Conservative Treatment of Acute Colonic Diverticulitis

S T van Dijk, S J Rottier, A A W van Geloven, M A Boermeester, S T van Dijk, S J Rottier, A A W van Geloven, M A Boermeester

Abstract

Purpose of review: Since the treatment of acute diverticulitis has become more conservative over the last years, knowledge of conservative treatment strategies is increasingly important.

Recent findings: Several treatment strategies that previously have been imposed as routine treatment are now obsolete. Uncomplicated diverticulitis patients can be treated without antibiotics, without bed rest, and without dietary restrictions; and a selected group of patients can be treated as outpatients. Also, patients with isolated pericolic extraluminal air can be treated conservatively as well. Whereas some patient subgroups have been suggested to suffer from a more virulent disease course or higher recurrence rates, current evidence does not support all traditional understandings. Patients on immunosuppression or non-steroidal anti-inflammatory drugs seem to have a higher risk of complicated diverticulitis, but young patients do not. Data on the risk of recurrent diverticulitis in young patients is conflicting but the risk seems comparable to elderly patients. Besides the traditional treatments, several new treatment strategies have emerged but have failed thus far. Mesalazine does not have any beneficial effect on preventing recurrent diverticulitis based on current literature. Rifaximin and probiotics have been studied insufficiently in acute diverticulitis patients to conclude on their efficacy. This review provides an overview of recent developments in conservative treatment strategies of acute diverticulitis and discusses the latest evidence on patient subgroups that have been suggested to suffer from an aberrant disease course.

Keywords: Acute diverticulitis; Antibiotics; Conservative treatment; Uncomplicated.

Conflict of interest statement

Conflict of Interest

Drs van Dijk, Rottier, van Geloven and Boermeester declare no conflicts of interests in regards to the development of this paper.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

References

    1. Bollom A, Austrie J, Hirsch W, Nee J, Friedlander D, Ellingson K, et al. Emergency department burden of diverticulitis in the USA, 2006-2013. Dig Dis Sci. 2017; 10.1007/s10620-017-4525-y.
    1. Boermeester MA, Humes DJ, Velmahos GC, Soreide K. Contemporary review of risk-stratified management in acute uncomplicated and complicated diverticulitis. World J Surg. 2016;40(10):2537–2545. doi: 10.1007/s00268-016-3560-8.
    1. Stam MA, Draaisma WA, van de Wall BJ, Bolkenstein HE, Consten EC, Broeders IA. An unrestricted diet for uncomplicated diverticulitis is safe: results of a prospective diverticulitis diet study. Color Dis. 2017;19(4):372–377. doi: 10.1111/codi.13505.
    1. van de Wall BJ, Draaisma WA, van Iersel JJ, van der Kaaij R, Consten EC, Broeders IA. Dietary restrictions for acute diverticulitis: evidence-based or expert opinion? Int J Color Dis. 2013;28(9):1287–1293. doi: 10.1007/s00384-013-1694-9.
    1. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS((R))) society recommendations. World J Surg. 2013;37(2):259–284. doi: 10.1007/s00268-012-1772-0.
    1. 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(4):532–539. doi: 10.1002/bjs.8688.
    1. Daniels L, Unlu C, de Korte N, van Dieren S, Stockmann HB, Vrouenraets BC, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52–61. doi: 10.1002/bjs.10309.
    1. Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65(7):632–635.
    1. Biondo S, Golda T, Kreisler E, Espin E, Vallribera F, Oteiza F, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial) Ann Surg. 2014;259(1):38–44. doi: 10.1097/SLA.0b013e3182965a11.
    1. Moya P, Arroyo A, Perez-Legaz J, Serrano P, Candela F, Soriano-Irigaray L, et al. Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis. Tech Coloproctol. 2012;16(4):301–307. doi: 10.1007/s10151-012-0847-0.
    1. Costi R, Cauchy F, Le Bian A, Honart JF, Creuze N, Smadja C. Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients. A 10-year experience with a nonoperative treatment. Surg Endosc. 2012;26(7):2061–2071. doi: 10.1007/s00464-012-2157-z.
    1. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54(6):663–671. doi: 10.1007/DCR.0b013e31820ef759.
    1. Lahat A, Avidan B, Sakhnini E, Katz L, Fidder HH, Meir SB. Acute diverticulitis: a decade of prospective follow-up. J Clin Gastroenterol. 2013;47(5):415–419. doi: 10.1097/MCG.0b013e3182694dbb.
    1. Mora Lopez L, Serra Pla S, Serra-Aracil X, Ballesteros E, Navarro S. Application of a modified Neff classification to patients with uncomplicated diverticulitis. Color Dis. 2013;15(11):1442–1447. doi: 10.1111/codi.12449.
    1. Sallinen VJ, Mentula PJ, Leppaniemi AK. Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients. Dis Colon Rectum. 2014;57(7):875–881. doi: 10.1097/DCR.0000000000000083.
    1. Thorisson A, Smedh K, Torkzad MR, Pahlman L, Chabok A. CT imaging for prediction of complications and recurrence in acute uncomplicated diverticulitis. Int J Color Dis. 2016;31(2):451–457. doi: 10.1007/s00384-015-2423-3.
    1. Holmer C, Lehmann KS, Grone J, Buhr HJ, Ritz JP. Perforation risk and patient age. Risk analysis in acute sigmoid diverticulitis. Chirurg. 2011;82(4):359–366. doi: 10.1007/s00104-010-1961-z.
    1. Lopez-Borao J, Kreisler E, Millan M, Trenti L, Jaurrieta E, Rodriguez-Moranta F, et al. Impact of age on recurrence and severity of left colonic diverticulitis. Color Dis. 2012;14(7):e407–e412. doi: 10.1111/j.1463-1318.2012.02976.x.
    1. Makela JT, Klintrup K, Takala H, Rautio T. The role of C-reactive protein in prediction of the severity of acute diverticulitis in an emergency unit. Scand J Gastroenterol. 2015;50(5):536–541. doi: 10.3109/00365521.2014.999350.
    1. Nelson RS, Ewing BM, Wengert TJ, Thorson AG. Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J Surg. 2008;196(6):969–972. doi: 10.1016/j.amjsurg.2008.07.035.
    1. Frileux P, Dubrez J, Burdy G, Roullet-Audy JC, Dalban-Sillas B, Bonnaventure F, et al. Sigmoid diverticulitis. Longitudinal analysis of 222 patients with a minimal follow up of 5 years. Color Dis. 2010;12(7):674–680. doi: 10.1111/j.1463-1318.2009.01866.x.
    1. Buchs NC, Konrad-Mugnier B, Jannots AS, Poletti PA, Ambrosetti P, Gervaz P. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg. 2013;100(7):976–979. doi: 10.1002/bjs.9119.
    1. Sallinen V, Mali J, Leppaniemi A, Mentula P. Assessment of risk for recurrent diverticulitis: a proposal of risk score for complicated recurrence. Medicine (Baltimore) 2015;94(8):e557. doi: 10.1097/MD.0000000000000557.
    1. Trenti L, Kreisler E, Galvez A, Golda T, Frago R, Biondo S. Long-term evolution of acute colonic diverticulitis after successful medical treatment. World J Surg. 2015;39(1):266–274. doi: 10.1007/s00268-014-2773-y.
    1. Oor JE, Atema JJ, Boermeester MA, Vrouenraets BC, Unlu C. A systematic review of complicated diverticulitis in post-transplant patients. J Gastrointest Surg. 2014;18(11):2038–2046. doi: 10.1007/s11605-014-2593-2.
    1. Larson ES, Khalil HA, Lin AY, Russell M, Ardehali A, Ross D, et al. Diverticulitis occurs early after lung transplantation. J Surg Res. 2014;190(2):667–671. doi: 10.1016/j.jss.2014.05.018.
    1. Vetter D, Schuurmans MM, Benden C, Clavien PA, Nocito A. Long-term follow-up of lung transplant recipients supports non-operative treatment of uncomplicated diverticulitis. Clin Transpl. 2016;30:1264–1270. doi: 10.1111/ctr.12817.
    1. Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Color Dis. 2014;16(6):O189–OO96. doi: 10.1111/codi.12516.
    1. Cologne KG, Skiada D, Beale E, Inaba K, Senagore AJ, Demetriades D. Effects of diabetes mellitus in patients presenting with diverticulitis: clinical correlations and disease characteristics in more than 1,000 patients. J Trauma Acute Care Surg. 2014;76(3):704–709. doi: 10.1097/TA.0000000000000128.
    1. Klarenbeek BR, Samuels M, Van Der Wal MA, Van Der Peet DL, Meijerink WJ, Cuesta MA. Indications for elective sigmoid resection in diverticular disease. Ann Surg. 2010;251(4):670–674. doi: 10.1097/SLA.0b013e3181d3447d.
    1. Festa V, Spila Alegiani S, Chiesara F, Moretti A, Bianchi M, Dezi A, et al. Retrospective comparison of long-term ten-day/month rifaximin or mesalazine in prevention of relapse in acute diverticulitis. Eur Rev Med Pharmacol Sci. 2017;21(6):1397–1404.
    1. Tursi A, Elisei W, Giorgetti GM, Inchingolo CD, Nenna R, Picchio M, et al. Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence. Eur Rev Med Pharmacol Sci. 2013;17(3):342–348.
    1. Parente F, Bargiggia S, Prada A, Bortoli A, Giacosa A, Germana B, et al. Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence: a randomised multicentre pilot double-blind placebo-controlled study of 24-month duration. Int J Color Dis. 2013;28(10):1423–1431. doi: 10.1007/s00384-013-1722-9.
    1. Stollman N, Magowan S, Shanahan F, Quigley EM, Group DI. A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial. J Clin Gastroenterol. 2013;47(7):621–629. doi: 10.1097/MCG.0b013e31828003f6.
    1. Kruis W, Kardalinos V, Eisenbach T, Lukas M, Vich T, Bunganic I, et al. Randomised clinical trial: mesalazine versus placebo in the prevention of diverticulitis recurrence. Aliment Pharmacol Ther. 2017;46:282–291. doi: 10.1111/apt.14152.
    1. Picchio M, Elisei W, Brandimarte G, Di Mario F, Malfertheiner P, Scarpignato C, et al. Mesalazine for the treatment of symptomatic uncomplicated diverticular disease of the colon and for primary prevention of diverticulitis: a systematic review of randomized clinical trials. J Clin Gastroenterol. 2016;50(Suppl 1):S64–S69. doi: 10.1097/MCG.0000000000000669.

Source: PubMed

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