• Colitis
• Differential diagnosis
• Diverticular disease
• Inflammatory bowel disease
• Segmental colitis associated with diverticulosis

• Adenoma detection rate
• Colorectal cancer
• Diverticulosis
• Scad
• Screening

• Crohn’s Disease
• Diverticulitis
• Inflammatory Bowel Disease
• SCAD
• Segmental Colitis Associated With Diverticulosis

• chronic colitis
• disease progression
• diverticular disease
• mesalamine
• ulcerative colitis

• Diverticulitis
• Inflammatory Bowel Disease
• Segmental Colitis Associated With Diverticulitis

• Female
• Humans
• Pyoderma Gangrenosum/diagnosis
• Pyoderma Gangrenosum/drug therapy
• Colitis, Ulcerative
• Abdominal Pain/diagnosis
• Abdominal Pain/etiology
• Gastrointestinal Hemorrhage

• biopsies
• diverticular disease
• drug-inducing colitis
• haematochezia
• segmental colitis associated with diverticulosis

• Crohn’s Disease
• Diverticulitis
• Diverticulosis
• Long-term Follow-up and Natural History
• SCAD
• Segmental Colitis

• colonic diverticulosis
• histology
• interdiverticular inflammation
• segmental colitis associated to diverticulosis

• Antibiotics
• Classification
• Diverticulitis
• Epidemiology
• Laparoscopic lavage
• Surgical resection

• Aged
• Colectomy
• Colon, Sigmoid/surgery
• Diverticulitis/surgery
• Diverticulitis, Colonic/diagnostic imaging
• Diverticulitis, Colonic/epidemiology
• Elective Surgical Procedures
• Humans
• Laparoscopy

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

• Age Factors
• Colonoscopy
• Diagnostic Imaging
• Digestive System Surgical Procedures
• Disease Management
• Diverticulitis, Colonic/diagnosis
• Diverticulitis, Colonic/therapy
• Humans
• Risk Factors

• K23 DK118192 NIDDK NIH HHS

Segmental colitis associated with diverticulosis (SCAD) is a rare inflammatory condition affecting segments of the colon with diverticular disease. We present an 85-year-old woman with flank pain, fevers, and chills found on imaging to have left colonic wall thickening and left-sided hydroureteronephrosis and workup confirming a diagnosis of SCAD. A detailed review of SCAD and discussion of the differential diagnosis are provided. This case emphasizes disease-specific clinical pearls and highlights hydroureteronephrosis as a rare complication seen in a patient with SCAD.

• Diverticular disease
• Diverticulitis
• Symptomatic uncomplicated diverticular disease

• colitis
• diverticular
• diverticulosis
• segmental
• sigmoid

• colonic diverticulosis
• pediatrics
• segmental colitis
• teenager
• ulcerative colitis

• Anti-Inflammatory Agents, Non-Steroidal/adverse effects
• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Diverticulitis, Colonic/prevention & control
• Humans
• Mesalamine/adverse effects
• Mesalamine/therapeutic use
• Randomized Controlled Trials as Topic
• Secondary Prevention

Segmental colitis associated with diverticulosis (SCAD) is an inflammatory process that affects colonic luminal mucosa in segments that are also affected by diverticulosis. Its prevalence varies between 1.15% and 11.4% amongst those suffering from diverticular disease (DD). Being closely associated with DD, it is slightly commoner in males and usually presents in the sixth decade of life. Although the exact pathogenesis of SCAD is unknown, it is probably heterogeneous and includes mechanisms that also play a part in inflammatory bowel disease (IBD). The clinical presentation is non-specific and similar to that of other pathologies involving the sigmoid colon, and its diagnosis is based on endoscopic findings in correlation with histology. Currently, there are no guidelines for its management, which is usually based on the administration of salicylates and antibiotics, with surgery being reserved for refractory cases. The rarity of SCAD may be multifactorial: whereas milder forms go undiagnosed or are attributed to DD, more severe forms can be misdiagnosed as IBD. This latter distinction is an important one to make, since SCAD and IBD differ as regards their natural history and prognosis, while very often no long-term medications are required in SCAD.

• Diverticular disease
• inflammatory bowel disease
• segmental colitis associated with diverticulosis

Segmental colitis associated diverticulosis (SCAD) has become increasingly appreciated as a form of inflammatory disease of the colon. Several features suggest that SCAD is a distinct disorder. SCAD tends to develop almost exclusively in older adults, predominately, but not exclusively, males. The inflammatory process occurs mainly in the sigmoid colon, and usually remains localized to this region of the colon alone. SCAD most often presents with rectal bleeding and subsequent endoscopic visualization reveals a well localized process with non-specific histopathologic inflammatory changes. Granulomas are not seen, and if present, may be helpful in definition of other disorders such as Crohn’s disease of the colon, an entity often confused with SCAD. Bacteriologic and parasitic studies for an infectious agent are negative. Normal rectal mucosa (i.e., “rectal sparing”) is present and can be confirmed with normal rectal biopsies. SCAD often resolves spontaneously without treatment, or completely after a limited course of therapy with only a 5-aminosalicylate. Recurrent episodes may occur, but most often, patients with this disorder have an entirely self-limited clinical course. Occasionally, treatment with other agents, including corticosteroids, or surgical resection has been required.

• Segmental colitis associated diverticulosis syndrome
• Ulcerative colitis
• Diverticulitis
• Segmental colitis
• Diverticulosis
• Inflammatory bowel disease

• Adrenal Cortex Hormones/therapeutic use
• Biopsy
• Colitis/diagnosis
• Colitis/pathology
• Colon/pathology
• Colon, Sigmoid/pathology
• Diverticulosis, Colonic/diagnosis
• Diverticulosis, Colonic/pathology
• Endoscopy
• Granuloma/pathology
• Hemorrhage
• Humans
• Inflammation
• Inflammatory Bowel Diseases/complications
• Inflammatory Bowel Diseases/diagnosis
• Inflammatory Bowel Diseases/pathology
• Rectum/pathology
• Treatment Outcome

• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Colitis/immunology
• Colitis/pathology
• Colitis, Ulcerative/immunology
• Colitis, Ulcerative/pathology
• Colonoscopy
• Diverticulum, Colon/drug therapy
• Diverticulum, Colon/immunology
• Diverticulum, Colon/pathology
• Glucocorticoids/therapeutic use
• Humans
• Immunohistochemistry
• Lymphocytes/immunology
• Male
• Mesalamine/therapeutic use
• Middle Aged
• Prednisolone/therapeutic use
• Tumor Necrosis Factor-alpha/analysis

• Diverticulosis
• consensus
• diagnosis
• diverticular disease
• diverticulitis
• medical therapy
• surgical therapy

• Aged
• Carcinoma/complications
• Carcinoma/diagnosis
• Colitis/complications
• Colonoscopy
• Diverticulosis, Colonic/complications
• Humans
• Male
• Neoplasms, Multiple Primary/complications
• Neoplasms, Multiple Primary/diagnosis
• Rectal Neoplasms/complications
• Rectal Neoplasms/diagnosis
• Sigmoid Neoplasms/complications
• Sigmoid Neoplasms/diagnosis

Inflammatory bowel disease (IBD) in patients aged > 60 accounts for 10%-15% of cases of the disease. Diganostic methods are the same as for other age groups. Care has to be taken to distinguish an IBD colitis from other forms of colitis that can mimick clinically, endoscopically and even histologically the IBD entity. The clinical pattern in ulcerative colitis (UC) is proctitis and left-sided UC, while granulomatous colitis with an inflammatory pattern is more common in Crohn’s disease (CD). The treatment options are those used in younger patients, but a series of considerations related to potential pharmacological interactions and side effects of the drugs must be taken into account. The safety profile of conventional immunomodulators and biological therapy is acceptable but more data are required on the safety of use of these drugs in the elderly population. Biological therapy has risen question on the possibility of increased side effects, however this needs to be confirmed. Adherence to performing all the test prior to biologic treatment administration is very important. The overall response to treatment is similar in the different patient age groups but elderly patients have fewer recurrences. The number of hospitalizations in patients > 65 years is greater than in younger group, accounting for 25% of all admissions for IBD. Mortality is similar in UC and slightly higher in CD, but significantly increased in hospitalized patients. Failure of medical treatment continues to be the most common indication for surgery in patients aged > 60 years. Age is not considered a contraindication for performing restorative proctocolectomy with an ileal pouch-anal anastomosis. However, incontinence evaluation should be taken into account an individualized options should be considered

• Inflammatory bowel diseases
• Ulcerative colitis
• Crohn’s disease
• Eldery population

• Adult
• Aged
• Aged, 80 and over
• Colitis/complications
• Colitis/metabolism
• Colitis/pathology
• Colitis, Ulcerative/metabolism
• Crohn Disease/metabolism
• Diverticulosis, Colonic/complications
• Diverticulosis, Colonic/metabolism
• Diverticulosis, Colonic/pathology
• Female
• Humans
• Immunohistochemistry
• Irritable Bowel Syndrome/metabolism
• Male
• Middle Aged
• Severity of Illness Index
• Tumor Necrosis Factor-alpha/metabolism
• Young Adult

Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended. Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.

• Sigmoid diverticulitis
• Diverticulitis management
• Diverticulitis surgery
• Acute diverticulitis
• Complicated diverticulitis
• Perforated diverticulitis
• Laparoscopic colectomy

• Adrenal Cortex Hormones/therapeutic use
• Aged
• Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
• Bacterial Infections/complications
• Bacterial Infections/diagnosis
• Colectomy
• Colitis/complications
• Colitis/diagnosis
• Colonic Neoplasms/complications
• Colonic Pouches
• Diagnosis, Differential
• Humans
• Inflammatory Bowel Diseases/complications
• Inflammatory Bowel Diseases/diagnosis
• Inflammatory Bowel Diseases/epidemiology
• Inflammatory Bowel Diseases/therapy
• Intestines/microbiology

An inflammatory process that involves the sigmoid colonic segment associated with diverticular disease (SCAD) appears to be a distinct clinical and pathological disorder. It has been described in older adults, often presenting with rectal bleeding. Most of the patients seem to respond to treatment only with a 5-aminosalicylate, but some spontaneously resolve with no treatment. Endoscopic evaluation usually shows a non-specific inflammatory process localized in the sigmoid colon alone that may resolve completely with histologically normal colonic mucosa. Repeated symptomatic events with discrete episodes of segmental colitis may occur, but most patients have an entirely benign clinical course. Definition of the underlying molecular events that occur with SCAD may be critically important in understanding the critical elements present in a colonic inflammatory process that can completely resolve without pharmacological or biological treatment.

• Segmental colitis
• Diverticulosis
• Crohn’s disease
• Natural history
• Ulcerative colitis
• Colon cancer