Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common Disorder

Abstract

A multidisciplinary panel consisting of a general gastroenterologist (LLS), colorectal surgeon (AMM), abdominal radiologist (JLF), and pathologist (BM) discussed a patient’s case history (void of protected health information) with LLS as moderator. We present a summary of the case history and discussion in the following article. A 60-year-old woman presented with recurrent abdominal pain, loose stools, malaise, anorexia, and low-grade fevers. She described her pain as severe cramping located in the left lower quadrant with lower abdominal bloating. Her first episode of pain and symptoms occurred 4 years earlier while she was on vacation. An urgent care provider made a presumptive diagnosis of diverticulitis. Treatment with ciprofloxacin and metronidazole resulted in severe nausea and diarrhea prompting an emergency department visit, where computerized tomography (CT) of the abdomen and pelvis demonstrated subtle inflammation and wall thickening of the sigmoid colon suggestive of uncomplicated diverticulitis. A subsequent colonoscopy found sigmoid diverticulosis and 2 small sessile serrated adenomas. Since that time, she had experienced 5 similar episodes. On 2 occasions, CT was obtained, again demonstrating mild uncomplicated sigmoid diverticulitis. Her white blood cell count was normal. Her symptoms tended to resolve after 1 to 2 weeks of conservative treatment with a low-residue diet and without antibiotics, which she avoids due to previous side-effects. However, 3 months ago, she had a protracted course lasting 5 weeks despite treatment with amoxicillin–clavulanic acid. Presently, she describes 4 weeks of stuttering symptoms. Sometimes her pain is fleeting and relieved with a bowel movement, and other times it lasts for days. She has been unable to advance to a regular diet. Her ongoing symptoms, restricted diet, and unpredictable attacks are significantly affecting her quality of life (QOL). In addition to her episodes of diverticulitis, she has long-standing gastrointestinal symptoms predating the onset of diverticulitis, including loose stools and bloating that improve with an antispasmodic and elimination of foods high in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. She also has a history of hypothyroidism and mild hypertension treated with levothyroxine and hydrochlorothiazide, respectively. There is no known family history of diverticulitis or other gastrointestinal illness. She has never smoked, and drinks 1 glass of wine per week. She jogs regularly. On examination, she appears comfortable. Her body mass index is 24 kg/m2, and her vital signs are normal. Abdominal examination demonstrates mild pain to deep palpation in the left lower quadrant without rebound or guarding. Laboratory studies show normal complete blood count, C-reactive protein, and comprehensive metabolic panel. Fecal calprotectin is 228 mg/kg (normal ≤50 mg/kg). Contrast-enhanced CT of the abdomen and pelvis demonstrates sigmoid diverticulosis with a small amount of fat stranding along the sigmoid colon unchanged from a CT scan 3 months earlier. There is a long segment of wall thickening in the mid-sigmoid without evidence of abscess or perforation (Figure 1A). A flexible sigmoidoscopy performed 1 month later reveals a narrow fixed area of sigmoid colon with patchy mild erythema and multiple small-mouthed diverticula (Figure 2A and B).Figure 2Endoscopic images of diverticulitis. (A) Mild patchy erythema in the sigmoid colon. (B) Narrowed tethered area in the sigmoid colon. (C) Acute diverticulitis including peri-diverticular edema and erythema with purulent discharge. (D) Edema and erythema of a sigmoid fold in acute diverticulitis (note that this finding is not representative of segmental colitis associated with diverticular disease).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Based on the patient’s QOL-limiting recurrent diverticulitis with evidence of ongoing inflammation and a possible sigmoid stricture, she was referred to colorectal surgery for evaluation. At the time of the surgery clinic visit, she had continued to have crampy abdominal pain that is often relieved after bowel movements. Her diet was very limited. After a thoughtful discussion, she elected to pursue sigmoid resection. Several months later, she underwent an elective robotic assisted resection of the sigmoid colon with primary anastomosis and was discharged from the hospital 2 days later. Surgical pathology demonstrated diverticulosis with diverticulitis complicated by intramural and peri-colic abscesses (Figure 3). She experienced 1 episode of mild Clostridium difficile infection after surgery. Three months later at a gastroenterology clinic visit, she reported resolution of abdominal pain, and significant improvement in her dietary restrictions. She takes a fiber supplement to prevent constipation and has 3 to 4 formed bowel movements per day. Question: Which of the following statements regarding this case is true?A.Given the patient’s history of irritable bowel syndrome (IBS), elective surgery for recurrent diverticulitis would be inappropriate.B.The number of episodes of diverticulitis is the primary factor used in determining the appropriateness of elective surgery.C.Elective sigmoid resection eliminates the risk of future diverticulitis.D.The decision to pursue elective resection for recurrent diverticulitis should be individualized. Look on page 545 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Grand Rounds. The correct answer is D. LLS: Jeff, I’d like to start the discussion with you. What features on imaging help you make the diagnosis of diverticulitis? Can CT findings help us predict the future course of disease? JLF: There is a broad differential diagnosis in patients presenting with left lower quadrant pain. Therefore, an optimized CT with intravenous contrast is usually performed to improve detection of specific abnormalities and their potential complications. Many institutions have stopped administering oral contrast to patients undergoing CT from the emergency department to improve patient throughput. Oral contrast may not be necessary owing to recent advances in CT technology that have improved resolution and soft tissue contrast. CT has sensitivity and specificity greater than 95% for the diagnosis of diverticulitis.1Andeweg C.S. Wegdam J.A. Groenewoud J. et al.Toward an evidence-based step-up approach in diagnosing diverticulitis.Scand J Gastroenterol. 2014; 49: 775-784Crossref PubMed Scopus (60) Google Scholar,2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar The characteristic findings of diverticulitis include an inflamed diverticulum with surrounding mesenteric inflammation (Figure 1B and C). However, the diverticulum may not be seen in all cases. The inflammatory changes may also involve a segment of the adjacent colon leading to segmental wall thickening and mural hyper-enhancement. In more severe cases of complicated diverticulitis, localized perforation with adjacent mesenteric air or free perforation can occur. Abscesses appear as rim-enhancing fluid collections in the surrounding mesenteric fat or in the wall of the colon. Sinus tracts or fistulas can be seen as enhancing tracts with or without central fluid. The tracts can course within the bowel wall or extend into the mesenteric fat and to adjacent organs. In cases of chronic diverticulitis, such as in this case, there can be a long segment of luminal narrowing, often with a spiculated appearance (Figure 1A). Without visualization of an inflamed diverticulum, this finding can pose a diagnostic dilemma. Shortening and thickening of the circular muscles of the colon (myochosis coli) in patients with significant diverticulosis can result in wall thickening that mimics inflammation. When the length of the inflamed segment is out of proportion to that expected due to a locally inflamed diverticulum, one should consider chronic diverticulitis, colitis (such as segmental colitis associated with diverticulitis) and Crohn’s disease in the differential diagnosis. CT findings that are predictive of recurrence include the presence of a complication (eg, abscess, perforation), increasing wall thickness, greater length of the inflamed segment, and overall severity of inflammation.3Dickerson E.C. Chong S.T. Ellis J.H. et al.Recurrence of colonic diverticulitis: identifying predictive CT findings—retrospective cohort study.Radiology. 2017; 285: 850-858Crossref PubMed Scopus (15) Google Scholar,4Hall J.F. Roberts P.L. Ricciardi R. et al.Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence?.Dis Colon Rectum. 2011; 54: 283-288Crossref PubMed Scopus (173) Google Scholar In this patient, there was a long segment of inflammation (∼10 cm), wall thickening up to 10 mm (normal <5 mm) and the suggestion of an early or developing peri-colonic fistula (Figure 1A). Based on published data, these findings would suggest a high likelihood of recurrence. LLS: Jeff, thanks for that excellent overview of CT findings in diverticulitis. Patients with recurrent diverticulitis tend to undergo multiple CTs. In the era of low-dose radiation protocols, are concerns regarding radiation exposure justified in this population? JLF: As you indicated, advances in CT technology have allowed the reduction of radiation dose for CT while maintaining diagnostic image quality. Many patients with recurrent diverticulitis are older and the benefits of CT outweigh any theoretical risk, including detection of complications and identification of other sites of diverticulitis and pathology that may mimic diverticulitis. In younger patients, other imaging tests can be considered to help reduce the cumulative radiation exposure. For example, in women, ultrasound can evaluate the female reproductive organs, which are a common source of left lower quadrant pain, as well as screen and detect findings suggestive of diverticulitis.5Onur M.R. Akpinar E. Karaosmanoglu A.D. et al.Diverticulitis: a comprehensive review with usual and unusual complications.Insights Imaging. 2017; 8: 19-27Crossref PubMed Scopus (23) Google Scholar There is increasing use of magnetic resonance imaging (MRI) to image the bowel for Crohn’s disease, and an optimized MRI can also be used to evaluate for diverticulitis. LLS: In Europe, abdominal ultrasound is used to diagnosis diverticulitis. Can you comment on the use of ultrasound in this setting, and drawbacks and barriers to its use in the U.S.? JFL: In experienced hands, ultrasound can identify changes of diverticulitis, including visualization of the inflamed diverticulum, the obstructing fecalith, surrounding mesenteric inflammation, and adjacent abscesses.5Onur M.R. Akpinar E. Karaosmanoglu A.D. et al.Diverticulitis: a comprehensive review with usual and unusual complications.Insights Imaging. 2017; 8: 19-27Crossref PubMed Scopus (23) Google Scholar, 6Abboud M.E. Frasure S.E. Stone M.B. Ultrasound diagnosis of diverticulitis.World J Emerg Med. 2016; 7: 74-76Crossref PubMed Google Scholar, 7Mazzei M.A. Cioffi Squitieri N. Guerrini S. et al.Sigmoid diverticulitis: US findings.Crit Ultrasound J. 2013; 5: S5Crossref PubMed Scopus (46) Google Scholar However, CT provides better assessment of overall extent and severity, including complications such as free air, fistulas, bowel obstruction, ascending septic thrombophlebitis, and peritonitis, and allows evaluation of other organs for pathology that can mimic diverticulitis. CT is also less user dependent. Ultrasound visualization of the sigmoid may be limited in obese patients. Increasing use of point-of care ultrasound may allow for screening of patients for diverticulitis, but in the U.S. many of those patients would still be referred for subsequent CT to evaluate for complications in suspected diverticulitis at ultrasound or to evaluate for another etiology if ultrasound is negative. More studies are needed to assess the added benefit of CT over ultrasound. LLS: Arden, practice guidelines recommend that the decision to perform elective surgery for uncomplicated recurrent diverticulitis be made on a case-by-case basis.2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar,8Stollman N. Smalley W. Hirano I. et al.American Gastroenterological Association Institute guideline on the management of acute diverticulitis.Gastroenterology. 2015; 149: 1944-1949Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar,9Qaseem A. Etxeandia-Ikobaltzeta I. Lin J.S. et al.Colonoscopy for diagnostic evaluation and interventions to prevent recurrence after acute left-sided colonic diverticulitis: a clinical guideline from the American College of Physicians.Ann Intern Med. 2022; 175: 416-431Crossref PubMed Scopus (4) Google Scholar What general factors do you consider when deciding to recommend conservative management vs surgery for a patient with recurrent uncomplicated diverticulitis? AMM: Historically, guidelines recommended elective surgery after 1 or 2 episodes of diverticulitis to prevent future complications, emergency surgery, and the possible need for colostomy or diverting loop ileostomy. Now, however, recurrent diverticulitis is known to be associated with a decreased risk of perforation and abscess compared with the first episode,10Bharucha A.E. Parthasarathy G. Ditah I. et al.Temporal trends in the incidence and natural history of diverticulitis: a population-based study.Am J Gastroenterol. 2015; 110: 1589-1596Crossref PubMed Scopus (161) Google Scholar and the need for emergency surgery and stoma is low.11Bolkenstein H.E. Consten E.C.J. van der Palen J. et al.Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial).Ann Surg. 2019; 269: 612-620Crossref PubMed Scopus (61) Google Scholar Therefore, the number of episodes alone no longer dictates the decision to pursue surgery. Broadly, the decision between conservative management and surgery balances risk of recurrence, severity of disease, and patient QOL with conservative treatment against the risks of operative complications, taking into account patient preferences and values. I will outline these risks. Without surgery, recurrence of uncomplicated diverticulitis is relatively common (15%–32% according to population-based studies).10Bharucha A.E. Parthasarathy G. Ditah I. et al.Temporal trends in the incidence and natural history of diverticulitis: a population-based study.Am J Gastroenterol. 2015; 110: 1589-1596Crossref PubMed Scopus (161) Google Scholar,12Thornblade L.W. Simianu V.V. Davidson G.H. et al.Elective surgery for diverticulitis and the risk of recurrence and ostomy.Ann Surg. 2021; 273: 1157-1164Crossref PubMed Scopus (16) Google Scholar Indeed, the risk of recurrence in this particular patient is extremely high, because risk increases iteratively with each new recurrence; after 3 episodes, the cumulative incidence is 40% at 3 years.10Bharucha A.E. Parthasarathy G. Ditah I. et al.Temporal trends in the incidence and natural history of diverticulitis: a population-based study.Am J Gastroenterol. 2015; 110: 1589-1596Crossref PubMed Scopus (161) Google Scholar Furthermore, the small risk of developing a fistula from the diseased colon to other pelvic organs or adjacent bowel increases with each recurrence. Severity of disease is an important but tricky consideration, because there is no consensus definition or measure for severity of acute uncomplicated diverticulitis. To date, the literature has defined severity according to the presence of complications or need for operative intervention. A patient’s reported symptoms or experiences have not been considered as part of the definition of severity. In practice, however, clinicians have become much more attuned to what patients themselves report,13Hawkins A.T. Rothman R. Geiger T.M. et al.Surgeons‘ perspective of decision making in recurrent diverticulitis: a qualitative analysis.Ann Surg Open. 2022; 3: e157Crossref PubMed Google Scholar for which we have come to use the umbrella term QOL. As in this case, factors influencing QOL in patients with recurrent diverticulitis include not only the frequency and severity of symptoms, but also fear and uncertainty regarding future episodes, impact on functional status such as the ability to work, and restrictions on behaviors such as travel and diet. Operative complications usually are categorized as bleeding, infection, and damage to nearby structures and occur in 10% to 20% of patients who have surgery.12Thornblade L.W. Simianu V.V. Davidson G.H. et al.Elective surgery for diverticulitis and the risk of recurrence and ostomy.Ann Surg. 2021; 273: 1157-1164Crossref PubMed Scopus (16) Google Scholar,14Regenbogen S.E. Hardiman K.M. Hendren S. et al.Surgery for diverticulitis in the 21st century: a systematic review.JAMA Surg. 2014; 149: 292-303Crossref PubMed Scopus (131) Google Scholar Anastomotic leak is particularly serious and often necessitates a return to the operating room with colostomy or diverting loop ileostomy. By definition, surgical resection removes the possibility of recurrent diverticulitis in the resected specimen. It is possible, however, for diverticulitis to recur in a different section of the colon after surgery. It is widely held that the 15% rate of postoperative recurrent diverticulitis in the past was due to residual distal sigmoid colon.14Regenbogen S.E. Hardiman K.M. Hendren S. et al.Surgery for diverticulitis in the 21st century: a systematic review.JAMA Surg. 2014; 149: 292-303Crossref PubMed Scopus (131) Google Scholar Recognition of best operative practices has made this less likely, and current accepted recurrence rates are around 7%.11Bolkenstein H.E. Consten E.C.J. van der Palen J. et al.Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial).Ann Surg. 2019; 269: 612-620Crossref PubMed Scopus (61) Google Scholar When eliciting patient preferences and values, it is important to be clear that the risks of conservative management can extend over a long time period. In contrast, the risk of operative complications can be significant but is highest within 30 days of surgery. Finally, I should mention that patients who are elderly, have substantial comorbid disease, or are immunocompromised have high risk of complications with both conservative management and operative management. Previous recommendations were for surgery after a first episode; however, newer large retrospective cohort studies confirm low risk from recurrent episodes even among immunocompromised patients.2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar Nonetheless, the care of patients with these conditions is more nuanced. LLS: Arden, thank you for your very informative response. This patient has chronic gastrointestinal symptoms suggestive of IBS that predate CT-confirmed diverticulitis by decades. Because surgery is not a treatment for functional bowel disease, how can clinicians distinguish between IBS and symptoms due to diverticulitis? I would like to address this issue. Because IBS is prevalent and the risk of functional bowel disease is increased 5-fold in patients with a history of diverticulitis, this is a common challenge.15Cohen E. Fuller G. Bolus R. et al.Increased risk for irritable bowel syndrome after acute diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1614-1619Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Chronic daily symptoms are characteristic of IBS, whereas diverticulitis typically manifests as discrete episodes of pain followed by long symptom-free periods. However, some patients, like this one, have a prolonged course, making this distinction difficult,11Bolkenstein H.E. Consten E.C.J. van der Palen J. et al.Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial).Ann Surg. 2019; 269: 612-620Crossref PubMed Scopus (61) Google Scholar and clinical evaluation and routine laboratory tests have poor diagnostic accuracy for acute diverticulitis.1Andeweg C.S. Wegdam J.A. Groenewoud J. et al.Toward an evidence-based step-up approach in diagnosing diverticulitis.Scand J Gastroenterol. 2014; 49: 775-784Crossref PubMed Scopus (60) Google Scholar CT and/or endoscopy are often required to detect ongoing inflammation, diverticular complications, or alternative diagnoses. If possible, endoscopy should be delayed until 6 weeks after an acute episode. I include increased risk of perforation and exacerbation of diverticulitis in the endoscopy consent, and use a narrow flexible endoscope (eg, pediatric colonoscope or upper endoscope), and water instead of CO2 insufflation. If there is significant patient discomfort, stricture, or inflammation, I abort the procedure. It is important to note that all guidelines recommend a colonoscopy after an incident episode of complicated diverticulitis and most guidelines recommend a colonoscopy after an incident episode of uncomplicated diverticulitis to exclude alternative diagnoses2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar,8Stollman N. Smalley W. Hirano I. et al.American Gastroenterological Association Institute guideline on the management of acute diverticulitis.Gastroenterology. 2015; 149: 1944-1949Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar—the incidences of misdiagnosed colon cancer are 2% and 8%, respectively.e1Meyer J. Orci L.A. Combescure C. et al.Risk of colorectal cancer in patients with acute diverticulitis: a systematic review and meta-analysis of observational studies.Clin Gastroenterol Hepatol. 2019; 17: 1448-1456.e17Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar However, endoscopy should not be performed after each episode of diverticulitis unless there is diagnostic uncertainty. Although studies in diverticulitis are very limited, in challenging cases, I obtain a fecal calprotectin as a noninvasive assessment of colonic inflammation. In this patient, findings on CT, endoscopy, and stool test were suggestive of ongoing diverticulitis as a cause of her symptoms. If there were no signs of ongoing inflammation, treatment of IBS (eg, fiber, antispasmodics, and/or neuromodulators) would have been appropriate. Arden, on endoscopy, patients with diverticulosis, including those without a history of diverticulitis, often have thickened folds and luminal narrowing in the sigmoid. What clinical features or tests help you determine whether an endoscopic narrowing is clinically significant? AMM: Luminal narrowing, whether due to muscular hypertrophy or fibrotic stricture formation, is an important and understudied topic in diverticulitis. Patients may report slowly progressive crampy abdominal pain or may not be aware of symptoms until the stricture reaches a critically narrow point. According to older studies, large bowel obstruction is due to diverticular stricture in 10% of cases and symptoms are manageable if the lumen is at least 1 cm in diameter. Previous studies of stent or balloon dilatation have not been encouraging owing to perforation, stricture recurrence, and stent migration. More recent work suggests that self-expanding metallic stents may function as a bridge to surgery (allowing decompression and mechanical bowel preparation).e2Fejleh M.P. Tabibian J.H. Colonoscopic management of diverticular disease.World J Gastrointest Endosc. 2020; 12: 53-59Crossref PubMed Google Scholar Overall, most authors agree that a tight stricture, ie, <1 cm, warrants surgery to definitively manage symptoms and prevent complete obstruction.2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar LLS: This patient had findings of ongoing inflammation on the surgical specimen despite surgery performed during a relatively quiescent period. How often do you find ongoing diverticulitis during an elective operation? AMM: I’m not surprised that this patient had intramural abscesses. In the operating room, even after symptoms of acute inflammation have subsided, we often see dense adhesions surrounding the chronically inflamed sigmoid colon. Distinguishing between the diseased colon and structures such as other loops of bowel, fallopian tubes, the bladder, and sometimes the peritoneum of the pelvic sidewall can be a challenge. In a randomized trial of surgery vs conservative therapy, 50% of patients who underwent surgery had evidence of ongoing inflammation and 10% had an abscess or covered perforation.11Bolkenstein H.E. Consten E.C.J. van der Palen J. et al.Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial).Ann Surg. 2019; 269: 612-620Crossref PubMed Scopus (61) Google Scholar An unexpected abscess is more common in patients with smoldering diverticulitis (∼50%). This patient’s course is consistent with smoldering diverticulitis, an uncommon presentation (<10%), defined as diverticulitis that persists or relapses shortly after stopping antibiotics. In a multi-center study of 158 sequential patients with symptomatic uncomplicated diverticulitis, 48% were found to have unexpected abscesses, with a significantly higher likelihood among those with smoldering disease.e3Mari G.M. Crippa J. Borroni G. et al.Symptomatic uncomplicated diverticular disease and incidence of unexpected abscess during sigmoidectomy: a multicenter prospective observational study.Dig Surg. 2020; 37: 199-204Crossref PubMed Scopus (5) Google Scholar Limited data also suggest that most patients with smoldering diverticulitis improve after surgery. Therefore, patients who have persistent inflammation and symptoms despite prolonged antibiotic treatment should be referred for a surgical consultation. LLS: One of patients’ biggest fears regarding surgery for diverticulitis is the potential for an ostomy. How frequently is an ostomy created in the elective setting? AMM: This is a quintessential example of individual preferences and values. Some patients who require an ileostomy or colostomy seem to take it in stride while others report that they can imagine nothing worse. Several randomized controlled trials (RCTs) have shown that primary anastomosis is safe in the acute setting, albeit sometimes protected by a temporary diverting loop ileostomy. There is no rationale for a planned ileostomy or colostomy in the elective setting, unless the patient is immunocompromised or nutritionally depleted, specifically requests a stoma, or has unexpected surgical findings that make an anastomosis unsafe. A large retrospective cohort study found that 4% of patients who underwent an elective sigmoid colectomy had an ileostomy or colostomy in the first year after surgery. I think it is safe to say that about 96% of patients who have an elective sigmoidectomy do not require an ileostomy or colostomy. LLS: Arden, that’s reassuring. I am more comfortable referring a patient for prophylactic surgery to prevent recurrent diverticulitis if previous episodes have been in the sigmoid. Does the location of previous episodes of diverticulitis alter your decision to perform surgery or your surgical approach? Are there operative practices that help to reduce the risk of recurrence? AMM: Surgeons generally think about an elective diverticulitis operation as a series of steps that broadly include 1) dissecting free the area to be resected, 2) performing the resection, and 3) reconstructing or otherwise managing the ends of bowel that are retained. During surgical resection of recurrent diverticulitis, it is important to remove the source of infection or inflammation and leave only soft pliable colon.2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar These clinical decisions depend more on what we encounter in the operation than on the preoperative imaging, although preoperative imaging is a critical guide. Leaving behind colon with diverticula is acceptable as long as it shows no signs of having been inflamed. To reduce the risk of recurrence, the surgeon should be meticulous about removing colon that shows evidence of previous inflammation, such as thickening or scarring, and must remove all of the distal sigmoid colon. As noted, most cases of colectomy for acute uncomplicated diverticulitis will include an anastomosis, and the distal side must include only true rectum (ie, tinea coli have flared to become circumferentially continuous). LLS: Thus far, our discussion has focused on diagnosis of diverticulitis and surgical approaches for prevention of recurrent diverticulitis. I want to 1) summarize medical treatment of acute recurrent diverticulitis and 2) review data on conservative vs surgical approaches for the prevention of recurrence. Treatment of acute, uncomplicated, recurrent diverticulitis parallels treatment of incident diverticulitis, and antibiotics should be considered on a case-by-case basis.2Hall J. Hardiman K. Lee S. et al.The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis.Dis Colon Rectum. 2020; 63: 728-747Crossref PubMed Scopus (126) Google Scholar,8Stollman N. Smalley W. Hirano I. et al.American Gastroenterological Association Institute guideline on the management of acute diverticulitis.Gastroenterology. 2015; 149: 1944-1949Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar Patients with multiple previous episodes may have treatment preferences based on past experience. Antibiotics should be prescribed in patients with immunocompromise, significant comorbidity, smoldering disease, or a severe presentation. Amoxicillin–clavulanic acid and the combination of metronidazole and ciprofloxacin are the most commonly recommended oral antibiotics. Amoxicillin–clavulanic acid has fewer serious side-effects.e4Gaber C.E. Kinlaw A.C. Edwards J.K. et al.Comparative effectiveness and harms of antibiotics for outpatient diverticulitis: two nationwide cohort studies.Ann Intern Med. 2021; 174: 737-746Crossref PubMed Scopus (6) Google Scholar A treatment course of 4 to 7 days is sufficient for most patients. However, patients with smoldering diverticulitis require longer (14 days or more) and often multiple courses of antibiotics. Unfortunately, no proven medical therapies are available for the prevention of diverticulitis. Seven RCTs and several meta-analyses found no benefit of 5-aminosalicylic acids (mesalamine) compared with placebo. Evidence for other medications, such as rifaximin and probiotics, is very limited. Guidelines recommend against the use of any of these agents.8Stollman N. Smalley W. Hirano I. et al.American Gastroenterological Association Institute guideline on the management of acute diverticulitis.Gastroenterology. 2015; 149: 1944-1949Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar,9Qaseem A. Etxeandia-Ikobaltzeta I. Lin J.S. et al.Colonoscopy for diagnostic evaluation and interventions to prevent recurrence after acute left-sided colonic diverticulitis: a clinical guideline from the American College of Physicians.Ann Intern Med. 2022; 175: 416-431Crossref PubMed Scopus (4) Google Scholar I rarely use these medications in my practice. However, modifiable diet and lifestyle factors are associated with reduced risk of incident diverticulitis, including high fiber and low red meat intake, regular physical activity, normal body mass index, and no smoking.e5Strate L.L. Morris A.M. Epidemiology, pathophysiology, and treatment of diverticulitis.Gastroenterology. 2019; 156: 1282-1298.e1Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar In a cohort study of more than 50,000 men followed for up to 22 years, adherence to 5 low-risk factors was associated with a 75% risk reduction.e6Liu P.H. Cao Y. Keeley B.R. et al.Adherence to a healthy lifestyle is associated with a lower risk of diverticulitis among men.Am J Gastroenterol. 2017; 112: 1868-1876Crossref PubMed Scopus (53) Google Scholar Nonsteroidal anti-inflammatory drugs, menopausal hormone therapy, and corticosteroids are associated with increased risk,e5Strate L.L. Morris A.M. Epidemiology, pathophysiology, and treatment of diverticulitis.Gastroenterology. 2019; 156: 1282-1298.e1Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar as well as low vitamin D levels and low ultraviolet light exposure.e7Maguire L.H. Song M. Strate L.E. et al.Higher serum levels of vitamin D are associated with a reduced risk of diverticulitis.Clin Gastroenterol Hepatol. 2013; 11: 1631-1635Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,e8Maguire L.H. Song M. Strate L.L. et al.Association of geographic and seasonal variation with diverticulitis admissions.JAMA Surg. 2015; 150: 74-77Crossref PubMed Scopus (32) Google Scholar Patients should be counseled regarding measures that may help prevent future episodes of diverticulitis. This patient lived a healthful lifestyle and had no known modifiable risk factors. Notably, about 50% of the tendency to develop incident diverticulitis is due to heritable factors.e9Granlund J. Svensson T. Olen O. et al.The genetic influence on diverticular disease—a twin study.Aliment Pharmacol Ther. 2012; 35: 1103-1107PubMed Google Scholar,e10Strate L.L. Erichsen R. Baron J.A. et al.Heritability and familial aggregation of diverticular disease: a population-based study of twins and siblings.Gastroenterology. 2013; 144: 736-742.e1Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar However, the genetics of recurrent diverticulitis has yet to be elucidated. Available data indicate that compared with conservative therapy, prophylactic surgery for recurrent or persistent diverticulitis improves QOL and reduces recurrence rates, but as mentioned, it is associated with a risk of operative complications. In an RCT of 109 patients at 2 academic hospitals in The Netherlands (DIRECT trial),11Bolkenstein H.E. Consten E.C.J. van der Palen J. et al.Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial).Ann Surg. 2019; 269: 612-620Crossref PubMed Scopus (61) Google Scholar the Gastrointestinal Quality of Life Index was significantly higher at 1-year and 5-year follow-up in the elective sigmoid resection arm compared with the conservative arm. At 5 years, recurrent diverticulitis occurred in 11% in the surgery arm (7.5% in a per-protocol analysis) and 30% in the conservative arm. In the conservative arm, 46% of patients ultimately underwent surgery. Surgical complications were higher than typically reported and included anastomotic leak (11%), re-operation (15%), and protective stomas (19%) (Figure 4). LLS: Thank you for the excellent multidisciplinary discussion of recurrent uncomplicated diverticulitis. The diagnosis and management of recurrent diverticulitis can be challenging due to overlap with other conditions, including IBS, the absence of effective medical therapies, and the need for an individualized management approach. We have reviewed the interpretation of radiologic, endoscopic, laboratory, surgical, and histologic findings in recurrent diverticulitis and present a management algorithm (Figure 5). The decision to pursue surgical treatment can be difficult for patients and requires a patient-centered, multi-disciplinary discussion of the risks of ongoing conservative management (the risk of recurrence, patient QOL, modifiable risk factors), and the risks and benefits associated with elective resection (reduced risk of recurrence, potentially improved QOL, and potential for operative complications). The ultimate goal of the management of patients with recurrent diverticulitis is to reduce recurrences and improve QOL. CME Exam 1: Recurrent Lower Abdominal Pain, Altered Bowel Habits, and Malaise: Conservative or Surgical Approach to a Common DisorderGastroenterologyVol. 164Issue 4Preview Full-Text PDF