) incidence of wound infection [129]. While this tech-
nique is interesting, often patients with large bowel obstruc-
tion have severely dilated colons that are not good candidates
for anastomosis with or without bowel preparation.
A number of authors have demonstrated that treatment of
acute colonic obstruction with self-expanding metal stents is
a viable option particularly in patients with obstructing colon
cancer [130, 131]. Colonic stenting for benign obstructions
is associated with a high rate of stent migration as well as
other delayed complications. In a series of 104 procedures
from one center, eight patients had obstruction from a benign
etiology [132]. After colonic stenting, many required re-
interventions and only three patients achieved a benefit from
stenting. From a technical standpoint, stenting a diverticular
stricture which is potentially longer or more angulated may
be more difficult than stenting a short segment stricture from
colon cancer. Colonic stenting in benign disease remains a
controversial procedure and should be embarked upon with
caution [133–135].
Operative Therapy
Elective Management
Open sigmoid resection is generally performed through a
midline incision. Preoperative mechanical bowel preparation
is not necessary but is often performed [128]. Preoperative
intravenous antibiotics are administered. The sigmoid colon
is mobilized, and proximal and distal points are selected for
resection. The proximal resection margin should be in soft
pliable bowel, and it is not necessary to resect all proximal
diverticula. The distal resection margin is the proximal rec-
39. Diverticular Disease 659

tum as anastomosis to the distal sigmoid is associated with a necessary to mobilize the splenic flexure to perform a
higher risk of recurrent diverticulitis [136, 137]. It may be tension-free anastomosis, and there is evidence that suggests
necessary to mobilize the splenic flexure to perform a that the incidence of splenic injury is lower with a laparo-
tension-free anastomosis; alternatively, rectal mobilization scopic approach [141]. Proximal and distal resection margins
will also afford additional length. One study suggested that can then be chosen. A hand-sewn or stapled anastomosis is
an inframesenteric dissection with preservation of the infe- performed. The anastomosis can be performed in an intracor-
rior mesenteric artery decreased the incidence of anasto- poreal fashion. Alternatively, the anastomosis can be fash-
motic leak [138]. A hand-sewn or stapled anastomosis is ioned through the specimen extraction site. The use of the
performed. The anastomosis is most often performed with an extraction site in cases of fistulas or abscesses often allows
EEA stapler. the laparoscopic completion of colectomies in patients with
In cases of fistulas to the bladder or the vagina, the fistula severe disease without conversion. Nonetheless, there are a
may be simply “pinched off,” and a resection of bladder and/ wide range of published conversion rates as demonstrated in
or vagina is not necessary. Once a fistula is pinched off, Table 39-6.
omentum can be used to interpose between the bladder and/ In the “conventional or straight” laparoscopic technique,
or vagina and the colon. the essential elements of the operation remain the same. The
Ureteral stents are generally not necessary but may be colon can be mobilized from a lateral to medial or medial to
used in selected cases. Although they do not prevent ureteral lateral approach. The specimen is typically extracted through
injuries, they permit easy recognition and repair of such inju- a periumbilical vertical incision and the anastomosis per-
ries [139]. A technique that may be helpful in mobilization formed in an intracorporeal fashion.
includes “proximal to distal” resection in which the colon is Prospective evaluation of hand-assisted laparoscopic tech-
divided proximal to the phlegmon with a linear stapler, and niques demonstrate that although operative times are similar
the colon is dissected proximal to distal, rather than perform- to conventional laparoscopic surgery, conversions are less
ing a lateral to medical dissection [140]. This technique may frequent (0% vs. 13%) [24].
facilitate easier identification of the ureter and avoid injury. Minimally invasive colectomy has a number of benefits.
Although the rectum is not primarily involved with diver- The Norfolk surgical group demonstrated that ileus and
ticulitis, inflammation of the proximal rectum may be encoun- length of stay were less in patients who had their sigmoid
tered from the diverticular phlegmon or from an associated colectomy completed laparoscopically [142]. Other authors
pelvic abscess or diverticular perforation. In such cases, have demonstrated decreased postoperative pain, wound
based on sound surgical judgment and specific intraoperative infection rates, operative blood loss, and transfusions and a
factors, primary anastomosis potentially to the mid-rectum faster return to preoperative activity levels [143, 144]. The
with proximal fecal diversion may be performed. outcomes of 676 patients undergoing laparoscopic colec-
tomy for diverticulitis were compared to those undergoing
laparoscopic colectomy for non-diverticular disease. No dif-
ferences were noted when comparing complications, mortal-
Minimally Invasive Surgery ity, length of stay, or oral feeding [145].
The advent of laparoscopic surgery is ushered in a new era in
the surgical management of diverticular disease. In the last TABLE 39-6. Conversion rates in selected laparoscopic colectomy
decade, increasing numbers of resections for diverticular dis- series
ease have been performed laparoscopically. Conventional Conversion
laparoscopic techniques allow the surgeon to perform all the Author Year Patients rate (%)
major portions of the case, including the anastomosis, Klarenbeek et al. [146] 2009 52 19.23
through small 5 or 12 mm trocars (Figure 39-9). Jones et al. [147] 2008 500 2.80
Cole et al. [148] 2008 151 12.58
A commonly practiced technique involves the use of a
Hassan et al. [149] 2007 91 26.40
“hand-assisted” technique. In this type of approach, the sur-
Belizon et al. [150] 2006 143 19.58
geon’s hand is placed into the abdomen though a small verti- Chang et al. [151] 2005 85 7.28
cal lower midline or Pfannenstiel incision to assist in the Schwandner et al. [152] 2004 396 6.82
mobilization of the colon. The dissection can be carried out Buillot et al. [153] 2002 179 13.97
in a medial to lateral or lateral to medial approach. Trebuchet et al. 2002 170 4.12
In the medial to lateral approach, a plane is made below the Vargas et al. [154] 2000 69 26.09
inferior mesenteric artery (IMA). The ureter, gonadal vessels, Burgel et al. [155] 2000 56 14.29
and other retroperitoneal structures are swept away. The IMA Siriser et al. [156] 1999 65 4.62
is then divided using a stapler or energy device. The sigmoid Berthou et al. [157] 1999 110 8.18
colon can then be mobilized up to the level of the splenic Koeckerling et al. [158] 1999 304 7.24
flexure by sweeping down the attachments of the left colonic Smadja et al. [159] 1999 54 9.26
mesocolon to Gerota’s fascia and retroperitoneum. It may be Stevenson et al. [160] 1998 100 8.00
660
Urgent and Emergent Procedures
The Hartmann procedure resects the diseased segment of
bowel, eliminates the septic focus, and allows for restoration
of bowel continuity on an elective basis. The patient is
approached through a midline laparotomy both to confirm
the diagnosis and assess the degree of contamination and
inflammation. Preoperative stoma site marking is helpful.
The affected sigmoid colon is mobilized, and a proximal to
distal approach is generally the easiest and safest. The bowel
can be transected proximally and dissection carried down to
the sacral promontory. A wide mesenteric dissection is
unnecessary. The ureter should ideally be identified. All dis-
eased and thickened bowel should be resected, and the resec-
tion margin should ideally be the proximal rectum.
Alternatively, distal sigmoid, if not inflamed, can be left in
place for later resection at the intended Hartmann reversal.
The proximal rectum is transected with a stapler or oversewn
depending on individual preference. The stoma is brought
out on the left side; splenic flexure mobilization may be nec-
essary to achieve adequate length particularly if there is sig-
nificant foreshortening of the mesentery from the diverticular
phlegmon. The colostomy is generally left in place for at
least 3 months allowing the patient to sufficiently heal and
hopefully facilitate identification of the Hartmann stump.
Waiting longer can make identification of the Hartmann
stump difficult secondary to fibrosis [161].
Selection of patients who may safely undergo resection
and primary anastomosis in the acute setting requires consid-
erable judgment and must take into consideration patient-
related and disease-related factors. Primary anastomosis is
not advisable for patients with hemodynamic instability, dif-
fuse fecal or purulent peritonitis, immunocompromised
patients, or those with severe anemia or malnutrition and
those with ischemia or edema of the bowel at the proposed
site of anastomosis [117]. Despite systematic reviews and a
focus in the literature on performing primary anastomosis in
the nonelective patient, a recent review of 267,000 patients
admitted with acute diverticulitis and 335,000 patients (from
1998 to 2005) operated on electively for diverticulitis found
no evidence that primary anastomosis was more commonly
performed [14].
Minimally Invasive Colectomy
for Complicated Disease
As laparoscopic colectomy has gained widespread use, this
technique has been applied to patients with complicated
diverticular disease. Martel et al. compared the outcomes of
laparoscopic colectomy following treatment of complicated
and uncomplicated disease in 183 patients. These authors
demonstrated no difference in anastomotic leak rates and
intraoperative complications. It should be noted however,
that patients with complicated disease underwent conversion
to open procedures more frequently (23% vs. 4%) [162].
J. Hall
While overall conversion rates differ among studies, higher
rates of conversion in patients with complicated diverticulitis
are noted in a number of series on this topic [142, 163, 164].
Some studies have noted that when complicated disease is
restricted to fistula or abscess, then there is no increased risk
of conversion when comparing patients with complicated
and uncomplicated disease [165, 166]. A Chinese group has
shown that laparoscopy is feasible in the management of
complicated right-sided diverticulitis. Although patients in
the laparoscopic group recovered bowel function more
quickly (3.5 days vs. 5 days), the length of stay in both
groups was similar [167].
Special Situations
Recurrent Diverticulitis
Recurrent diverticulitis following resection is uncommon. In
the patient presenting with abdominal pain following resec-
tion for diverticulitis, a systematic evaluation should be per-
formed to exclude other causes of pain. Etiologies such as
inflammatory bowel disease, ischemic colitis, colorectal can-
cer, adhesive disease, gynecologic pathology, and irritable
bowel syndrome should be considered. Patients with diver-
ticular disease have significant overlap with irritable bowel
syndrome. Additional pathology review of the resected seg-
ment of sigmoid colon may be helpful. Patients who present
with “recurrent diverticulitis” may not have had diverticuli-
tis (but only diverticulosis) on initial resection.
The development of recurrent diverticulitis should be dis-
tinguished from patients that develop persistent poorly char-
acterized abdominal pain following resection. Munson et al.
found that 27.2% of patients following resection for diver-
ticular disease continued to have pain [168]. Parks and
Connell noted persistence of mild symptoms in 24% of
patients who underwent a three-stage resection for diverti-
culitis [169].
The most established risk factor for recurrent diverticulitis
following resection is the level of anastomosis. Although
diverticulitis may only involve a portion of the sigmoid
colon, the entire sigmoid should be resected and anastomosis
performed to the proximal rectum. The rectum is identified at
the level at which the taenia fan out which is generally
around the sacral promontory. The proximal resection mar-
gin is less well established, and the dictum has been to anas-
tomose in “soft pliable bowel” [8]. It is unnecessary to
remove all diverticula of the colon, but the anastomosis
should be performed in an area that is free of diverticula.
Two studies have looked at the level of anastomosis and the
risk of recurrent diverticulitis. Benn et al. examined 501
patients undergoing sigmoid resection for diverticular dis-
ease. The incidence of recurrent diverticulitis was 6.7% with
anastomosis to the proximal rectum compared with 12.5% in
patients who underwent anastomosis to the distal sigmoid
39. Diverticular Disease
colon. Thaler et al. also noted that the level of anastomosis
was the only predictor of recurrence in regression analysis
with patients with a colosigmoid anastomosis having a four
times higher risk of recurrence compared to patients with a
colorectal anastomosis [136].
Giant Colonic Diverticulum
The condition of giant colonic diverticulum is rare and was
first reported by Bonvin and Bonte in 1946 [170]. Less than
150 cases have been reported in the literature [171]. These
diverticula affect men and women equally and are most com-
monly found in the sigmoid colon. The average diameter is
13 cm, but diverticula as large as 40 cm have been reported.
Two theories have been put forth for the development of
giant diverticulum; one proposed theory is that the diverticu-
lum becomes massive because of a ball-valve mechanism
allowing air into but not out of the diverticulum [172].
Another theory suggests that air is trapped into the diverti-
culum because of gas-forming microorganisms without
obstruction at the neck of the diverticulum.
Many patients with this entity are minimally symptomatic
or present with mild episodes of pain. On abdominal palpa-
tion, a soft mobile mass may be appreciated. The differential
diagnosis includes colonic duplication, pancreatic pseudo-
cyst, Meckel’s diverticulum or jejunal diverticulum, sigmoid
volvulus, or emphysematous cholecystitis. More commonly,
the abnormality is noted on abdominal CT scan. Treatment
consists of sigmoid resection with anastomosis. Diverticu-
lectomy, which was has been employed in earlier reports, is
rarely performed today.
Diverticulitis: Other Sites
Right Colonic Diverticulitis
Right-sided diverticulitis is rare in the Western countries and
more common in the Far East [173]. Cecal diverticula are of
two types, both true and false. True diverticula contain all lay-
ers of the bowel wall and are usually congenital and tend to
be solitary. Acquired diverticula of the cecum are false, con-
taining mucosa and muscularis mucosa, tend to be multiple
and tend to be associated with diverticula elsewhere in the
colon. Patients with cecal diverticulitis present at a younger
age than the average patient with sigmoid diverticulitis. The
main differential diagnosis is that of acute appendicitis, and it
may be difficult in the patient with right-sided abdominal
pain, fever, and leukocytosis to distinguish cecal diverticulitis
from acute appendicitis. Other differential diagnoses include
chronic cholecystitis, mesenteric adenitis, ischemic colitis,
pelvic inflammatory disease, pancreatitis, Meckel’s diverticu-
litis, pyelonephritis, and sigmoid diverticulitis (with a redun-
dant sigmoid loop). Laparoscopy is sometimes helpful to
661
TABLE 39-7. Cecal diverticulitis classification system
Grade I Easily recognizable projecting inflamed cecal
diverticulum
Grade II Inflamed cecal mass
Grade III Localized abscess or fistula
Grade IV Free perforation or ruptured abscess with diffuse
peritonitis
Modified from Hinchey et al. [141]
distinguish between cecal diverticulitis and appendicitis.
A retrospective review of 49 patients at a single institution
found the ratio of acute appendicitis to cecal diverticulitis to
be 150:1 [174]. In the absence of peritoneal signs, patients
may be treated with antibiotics. For those patients with
repeated attacks or complications including perforation or
abscess, resection is indicated. Fang and coworkers reviewed
85 patients treated for cecal diverticulitis [175]. Less than
40% were treated with antibiotics and bowel rest. Sixty-seven
patients ultimately underwent laparotomy. In the 47 patients
with a preoperative diagnosis of appendicitis, 24 underwent
appendectomy, 9 underwent diverticulectomy, and 14 under-
went right colectomy. In the 20 patients with a preoperative
diagnosis of diverticulitis, all underwent right colectomy.
Thorson and Ternent [176] have suggested a grading system
to aid with the management of cecal diverticulitis (Table 39-7).
These authors suggested that when diagnosis is uncertain
then right colectomy is most likely the best option [176].
With refinements in technology and with the widespread use
of CT scanning for evaluation of patients with abdominal
pain, proceeding to laparotomy or laparoscopy without a rela-
tively secure diagnosis is uncommon.
Rectal Diverticulitis
Rectal diverticula are rare, are typically solitary, and are true
diverticula including all layers of the bowel wall [37].
Transverse Colonic Diverticulitis
Diverticulitis involving the transverse colon is exceedingly
rare with less than 50 cases reported and often confused with
other conditions such as cholecystitis [177]. In a large series
of 951 patients who all underwent CT scan on initial presen-
tation of diverticulitis, Hall et al. found that the prevalence of
transverse colon diverticulitis was 2.6% [42].
Immunocompromised Patients
Immunocompromised patients include patients on systemic
steroids, patients with diabetes mellitus or renal failure,
transplant patients who are immunosuppressed, patients
with cirrhosis, patients with underlying malignancy, and
662
patients being treated with chemotherapy. Patients who are
immunosuppressed are more likely to present with free per-
foration, presumably because of the inability to mount an
inflammatory response and wall off the infection and are
therefore more likely to require emergency surgery with
resultant increased postoperative morbidity and mortality. In
the combined series of patients who were immunocompro-
mised who presented with diverticulitis, 40% had free perfo-
ration, 60% required emergency operation, and the overall
postoperative morbidity and mortality were 65% and 40%,
respectively [178–181]. Immunocompromised patients who
present with acute diverticulitis and require emergent
laparotomy should undergo resection, with colostomy, and
should not undergo primary anastomosis because of the
impaired immune system and impaired healing.
Conclusion
Colonic diverticular disease represents a wide spectrum of
presentations and treatment options. While many of the cur-
rent treatment methods have been used for the greater part of
a century, their mode of application continues to evolve. As
in all inflammatory conditions, the initial goal of therapy is
to control infection. Once this is done, the surgeon is left
with a variety of treatment algorithms and options which
must be individualized for each patient.
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40
Large Bowel Obstruction
Karim Alavi and Charles M. Friel
Key Concepts
• Initial management of large bowel obstruction should
include early correction of fluid and electrolyte abnor-
malities and surgical or endoscopic decompression.
• The current indications of endoluminal colonic stents
include palliation in cancer and in patients who are medi-
cally unfit.
• Following correction of fluid and electrolyte abnormali-
ties in patients with acute colonic pseudo-obstruction,
intravenous neostigmine should be attempted as the next
step in management.
• Following successful endoscopic decompression of a sig-
moid volvulus, given the high recurrence rates, the next
step in management should be a segmental resection dur-
ing the same hospitalization.
• CT scan is the imaging modality of choice for the diagnosis
and subsequent management of large bowel obstruction.
Introduction
Large bowel obstruction (LBO) is a common surgical emer-
gency encountered in a colon and rectal surgical practice [1].
It is caused by the blockage of fecal flow. While most causes
are mechanical, nonmechanical causes (pseudo-obstruction)
have also been described. LBO is a complex problem that
will challenge even the most seasoned clinicians. The sur-
geon must not only manage the immediate emergency (i.e.,
the obstruction) but also consider the treatment of the under-
lying etiology and consider the long-term outcomes of any
particular intervention. Therefore, no one strategy will be
adequate for all patients. Surgeons must be familiar with all
the causes of LBO and understand the myriad of treatment
options so that therapeutic plans can be tailored to a variety
of clinical presentations.
© Springer International Publishing 2016
S.R. Steele et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, DOI 10.1007/978-3-319-25970-3_40
Etiology
Most LBOs are due to progressive narrowing of the bowel lumen
caused by intrinsic lesions of the bowel wall (Table 40-1). The
most common example of an intrinsic lesion is colorectal cancer,
which accounts for nearly 50% of all LBOs. In fact, approxi-
mately 10% of all colorectal cancer will present with evidence of
a LBO [1]. Diverticular disease also causes intrinsic compres-
sion of the lumen and is generally considered the second most
common cause of LBO (≈10–20%). Other less common exam-
ples of intrinsic narrowing include Crohn’s disease, ischemia,
endometriosis, and radiation, all of which cause progressive
thickening of the bowel wall and obliteration of the lumen and
can often be difficult to distinguish from colorectal cancer.
Extrinsic lesions can also impinge the bowel lumen. Most
commonly extrinsic compression is caused by non-colorectal
malignancy, such as ovarian cancer. Other less common
causes of extrinsic compression are hernias and adhesions,
the most likely causes of small bowel obstructions but rare
for LBO.
Because both intrinsic and extrinsic compressions are
slowly progressive, the clinical presentation of LBO is often
insidious. Even when patients seemingly present with an
acute LBO, the astute physician can elicit a history of pro-
gressive constipation and narrowed stools for left-sided
obstruction or crampy abdominal pain for right-sided dis-
ease. Depending on when patients seek care, the clinical pre-
sentation can be quite varied and management strategies will
have to be adjusted accordingly. Mild obstruction, or bowel
stenosis, may cause symptoms such as pain, cramps, and
constipation. During colonoscopy, the endoscope may not
pass through the stricture, and on barium enema the patient
may have a classic “apple-core” lesion (Figure 40-1). Since
these patients have no proximal bowel dilation and no stool
and fluid accumulating upstream of the obstruction, they will
not present with signs of systemic toxicity. Management of
669