Diagnosis And Management Of Acute Diverticulitis
Diagnosis and Managementof Acute DiverticulitisTHAD WILKINS, MD; KATHERINE EMBRY, MD; and RUTH GEORGE, MD, Georgia Regents University, Augusta, GeorgiaUncomplicated diverticulitis is localized diverticular inflammation, whereas complicated diverticulitis is diverticularinflammation associated with an abscess, phlegmon, fistula, obstruction, bleeding, or perforation. Patients with acutediverticulitis may present with left lower quadrant pain, tenderness, abdominal distention, and fever. Other symptoms may include anorexia, constipation, nausea, diarrhea, and dysuria. Initial laboratory studies include a completeblood count, basic metabolic panel, urinalysis, and measurement of C-reactive protein. Computed tomography, themost commonly performed imaging test, is useful to establish the diagnosis and the extent and severity of disease,and to exclude complications in selected patients. Colonoscopy is recommended four to six weeks after resolution ofsymptoms for patients with complicated disease or for another indication, such as age-appropriate screening. In mild,uncomplicated diverticulitis, antibiotics do not accelerate recovery, or prevent complications or recurrences. Hospitalization should be considered if patients have signs of peritonitis or there is suspicion of complicated diverticulitis.Inpatient management includes intravenous fluid resuscitation and intravenous antibiotics. Patients with a localizedabscess may be candidates for computed tomography–guided percutaneous drainage. Fifteen to 30 percent of patientsadmitted with acute diverticulitis require surgical intervention during that admission. Laparoscopic surgery resultsin a shorter length of stay, fewer complications, and lower in-hospital mortality compared with open colectomy. Thedecision to proceed to surgery in patients with recurrent diverticulitis should be individualized and based on patientpreference, comorbidities, and lifestyle. Interventions to prevent recurrences of diverticulitis include increased intakeof dietary fiber, exercise, cessation of smoking, and, in persons with a body mass index of 30 kg per m2 or higher,weight loss. (Am Fam Physician. 2013;87(9):612-620. Copyright 2013 American Academy of Family Physicians.) Patient information:A handout on this topic,written by the authorsof this article, is available at http://www.aafp.org/afp/2013/0501/p612-s1.html. Access tothe handout is free andunrestricted.Acute diverticulitis is inflammationof the colonic diverticulum, whichmay involve perforation or microperforation (Figures 1 and 2).In Western societies, most diverticula(85 percent) are found in the sigmoidand descending colons; diverticula in theascending colon are more common in Asianpopulations.1 Uncomplicated diverticulitisis localized inflammation, and complicateddiverticulitis is inflammation associatedwith an abscess, phlegmon, fistula, obstruction, bleeding, or perforation.2 This articlereviews acute diverticulitis in adults andexcludes special populations, such as children and pregnant women.diverticulitis in the United States, resulting in 2.4 billion in health care expenditures and approximately 3,400 deaths.3From 1998 to 2005, the annual age-adjustedadmissions for diverticulitis increased by26 percent, with the greatest increased ratesof admissions occurring in persons 18 to44 years of age (82 percent) and 45 to 74 yearsof age (36 percent).4 In the United States,there is an increased incidence of admissions for acute diverticulitis in the summer months compared with other months,regardless of age, sex, race, or geographicregion.5 Of those who have diverticulosis,the lifetime prevalence of developing acutediverticulitis is approximately 25 percent.6EpidemiologyDiverticulosis, defined as the presence ofdiverticula in the absence of inflammation, occurs in 5 to 10 percent of personsolder than 45 years and approximately80 percent of those older than 85 years.1 In1998, there were 2.2 million cases of acuteEtiology and Risk FactorsFactors associated with diverticulosis includealterations in colonic wall resistance, colonicmotility, and dietary issues, such as lack offiber, that contribute to increased intraluminal pressure and weakness of the bowelwall.1 Genetic susceptibility is an important612 afpVolume87,Physicians.NumberFor9 theMay1, 2013the AmericanFamily Physician website at www.aafp.org/afp.Copyright 2013 American Academyof Familyprivate,non commercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
Acute Diverticulitisgastrointestinal tract, urologic and gynecologic disorders, functional disorders, andmalignancy (Table 1).HISTORY AND PHYSICAL EXAMINATIONFigure 1. Colonoscopic image demonstrating peridiverticular inflammation (thin arrow) and showing multiple blood clots within diverticula (thick arrows).AILLUSTRATION BY RENEE CANNONBFigure 2. (A) Diverticulosis is the presence of diverticula in the absenceof inflammation. (B) Diverticulitis is inflammation of a diverticulum.component for the development of diverticular diseasebecause monozygotic twins are twice as likely as dizygotic twins to develop diverticulosis.7 Aspirin and nonsteroidal anti-inflammatory drugs increase the risk ofdiverticulitis (hazard ratio 1.2 to 1.7).8 Other risk factors for diverticulitis include increasing age, obesity, andlack of exercise.1DiagnosisSymptom severity, signs of peritonitis, and the patient’sability to tolerate oral intake guide diagnostic testingand clinical management. The differential diagnosisincludes mechanical and inflammatory disorders of theMay 1, 2013 Volume 87, Number 9Patients often present with acute, constantabdominal pain that is usually in the leftlower quadrant.1,9 Other possible symptomsinclude anorexia, constipation, nausea,diarrhea, and dysuria.1 Patients may havea history of diverticulosis or diverticulitis. Although patients with diverticulitistypically have a fever (usually below 102 F[39 C]), in one study, nine of 62 patientswith acute diverticulitis were afebrile.10Tachycardia and hypotension may occurand should raise suspicion for complicateddiverticulitis. On examination, tendernessonly in the left lower quadrant significantlyincreases the likelihood of acute diverticulitis (positive likelihood ratio 10.4), as doa palpable mass and abdominal distention.9Rebound tenderness, rigidity, and theabsence of peristalsis are not accurate fordiagnosis of acute diverticulitis, but maysuggest peritonitis (positive likelihoodratio 1.6; negative likelihood ratio 0.4).11A rectal examination may reveal tenderness or a mass if a low-lying pelvic abscess ispresent.2 Table 2 provides a summary of theaccuracy of signs, symptoms, and laboratorytests for diagnosis of acute diverticulitis.9,12-14Figure 3 provides an algorithmic approach topatients with suspected acute diverticulitis.15LABORATORY STUDIESBecause leukocytosis is present in 55 percentof patients with acute diverticulitis, a complete blood count should be obtained.2 Blood should becollected for a basic metabolic panel to assess electrolytes and renal function. A urinalysis is useful for ruling out urinary tract infection, and a human chorionicgonadotropin urine test should be considered in premenopausal women to exclude pregnancy, particularlyif antibiotics, imaging, or surgery is being considered.During the rectal examination, stool should be obtainedfor a fecal occult blood test to exclude occult gastrointestinal bleeding.Measurement of C-reactive protein (CRP) shouldbe considered. When the patient has left lower quadrant tenderness and a CRP level greater than 50 mgwww.aafp.org/afp American Family Physician 613
Acute DiverticulitisTable 1. Differential Diagnosis of PatientsPresenting with Symptoms of Acute DiverticulitisTable 2. Accuracy of Signs, Symptoms, andTests for the Diagnosis of Acute isRight lower quadrant pain, fever,anorexiaAbdominal pain, nausea andvomiting, abnormalities onabdominal radiographyWeight loss, anemia, gastrointestinalbleedingPositive pregnancy test, abdominal orpelvic pain with vaginal bleedingAbdominal pain, nausea, vomitingDiarrhea, weight loss, rectal bleeding,mucus in stoolGroin pain associated with mass orswelling, typically more prominentwhen the patient coughsAbdominal spasms relieved withdefecationAbdominal pain out of proportion toexamination findings and a historyof atherosclerotic cardiovasculardiseaseFlank pain, hematuria, nephrolithiasison abdominal radiographyVague and ill-defined symptoms,abdominal or pelvic painSharp, stabbing pain in lowerabdomen or pelvis with nausea andvomitingEpigastric pain with nausea andvomitingPelvic pain, fever, chills, complicationof pelvic inflammatory diseaseAbnormal urinalysis, flank pain, feverSigns and symptoms9Localized tenderness only in LLQHistory of LLQ painAbsence of vomitingHistory of feverLaboratory tests and imagingComputed tomography12*Ultrasonography13*Magnetic resonance imaging14*C-reactive protein level 50 mg per L(476.20 nmol per L) 9CombinationLLQ tenderness, the absence ofvomiting, and a C-reactive proteinlevel 50 mg per L all present9Bowel obstructionColorectal cancerEctopic pregnancyGastroenteritisInflammatorybowel diseaseInguinal herniaIrritable bowelsyndromeIschemic colitisNephrolithiasisOvarian malignancyOvarian torsionPancreatitisTubo-ovarianabscessUrinary tractinfectionper L (476.20 nmol per L) in the absence of vomiting, the likelihood of acute diverticulitis is significantly increased (positive likelihood ratio 18).9However, this simple decision rule has not been prospectively validated. Also, in a series of 247 patients(of whom 35 percent had a perforation), only about20 percent with a CRP level less than 50 mg per L had aperforation, compared with 69 percent with a CRP levelgreater than 200 mg per L (1,904.80 nmol per L).16IMAGING STUDIESImaging is not necessary in most patients with mildsymptoms. Abdominal radiography may be helpful inpatients with suspected perforation of a diverticulum,because it may demonstrate free air. Computed tomography (CT), ultrasonography, and magnetic resonanceimaging (MRI) are useful in selected patients to establish the diagnosis and the extent and severity of disease,614 American Family PhysicianLR 070.3180.65LLQ left lower quadrant; LR positive likelihood ratio; LR– negative likelihood ratio.*—LR relates to positive findings on imaging and LR– relates tonegative findings on imaging.Information from references 9, and 12 through 14.and to exclude complications.13 Abdominal CT is the testof choice in patients with suspected diverticulitis.12,17 Ameta-analysis of eight studies involving 684 patientsfound the diagnostic accuracy of CT to be excellent, andCT is the most commonly performed test.12 The mostsensitive CT findings are bowel wall thickening andfat stranding, and the most specific findings includeabscesses, arrowhead sign, fascial thickening, free air,inflamed diverticulum, intramural air, intramuralsinus tract, and phlegmon.17 A disadvantage of CT is thepotentially harmful effects of ionizing radiation. Table 3lists the accuracy of CT findings for the diagnosis ofacute diverticulitis.17 Figure 4 includes CT images showing changes characteristic of diverticulitis.Ultrasonography has good diagnostic accuracy fordiverticulitis compared with CT; however, it is inferiorto CT for estimating the extent of large abscesses andfor evaluating for free air.13 The accuracy of ultrasonography is suboptimal in patients who are obese andin patients with overlying gas that may obscure structures.13 Ultrasonography should be considered for pregnant women suspected of having diverticulitis to avoidionizing radiation.MRI has good diagnostic accuracy.14 Advantages ofMRI include excellent soft tissue detail and the lack ofionizing radiation. However, MRI takes significantlylonger than CT and may not be acceptable in critically illpatients.13,14 Patients with severe claustrophobia, certainwww.aafp.org/afpVolume 87, Number 9 May 1, 2013
Evaluation and Management of Suspected Acute DiverticulitisSuspect diverticulitis: left lower quadrant pain, tenderness, fever (Table 2)Perform complete blood count, basic metabolic panel, measurementof C-reactive protein, urinalysis, human chorionic gonadotropinurine test, fecal occult blood test, and abdominal radiographySuspect other diagnosisSuspect diverticulitisConsider differentialdiagnosis (Table 1)Assess severity: mild symptoms, able to tolerate oral intake, and no signs of peritonitis?Yes: mildNo: moderateor severeOutpatient management with clear liquiddiet and follow-up in two to three daysMild symptoms persist,able to tolerate oral intake,and no signs of peritonitisModerate to severe symptomsdevelop, unable to tolerate oralintake, or signs of peritonitisOutpatient management with oralantibiotics (Table 4), clear liquid diet,and follow-up in two to three daysSymptoms improveSymptoms persistColonoscopy not indicatedDiscuss preventive measuresNegative imaging findingsAdmit to hospital, intravenous fluids, intravenous antibiotics (Table 4), no foodor drink, perform imaging (usually computed tomography), and assess severityImaging diagnostic fordiverticulitis (Table 3)Consider differentialdiagnosis (Table 1)Imaging shows peridiverticular abscessPercutaneousdrainage of abscessAssess symptomsContinue conservative managementSymptoms improveImaging shows largeabscess, perforation,or bowel obstructionUse clinical scoring system topredict mortality in patientswith peritonitis (Table 5)Surgical consultationSymptoms persistRepeat imagingConsider follow-up colonoscopyin four to six weeksSurgical consultationDiscuss preventive measuresFigure 3. Algorithmic approach to patients with suspected acute diverticulitis.Adapted with permission of Wiley, Inc. Wilkins T, Coffin J, Holmes K. Diverticulitis. In: Ferenchick G, French L, eds. Essential Evidence Plus. Hoboken, N.J.:John Wiley & Sons; copyright 2011.
Acute DiverticulitisTable 3. Accuracy of Computed Tomography Findingsfor the Diagnosis of Acute Diverticulitistypes of surgical clips, metallic fragments, orcardiac pacemakers cannot undergo MRI.COLONOSCOPYColonoscopy is contraindicated in acutediverticulitis, but historically was recommended to be performed four to six weeksafter resolution of acute diverticulitis toconfirm the diagnosis and to exclude othercauses (e.g., colorectal cancer). A retrospective cohort study of 1,088 patients with leftsided diverticulitis diagnosed by CT foundan increased risk of colorectal cancer inpatients with an abscess (odds ratio [OR] 7)or fistula (OR 18) found on CT.18 However,another retrospective longitudinal studyof 292 patients suggested that colonoscopyis unnecessary in uncomplicated diverticulitis.19 Therefore, colonoscopy is recommended four to six weeks after resolution ofsymptoms in patients with complicated disease or for another indication, such as ageappropriate screening.TreatmentAlthough most patients (94 percent) can betreated on an outpatient basis, a retrospectiveanalysis of 693 patients found that women(OR 3.1) and those with free fluid on CT(OR 3.2) are at higher risk of outpatienttreatment failure.20 Outpatient managementhas traditionally consisted of a clear liquiddiet, oral broad-spectrum antibiotics, andfollow-up in two to three days.2 Outpatientmanagement with rest and fluids is effectivefor patients with mild diverticulitis.2The decision to hospitalize a patient withuncomplicated diverticulitis depends onseveral factors, including the patient’s ability to tolerate oral intake, severity of illness,comorbidities, and outpatient support systems.2 Hospitalization should be consideredif patients have signs of peritonitis or thereis suspicion of complicated diverticulitis.Inpatient management includes no food ordrink by mouth, intravenous fluid resuscitation (normal saline or lactated Ringer solution), and intravenous antibiotics.2 Clinicalimprovement is expected within two to fourdays and includes decreasing fever, leukocytosis, and pain.2 A randomized controlled616 American Family PhysicianFindingSensitivity(%)Specificity(%)LR LR–Fascial thickeningInflamed diverticulumFree airArrowhead sign*Free fluidBowel wall thickeningFat strandingAbscessPhlegmonIntramural airIntramural sinus 500.570.700.840.570.040.060.930.960.970.980.13LR positive likelihood ratio; LR– negative likelihood ratio.*—Defined as focal colonic wall thickening with arrowhead-shaped lumen pointingto inflamed diverticula.Information from reference 17.ABFigure 4. Computed tomography with oral contrast media showingchanges characteristic of diverticulitis. (A) Sigmoid diverticula withand without contrast media (arrows), with associated thickening ofbowel wall. (B) Extensive segment sigmoid diverticulitis (arrows) demonstrating multiple diverticula with pericolonic inflammation.www.aafp.org/afpVolume 87, Number 9 May 1, 2013
Acute DiverticulitisTable 4. Primary and Alternative Antibiotic Regimens for the Treatment of Acute atient (mild)Not recommended in mild, uncomplicated diverticulitis; recent trials suggest that taking no antibiotics is anoption with appropriate follow-up23,24Outpatient(mild, but withpersistent orworseningsymptoms)Trimethoprim/sulfamethoxazole DS, 160/800 mg orallyevery 12 hoursorCiprofloxacin (Cipro), 750 mg orally every 12 hours, orlevofloxacin (Levaquin), 750 mg orally every 24 hours,plus metronidazole (Flagyl), 500 mg orally every six hoursAmoxicillin/clavulanate extended release(Augmentin XR), two 1,000/62.5-mg tabletsorally every 12 hoursorMoxifloxacin (Avelox), 400 mg orally every24 hoursInpatient (mild tomoderate)Piperacillin/tazobactam (Zosyn), 3.375 g IV every six hoursor 4.5 g IV every eight hoursorTicarcillin/clavulanate (Timentin), 3.1 g IV every six hoursorErtapenem (Invanz), 1 g IV every 24 hoursorMoxifloxacin, 400 mg IV every 24 hoursCiprofloxacin, 400 mg IV every 12 hours, orlevofloxacin, 750 mg IV every 24 hours, plusmetronidazole, 500 mg IV every six hours or1 g IV every 12 hoursorTigecycline (Tygacil), 100 mg IV first dose, then50 mg IV every 12 hoursorMoxifloxacin, 400 mg IV every 24 hoursSevere (lifethreatening)Imipenem/cilastatin (Primaxin), 500 mg IV every six hoursorMeropenem (Merrem), 1 g IV every eight hoursorDoripenem (Doribax), 500 mg IV every eight hoursAmpicillin, 2 g IV every six hours, plusmetronidazole, 500 mg IV every six hours,plus ciprofloxacin, 400 mg IV every 12 hours,or levofloxacin, 750 mg IV every 24 hoursorAmpicillin, 2 g IV every six hours, plusmetronidazole, 500 mg IV every six hours,plus amikacin, gentamicin, or tobramycinIV intravenously.Information from references 22 through 24.trial including 50 patients found that starting oral antibiotics after clinical improvement with intravenous antibiotics resulted in shorter hospitalizations, greater costsavings, and no increased risk of recurrence comparedwith longer treatment with intravenous antibiotics.21ANTIBIOTIC THERAPYThe usual practice in the United States for the treatmentof diverticulitis includes broad-spectrum anti bioticsagainst gram-negative rods and anaerobic bacteria(Table 4).22-24 However, evidence supporting their usein uncomplicated diverticulitis is lacking. A study randomized 623 patients to antibiotics or placebo and foundthat antibiotic therapy for uncomplicated diverticulitisdid not accelerate recovery, prevent complications, orMay 1, 2013 Volume 87, Number 9prevent recurrence.23 This finding was corroborated bya Cochrane review of three randomized trials.24 A smallrandomized controlled trial with 79 patients found thatoral antibiotics are as effective as intravenous antibioticsfor uncomplicated diverticulitis (oral and intravenousregimens used were ciprofloxacin [Cipro] and metronidazole [Flagyl]).25 Patients who do not improve withmedical management may have complicated diverticulitis, and additional imaging should be performed.Complicated DiverticulitisPatients with a localized abscess may be candidates forCT-guided percutaneous drainage, a procedure thatdoes not increase the risk of recurrent diverticulitis.26Patients at increased risk of colonic perforation includewww.aafp.org/afp American Family Physician 617
Acute Diverticulitisimmunocompromised patients and patients takingnonsteroidal anti-inflammatory drugs, corticosteroids,or chronic opioid analgesics.6,27 Although the rates ofabscess increased from 5.9 percent in 1991 to 9.6 percentin 2005, the rates of perforation remained unchanged.28A prospective study of 626 women with diverticulitisfound that being overweight (relative risk 1.3), obese(relative risk 1.3), or physically inactive (relativerisk 1.4) increased admissions secondary to diverticulitis, and women who were obese had a twofold increasedrisk of complicated diverticulitis (relative risk 2.0).29The Mannheim Peritonitis Index is a validated measure based on age, sex, presence of organ failure, malignancy, and duration of peritonitis to predict mortality inpatients with perforation. It should be used to stratify apatient’s risk before surgery (Table 5).30 Other complications requiring surgical consultation include phlegmon,fistula, and obstruction.Table 5. Mannheim Peritonitis Index: ClinicalScoring System to Predict Mortality in Patientswith PeritonitisRisk factorOrgan failureDiffuse peritonitisAge older than 50 yearsFemale sexMalignancyOrigin of sepsis not colonicPreoperative duration of peritonitis 24 hoursExudateFecalCloudy, purulentClearTotal:ScoreMortalityrate (%)0 to 56 to 1314 to 2122 to 2930 to 39020132664SURGICAL THERAPYFifteen to 30 percent of patients admitted with acutediverticulitis require surgical intervention during thatadmission.2 A large retrospective analysis of dischargesin the United States from 1991 through 2005 found asignificant decline in colectomies for uncomplicateddiverticulitis (17.9 percent in 1991 to 13.7 percent in2005; P .0001) and complicated diverticulitis (71 percent in 1991 to 56 percent in 2005; P .0001).28 Surgical options include laparoscopic or open approaches fordrainage, washout, or resection. Laparoscopic surgeryresults in a shorter length of stay, fewer complications,and lower in-hospital mortality compared with opencolectomy.31 Emergency colectomy is associated withsignificant morbidity (e.g., pneumonia [25 percent],respiratory failure [15 percent], myocardial infarction[12 percent]) andincreased mortalRisk factors for diverticulitisity in older perinclude use of non steroidalsons.32 A systematicanti-inflammatory drugs,review of 54 studincreasing age, obesity,ies concluded thatand a sedentary lifestyle.resection with primary anastomosisin selected patients is a safe alternative to the traditionalmultistage procedure (Hartmann procedure).33Recurrent DiverticulitisPatients who present with symptoms consistent withrecurrent diverticulitis warrant a complete evaluation.Studies have shown recurrence rates of diverticulitis from 9 to 36 percent. In a large retrospective study618 American Family PhysicianScore76554441260Adapted with permission from Biondo S, Ramos E, Fraccalvieri D,Kreisler E, Ragué JM, Jaurrieta E. Comparative study of left colonicPeritonitis Severity Score and Mannheim Peritonitis Index. Br J Surg.2006;93(5):617.involving 3,165 patients treated for diverticulitis with amean follow-up of nine years, 9 percent had one recurrence and 3 percent had more than one recurrence afterinitial nonoperative management.26A retrospective study analyzing 954 consecutivepatients with diverticulitis found the five-year recurrence rate was 36 percent, with 3.9 percent of patientshaving a complicated recurrence including abscesses,fistula, or free perforation.34 Age 50 years or older wasassociated with lower risk of recurrent diverticulitis (12.2 percent) compared with age younger than50 years (16.2 percent), with a hazard ratio of 0.68(95% confidence interval, 0.53 to 0.87).26 A modelinganalysis found that the most cost-effective approach wasto perform surgery only after the third episode of acuteuncomplicated diverticulitis requiring hospitalization,but the decision to proceed to surgery should be individualized and based on patient preference, comorbidities, and lifestyle.35www.aafp.org/afpVolume 87, Number 9 May 1, 2013
Acute DiverticulitisSORT: KEY RECOMMENDATIONS FOR PRACTICEClinical recommendationAbdominal computed tomography is the test of choice in patients with suspected diverticulitis.Colonoscopy is unnecessary in patients with uncomplicated diverticulitis.Outpatient management with rest and fluids is effective for patients with mild diverticulitis.Inpatient management is recommended in patients with moderate to severe diverticulitis.Broad-spectrum antibiotics covering gram-negative rods and anaerobic bacteria should be used inpatients with complicated diverticulitis.Antibiotics may not be necessary in patients with uncomplicated diverticulitis who are being treatedin the outpatient setting.Computed tomography–guided percutaneous drainage of abscesses should be considered in patientswith diverticulitis.In patients with diverticulitis, laparoscopic surgery results in a shorter length of stay, fewercomplications, and lower in-hospital mortality compared with open colectomy.There is no evidence that avoiding nuts, corn, or popcorn decreases the risk of diverticulosis ordiverticular complications, such as diverticulitis.EvidenceratingReferencesCCCCC12, 1718, 192222B23, 24C26C31B40A consistent, good-quality patient-oriented evidence; B inconsistent or limited-quality patient-oriented evidence; C consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to tions to prevent recurrences of diverticulitisinclude increased intake of dietary fiber, exercise, and,in persons with a body mass index of 30 kg per m2 orhigher, weight loss.36-38 Counseling for smoking cessation is recommended because smoking is associated withan increased incidence of complicated diverticulitis andless favorable outcomes (e.g., surgery at a younger age,higher risk of recurrence).39 Evidence from a prospectivecohort study of 47,228 men in the United States found noevidence that avoiding nuts, corn, or popcorn decreasesthe risk of diverticulosis or diverticular complications,such as diverticulitis.40 A small prospective study foundthat mesalamine and Lactobacillus casei are effective inpreventing recurrence.41 A meta-analysis of four randomized controlled trials with 1,660 patients who hadexperienced at least one episode of diverticulitis foundthat rifaximin (Xifaxan) plus fiber provided one year ofcomplete symptom relief (number needed to treat 3)and fewer complications (number needed to treat 59)compared with fiber alone.42Data Sources: A PubMed search was completed in Clinical Queriesusing the key terms diverticulitis, diverticulosis, diverticular disease,pathogenesis, diagnosis, and treatment. The search included metaanalyses, randomized controlled trials, clinical trials, and reviews. Wealso searched the Agency for Healthcare Research and Quality evidencereports, Clinical Evidence, the Cochrane database, Essential EvidencePlus, the National Guideline Clearinghouse database, and DynaMed.Search date: April 15, 2012.May 1, 2013 Volume 87, Number 9The AuthorsTHAD WILKINS, MD, FAAFP, is director of academic development and aprofessor in the Department of Family Medicine at Georgia Regents University in Augusta.KATHERINE EMBRY, MD, is a resident in the Department of Family Medicine at Georgia Regents University.RUTH GEORGE, MD, FACS, is a resident in the Department of Family Medicine at Georgia Regents University.Address correspondence to Thad Wilkins, MD, FAAFP, Georgia RegentsUniversity, 1120 15th Street, HB-4032, Augusta, GA 30912 (e-mail:jwilkins@gru.edu). Reprints are not available from the authors.Author disclosure: No relevant financial affiliations.REFERENCES1. Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med.1998;338(21):1521-1526.2. Stollman NH, Raskin JB; Ad Hoc Practice Parameters Committee ofthe American College of Gastroenterology. Diagnosis and management of diverticular disease of the colon in adults. Am J Gastroenterol.1999;94(11):3110-3121.3. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestivediseases in the United States. Gastroenterology. 2002;122(5):1500-1511.4. Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Diverticulitis in theUnited States: 1998-2005: changing patterns of disease and treatment.Ann Surg. 2009;249(2):210-217.5. Ricciardi R, Roberts PL, Read TE, et al. Cyclical increase in diverticulitisduring the summer months. Arch Surg. 2011;146(3):319-323.6. Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee ofAmerican Society of Colon and Rectal Surgeons. Practice parametersfor sigmoid diverticulitis. Dis Colon Rectum. 2006;49(7):939-944.www.aafp.org/afp American Family Physician 619
Acute Diverticulitis7. Granlund J, Svensson T, Olén O, et al. The genetic influence on diverticular disease – a twin study. Aliment Pharmacol Ther. 2012;35(9):1103-1107.25. Ridgway PF, Latif A, Shabbir J, et al. Randomized controlled trial of oralvs intravenous therapy for the clinically diagnosed acute uncomplicateddiverticulitis. Colorectal Dis. 2009;11(9):941-946.8. Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin ornonsteroidal anti-inflammatory drugs increases risk for diverticulitis anddiverticular bleeding. Gastroenterology. 2011;140(5):1427-1433.26. Broderick-Villa G, Burchette RJ
May 01, 2013 · Acute Diverticulitis . SURGICAL THERAPY. P
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