Update on the management of sigmoid diverticulitis

Table 1 Differential diagnosis for acute and chronic presentations of diverticulitis

Acute presentation	Chronic presentation
Appendicitis	Malignancy
Anastomotic leak (post-surgical)	IBS/SUDD
Perforating malignancy	IBD
Constipation	Constipation
IBS	Post-surgical
IBD
Ischemic colitis
Post-radiation enteritis
Urogynecological pathology (tubo-ovarian abscess, endometriosis, pyelonephritis, cystitis etc.)
Non-malignant viscus perforation (peptic ulcer)

IBD: Inflammatory bowel disease; IBS: Irritable bowel disease; SUDD: Symptomatic uncomplicated diverticular disease.

Table 2 Workup for acute and chronic presentations of diverticulitis

	Acute	Chronic
History	Onset, progression, severity, location. Previous colon evaluation (< 2 yr). Previous episodes. Bowel habits	Recurrent attacks. Previous hospitalizations.Previous imaging. Previous colon evaluation (< 2 yr). Change in bowel habits
Physical examination	Localized vs diffuse peritonitis?	Abdominal distension. Fistula
Lab tests	WBC, CRP	Anemia? UTI?
Imaging	CT with oral/rectal and intravenous contrast: (1) Phlegmon; (2) Abscess/contrast extravasation; (3) Free air; and (4) Findings suggestive of other diagnosis	CT with oral/rectal and intravenous contrast: (1) Wall thickening; (2) Extraluminal contrast/air; (3) Fistulization; (4) Proximal colon distention; and (5) Rule out cancer features
Endoscopy	Avoid in acute phase, plan after 6 wk à rule out malignancy/IBD and/or synchronous pathology	Always à assess for mucosal pathology at target site and for synchronous pathology in the rest of the colon
Additional	(1) Possible CT-guided abscess drainage; and (2) Possible water-soluble contrast enema	(1) If colon evaluation incomplete à CT colonography or barium double contrast enema; and (2) Potentially cystoscopy, colposcopy

WBC: White blood cell; CRP: C-reactive protein; UTI: Urinary tract infection; CT: Computed tomography; IBD: Inflammatory bowel disease.

Table 3 Hinchey classification and modified Hinchey classification of acute diverticulitis

Hinchey classification[66]		Modified Hinchey classification[60,69,91] (imaging- or surgery-defined)		Comment
I	Pericolic abscess or phlegmon	0	Mild clinical diverticulitis	LLQ pain, elevated WBC, fever, no confirmation by imaging or surgery
		I	Confined pericolic inflammation: Phlegmon
		I	Confined pericolic abscess	In immediate adjacency to inflamed bowel segment
II	Pelvic, intra-abdominal or retroperitoneal abscess	II	Pelvic, distant intra-abdominal, or retroperitoneal abscess
III	Generalized purulent peritonitis	III	Generalized purulent peritonitis	No open communication with bowel lumen (ruptured abscess)
IV	Generalized fecal peritonitis	IV	Fecal peritonitis	Free perforation, open communication with bowel lumen
		SMOL1	Smoldering diverticulitis/peridiverticulitis	Recurrent/intermittent or chronic
		FIST2	Colovesical/vaginal/enteric/cutaneous fistula	Chronic or acute
		OBST3	Large and/or small bowel obstruction	Chronic or acute

¹Smoldering.

²Fistula formation.

³Obstruction. LLQ: Left lower quadrant; WBC: White blood cell.

Table 4 Randomized controlled trials of antibiotics vs omission of antibiotics in the treatment of uncomplicated diverticulitis

Ref.	Number of patients	Antibiotics group	Control group	Primary outcome	Conclusions
AVOD[86]	623	At least 10 d of Abx, IV initially, then PO after admission or upon discharge	IV fluids	Complications, length of stay, need for surgery	Complications: 1% in Abx arm, 1.9% in control group (P = 0.302). LOS: 3 d in both groups. Recurrent diverticulitis/readmission in 1 year: 16% in both groups (P = 0.881)
DIABOLO[63]	528	10 d course of Abx, IV for 2 d, then PO	Observation as outpatient if clinical criteria satisfied	Time to recovery	Median time (d) to recovery: Observation 14 (IQR 6-35); antibiotic 12 (7-30; HR 0.91; P = 0.151)

Abx: Antibiotics; LOS: Length of stay; IQR: Interquartile range; HR: Hazard ratio; AVOD: Antibiotika Vid Okomplicerad Divertikulit.

Table 5 Randomized controlled trials comparing laparoscopic peritoneal lavage for perforated diverticulitis

Ref.	Number of patients	Morbidity (%)	Mortality (%)	Nonresolution (%)	Recurrence (%)	Elective resection (%)	No resection needed (%)
LADIES/LOLA[154]
-Laparoscopic lavage	47	44	2	20	13	2	52
-Sigmoidectomy	43	29	1	N/A	N/A	71	N/A
SCANDIV[155]
-Laparoscopic lavage	101	26	8	Not recorded	Not recorded	Not recorded	Not recorded
-Sigmoidectomy	98	14	7	N/A	N/A	Not recorded	N/A
DILALA[156]
-Laparoscopic lavage	43	21	8	Not recorded	0	0	Not recorded
-Open Hartmann’s	40	17	11	N/A	N/A	Not recorded	N/A

N/A: Not applicable; LOLA: L-ornithine L-aspartate; SCANDIV: Scandinavian diverticulitis.