Diverticulitis Guidelines: Medical Society Guidelines

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Diverticulitis

Guidelines

Medical Society Guidelines

2015 American Gastroenterological Association (AGA) guidelines

The AGA recommendations on the treatment of diverticulitis include the following^[5]:

Antibiotics should be used selectively in uncomplicated diverticulitis.
Colonoscopy should be performed after resolution of acute diverticulitis if a high-quality examination has not been done recently.
Prophylactic colonic resection in uncomplicated diverticulitis should be done on a case-by-case basis.
A fiber-rich diet or fiber supplementation as well as physical activity (ideally, daily rigorous exercise) are recommended after resolution.
Aspirin use can be continued after resolution, particularly if it is being used for secondary prevention.
It is not necessary to avoid nuts and popcorn in patients with diverticulosis or diverticulitis.
Avoid nonaspirin, nonsteroidal anti-inflammatory drugs if possible.
Mesalamine, rifaximin, and probiotics are not recommended to prevent recurrence.

2006 American Society of Colon and Rectal Surgeons (ASCRS) practice parameters

The ASCRS recommendations on the management of diverticulitis include the following^[44]:

The initial evaluation should include a history and physical examination, complete blood cell count, urinalysis, and abdominal imaging in select cases.
Computed tomography (CT) scanning of the abdomen and pelvis is the most appropriate initial imaging method.
Ultrasonography and magnetic resonance imaging (MRI) can be useful imaging alternatives.
Nonsurgical treatment includes oral or intravenous antibiotics and diet modification.
Image-guided percutaneous drainage is usually the most appropriate treatment for stable patients with large diverticular abscesses.
After resolution of the incident diverticulitis, colonoscopy should be performed if it has not been done recently.
The decision regarding elective sigmoid colectomy should be individualized.
Elective colectomy should be considered after recovery from complicated diverticulitis.
Routine elective resection based on young age (< 50 years) is not recommended.
Urgent sigmoid colectomy is required for diffuse peritonitis or when nonsurgical management fails.
The decision to restore bowel continuity after resection must incorporate patient factors, intraoperative factors, and surgeon preference.

Medication

[Guideline] Murphy T, Hunt RH, Fried M, Krabshuis JH. WGO Practice Guidelines. Diverticular disease. World Gastroenterology Organisation (WGO). Available at http://www.worldgastroenterology.org/diverticular-disease.html. 2007; Accessed: June 10, 2011.
Swanson SM, Strate LL. Acute colonic diverticulitis. Ann Intern Med. 2018 May 1. 168(9):ITC65-80. [Medline]. [Full Text].
Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg. 1999 Jul. 65(7):632-5; discussion 636. [Medline].
Cuomo R, Cargiolli M, Cassarano S, Carabotti M, Annibale B. Treatment of diverticular disease, targeting symptoms or underlying mechanisms. Curr Opin Pharmacol. 2018 Oct 3. 43:124-31. [Medline].
[Guideline] Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015 Dec. 149(7):1944-9. [Medline]. [Full Text].
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Peery AF, Stollman N. Antibiotics for acute uncomplicated diverticulitis: time for a paradigm change?. Gastroenterology. 2015 Dec. 149(7):1650-1. [Medline]. [Full Text].
Brochmann ND, Schultz JK, Jakobsen GS, Oresland T. Management of acute uncomplicated diverticulitis without antibiotics: a single-centre cohort study. Colorectal Dis. 2016 Nov. 18(11):1101-7. [Medline].
US Food and Drug Administration. FDA Drug Safety Communication: Increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections. Available at https://www.fda.gov/Drugs/DrugSafety/ucm224370.htm. September 1, 2010; Accessed: September 7, 2010.
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Trivedi CD, Das KM, NDSG. Emerging therapies for diverticular disease of the colon. J Clin Gastroenterol. 2008 Nov-Dec. 42(10):1145-51. [Medline].
Stollman N, Magowan S, Shanahan F, Quigley EM, DIVA Investigator Group. A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial. J Clin Gastroenterol. 2013 Aug. 47(7):621-9. [Medline].
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Riansuwan W, Hull TL, Millan MM, Hammel JP. Nonreversal of Hartmann's procedure for diverticulitis: derivation of a scoring system to predict nonreversal. Dis Colon Rectum. 2009 Aug. 52(8):1400-8. [Medline].
Fleming FJ, Gillen P. Reversal of Hartmann's procedure following acute diverticulitis: is timing everything?. Int J Colorectal Dis. 2009 Oct. 24(10):1219-25. [Medline].
Rink AD, John-Enzenauer K, Haaf F, Straub E, Nagelschmidt M, Vestweber KH. Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption. Dis Colon Rectum. 2009 Oct. 52(10):1738-45. [Medline].
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Lahat A, Avidan B, Sakhnini E, Katz L, Fidder HH, Meir SB. Acute diverticulitis: a decade of prospective follow-up. J Clin Gastroenterol. 2013 May-Jun. 47(5):415-9. [Medline].
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Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005 Jun. 140(6):576-81; discussion 581-3. [Medline].
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Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med. 1998 May 21. 338(21):1521-6. [Medline].
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Rampton DS. Diverticular colitis: diagnosis and management. Colorectal Dis. 2001 May. 3(3):149-53. [Medline].
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Media Gallery

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Modified Hinchey Classification Stage	Category
0	Clinically mild diverticulitis, or diverticula with colonic wall thickening on CT	Uncomplicated
Ia	Colonic reaction with inflammatory reaction in the pericolic fat (phlegmon)	Uncomplicated
Ib	Pericolic or mesenteric abscess	Complicated
II	Intra-abdominal abscess, pelvic or retroperitoneal abscess	Complicated
III	Generalized purulent peritonitis	Complicated
IV	Generalized fecal peritonitis	Complicated

Author

Elie M Ghoulam, MD, MS Resident Physician, Department of Internal Medicine, St Louis University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Danisa M Clarrett, MD, MS Fellow, Division of Gastroenterology and Hepatology, St Louis University School of Medicine

Danisa M Clarrett, MD, MS is a member of the following medical societies: American College of Gastroenterology, American Medical Association, Student National Medical Association

Disclosure: Nothing to disclose.

Elizabeth V Marsicano, MD Assistant Professor of Internal Medicine, Associate Program Director of Gastroenterology, Director of Clinical Operations, Division of Gastroenterology and Hepatology, St Louis University School of Medicine

Elizabeth V Marsicano, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Neurogastroenterology and Motility Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Marc D Basson, MD, PhD, MBA, FACS Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Stanley K Dea, MD Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology

Stanley K Dea, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy, Southern California Society of Gastroenterology

Disclosure: Nothing to disclose.

Yuvrajsinh Narendrasinh Chudasama, MD Staff Physician, Department of Internal Medicine, Olive View-UCLA Medical Center; Assistant Clinical Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine

Yuvrajsinh Narendrasinh Chudasama, MD is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Kamyar Shahedi, MD Clinical Instructor, Olive View-UCLA Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Kamyar Shahedi, MD is a member of the following medical societies: American College of Physicians, American Medical Association, California Medical Association

Disclosure: Nothing to disclose.

Duminda B Suraweera, MD Resident Physician, Department of Medicine, Olive View–UCLA Medical Center

Duminda B Suraweera, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy