Management of acute colonic diverticulitis in the general and surgical emergency departments

Abstract

Acute left colonic diverticulitis is a very common disease that primarily affects the older population in the Western world. The pathogenesis of acute inflammation of the diverticula may not be as simple as once thought, and the disease cascade could involve a combination of chronic inflammation and altered gut microbiota. Several lifestyle risk factors such as obesity, low-fibre diet, smoking, use of non-steroid anti-inflammatory drugs, inadequate physical activity and others have been associated with a higher risk for diverticulitis. It has been proven that uncomplicated diverticulitis in immunocompetent patients without systemic signs of infection can be treated symptomatically. Outpatient treatment with peroral antibiotics is effective for managing patients with uncomplicated diverticulitis and signs of systemic inflammation. New, less- invasive surgical options have been recognised as appropriate for a select group of patients with complicated diverticulitis. Laparoscopic lavage and drainage are suitable for abscesses where the bowel wall is intact. Resection with primary anastomosis with or without ileostomy is now considered an option for some patients that would historically have to undergo Hartmann’s procedure. The latter still remains the most common operating option even in tertiary referral centres around the world as it is suitable for more complicated cases and critically ill patients. Current evidence does not support routine colonoscopic evaluation for uncomplicated diverticulitis in younger patients without risk factors. Recurrent diverticulitis is now understood to be more benign than was previously thought. Elective resection of the sigmoid colon is therefore no longer a standard treatment for all patients with two or more episodes of acute diverticulitis.