Treatment Of Diverticular Disease Research Articles

Diverticular Disease and Rifaximin: An Evidence-Based Review

There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.

Diagnosis and Treatment of Colonic Diverticular Disease

Colonic diverticulosis is one of the most common conditions of the digestive system and patients generally remain asymptomatic. However, about 20% of patients develop symptomatic diverticular disease such as acute diverticulitis or diverticular hemorrhage, and these have become a huge burden on healthcare systems worldwide. Recent understanding of the pathophysiology of diverticulosis and diverticular disease suggests the role of multiple factors including genetic and environment. Based on this understanding, a preventive strategy to reduce the risk factors of diverticulosis and diverticular disease is highly recommended. The diagnosis of the acute diverticulitis relies on imaging modalities such as an abdominal-pelvic CT scan together with symptoms and signs. Treatment of diverticular disease should be individualized and include modification of lifestyle, use of antibiotics, and surgery. Recent guidelines recommend pursuing less aggressive treatment for patients with acute diverticulitis. This review will provide an overview of both the existing and evolving understanding regarding colonic diverticulosis and diverticular disease and can help clinicians in the management of their patients with diverticular disease.

The Dilemma of the Level of the Inferior Mesenteric Artery Ligation in the Treatment of Diverticular Disease: A Systematic Review of the Literature.

Background and aim: Although sigmoidectomy is a well-standardized procedure for diverticular disease, there are still unclear areas related to the varying morphology and vascular supply of the sigmoid colon. The level of vascular ligation could affect the functional outcomes of patients operated on for diverticular disease. The aim of this review is to primarily evaluate sexual, urinary and defecatory function outcomes, as well as postoperative results, in patients who underwent surgery for diverticular disease, with or without inferior mesenteric artery (IMA) preservation. Materials and methods: The MEDLINE/PubMed, WOS and Scopus databases were interrogated. Comparative studies including patients who underwent sigmoidectomy for diverticular diseases were considered. Bowel function, genitourinary function, anastomotic leak, operation time, conversion to open surgery, anastomotic bleeding, bowel obstruction were the main items of interest. Results: Twelve studies were included in the review, three randomized and nine comparative studies. Bowel and genitourinary function are not differently affected by the level of vascular ligation. The site of ligation of IMA did not influence the rate of functional complications, anastomotic leak and bleeding. Of note, the preservation of IMA is associated with a higher conversion rate and longer operative time. Conclusions: Despite the heterogeneity of patient groups, and although the findings should be interpreted with caution, functional and clinical outcomes after sigmoidectomy for diverticular disease do not seem to be affected by the level of vascular ligation as long as the IMA is ligated far from its origin.

World Gastroenterology Organisation Global Guidelines: Diet and the Gut.

World Gastroenterology Organisation Global Guidelines: Diet and the Gut.

Early or delayed sigmoid resection in complicated diverticular disease? A single-center experience

Summary Background Diverticular disease appears to be one of the most common conditions in the Western world. The standard approach in treatment of diverticular disease is a laparoscopic resection, usually after an inflammation-free time of 4 to 6 weeks. The aim of this study was to evaluate the timing of operation. Materials and methods A total of 61 patients underwent left-sided colonic resection because of diverticular disease between January 2017 and February 2020. Because of complicated diverticulitis (CDD stage 2a or 2b) 37 patients were treated either early within 7 days after first symptoms (group A: n = 17) or delayed about 6 weeks after the first contact and conservative therapy (group B: n = 20). Results Overall mortality was 0%. The average operation time was shorter in the early elective group (group A: 140.4 min vs. group B: 151.2 min; p = 0.29). The hospital stay (group A: 9.9 days vs. group B: 16.9 days) and the postoperative stay (group A: 4.8 days vs. group B: 8.1 days) were significantly longer in group B (p = 0.01). We observed—although not reliable due to the low number of patients—more postoperative complications in the delayed group (group A: 5.9% vs. group B: 15.0%; p = 0.61). Conclusion The data in this study confirm the early operation as safe and efficient due to lower costs. We can recommend an early approach in selected cases with the first episode of a complicated diverticulitis.

DISCUSSION ASPECTS OF TREATMENT FOR DIVERTICULAR DISEASE COMPLICATED WITH FIRST EPISODE OF ACUTE DIVERTICULITIS

AIM: evaluating the effectiveness of conservative treatment for diverticular disease complicated with first episode of acute diverticulitis. PATIENTS AND METHODS: we investigated the results of the conservative treatment of 68 patients with diverticular disease complicated with first episode of acute diverticulitis. The ages of patients range from 32 to 78. The diagnosis was made based on clinical examination, laboratory tests (markers of inflammation – CRP, faecal calprotectin) and imaging studies (irrigoscopy, colonoscopy, USG, CT, laparoscopy). In 19 of 68 patients (28%) affected segment of the colon was descending colon, in 49 (72%) patients sigmoid colon was effected.RESULTS: all 68 patients received conservative treatment (spasmolytics, antibiotics, probiotics, anti-inflammatory, antibacterial drugs, and diet). Rifaximin was used as antibiotic (daily dose 600-1200 mg). Treatment course lasted for 7 days. We used probiotic (Enterol) to normalize colonic microflora (1 capsule 2 times a day), treatment course lasted for 7-10 days. Long-term outcome of treatment and quality of life of 54 (79,4%) patients were evaluated 2-5 years after a first episode of uncomplicated acute diverculitis. 12 (22,2%) patients underwent medical examinations, in 54 (79,4%) patients we used a questionnaire for assessment. Two scales of MOS 36-Item Short Form Health Survey (MOS SF-36) were evaluated: physical functioning and mental health. Analysis the results of the treatment showed that recurrent episodes of acute diverticulitis did not occur. The analyse of the survey results showed that the mean score of the patients were close to the results of healthy population.CONCLUSION: pathogenetically based multicomponent conservative treatment in the first episode of acute diverticulitis can make a regression and normalize laboratory values.The study showed that no reccurence was reported and the quality of life of the patients was similar to healthy ones after conservative treatment. It confirmes that the conservative treatment is an alternative treatment method for a first episode of uncompliated acute diverticulitis.

Diet in colonic diverticulosis: is it useful?

Diverticulosis of the colon is the most common anatomic alteration of the human colon. Diet may be important in the management of diverticular disease (DD). It is known that high‑fiber diet does not prevent diverticulosis, and there are conflicting data on the prevention and treatment of DD and acute diverticulitis. No association has been reported between nut, corn, or popcorn consumption and the development of diverticulosis, DD, and acute diverticulitis. However, there seems to be a mild association between high alcohol intake and diverticulosis, whereas alcohol dependence seems to be related to a lower risk of in‑hospital mortality due to acute diverticulitis. Higher consumption of red meat was associated with a mild increase in the risk of acute diverticulitis, especially when consumed as unprocessed red meat (defined as consumption of "beef or lamb as main dish," "pork as main dish," "hamburger," and "beef, pork or lamb as a sandwich or mixed dish"). On the other hand, higher consumption of poultry (white meat) was not associated with the risk of acute diverticulitis. Finally, higher fish intake was associated with a reduced risk of diverticulitis in an age‑adjusted model but not after adjustment for other potential confounders.

New clinical guidelines recommend taking ispaghula husk or methylcellulose to treat diverticular disease

British Journal of Healthcare ManagementVol. 25, No. 11 CommentNew clinical guidelines recommend taking ispaghula husk or methylcellulose to treat diverticular diseaseGemma HarrisGemma HarrisEmail: E-mail Address: [email protected]Freelance Journalist, Birmingham, UKSearch for more papers by this authorGemma HarrisPublished Online:18 Nov 2019https://doi.org/10.12968/bjhc.2019.0094AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesBupa. Diverticular disease. 2019. https://www.bupa.co.uk/health-information/digestive-gut-health/diverticular-disease-diverticulitis (accessed 3 September 2019) Google ScholarGuts UK. Diverticular disease. 2019a. https://gutscharity.org.uk/advice-and-information/conditions/diverticular-disease/ (accessed 3 September 2019) Google ScholarGuts UK. Help Guts UK influence national guidelines for Diverticular Disease. 2019b. https://gutscharity.org.uk/2019/07/help-guts-uk-write-national-guidelines-for-diverticular-disease/ (accessed 3 September 2019) Google ScholarHodgson J. Effect of methylcellulose on rectal and colonic pressures in treatment of diverticular disease. Br Med J. 1972;3(5829):729–731. https://doi.org/10.1136/bmj.3.5829.729 Crossref, Google ScholarNHS. Diverticular disease and diverticulitis. 2017. https://www.nhs.uk/conditions/diverticular-disease-and-diverticulitis/ (accessed 3 September 2019) Google ScholarNHS. Fybogel (ispaghula husk). 2019. https://www.nhs.uk/medicines/fybogel-ispaghula-husk/ (accessed 5 September 2019) Google ScholarNICE. Diverticular disease. 2019a. https://cks.nice.org.uk/diverticular-disease#!prescribingInfoSub (accessed 5 September 2019) Google ScholarNICE. Diverticular disease final scope. 2019b. https://www.nice.org.uk/guidance/gid-ng10064/documents/final-scope-2 (accessed 3 September 2019) Google ScholarNICE. Help Guts UK influence national guidelines for Diverticular Disease. 2019c. https://www.nice.org.uk/guidance/GID-NG10064/documents/draft-guideline-2 (accessed 5 September 2019) Google Scholar FiguresReferencesRelatedDetails 2 November 2019Volume 25Issue 11ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 18 November 2019 Published in print 2 November 2019 Information© MA Healthcare LimitedPDF download

Sigmoid resection for diverticular disease - to ligate or to preserve the inferior mesenteric artery? Results of a systematic review and meta-analysis.

In colorectal cancer, ligation of the inferior mesenteric artery (IMA) is a standard surgical approach. In contrast, ligation of the IMA is not mandatory during treatment of diverticular disease. The object of this meta-analysis was to assess if preservation of the IMA reduces the risk of anastomotic leakage. A search was performed up to August 2018 using the following electronic databases: MEDLINE/PubMed, ISI Web of Knowledge and Scopus. The measures of treatment effect utilized risk ratios for dichotomous variables with calculation of the 95% CI. Data analysis was performed using the meta-analysis software Review Manager 5.3. Eight studies met the inclusion criteria and were included in the meta-analysis: two randomized controlled trials (RCTs) and six non-RCTs with 2190 patients (IMA preservation 1353, ligation 837). The rate of anastomotic leakage was higher in the IMA ligation group (6%) than the IMA preservation group (2.4%), but this difference was not statistically significant [risk ratio (RR) 0.59, 95% CI 0.26-1.33, I2 =55%]. The conversion to laparotomy was significantly lower in the IMA ligation group (5.1%) than in the IMA preservation group (9%) (RR 1.74, 95% CI 1.14-2.65, I2 =0%). Regarding the other outcomes (anastomotic bleeding, bowel injury and splenic damage), no significant differences between the two techniques were observed. This meta-analysis failed to demonstrate a statistically significant difference in the anastomotic leakage rate when comparing IMA preservation with IMA ligation. Thus, to date there is insufficient evidence to recommend the IMA-preserving technique as mandatory in resection for left-sided colonic diverticular disease.

Paradigm shift: the Copernican revolution in diverticular disease.

Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a “curative” endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of “Copernican revolution” in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.

Treatment of diverticular disease: an update on latest evidence and clinical implications.

BackgroundDiverticular disease (DD) is a common condition, especially in Western countries. In about 80% of patients, colonic diverticula remain asymptomatic (diverticulosis), while approximately 20% of patients may develop abdominal symptoms (symptomatic uncomplicated diverticular disease, SUDD) and, eventually complications as acute diverticulitis (AD). The management of this condition has been improved, and in the last five years European countries and the USA have published guidelines and recommendations.ScopeTo summarize the latest evidence and clinical implication in treatment of DD focusing the attention either on the treatment of diverticulosis, SUDD and AD together with the primary and secondary prevention of diverticulitis.FindingsThe present review was based on the latest evidence in the treatment of DD in the last 10 years. In the last 5 years, six countries issued guidelines on DD with differences regarding covered topics and recommendations regarding treatments. At present there is a lack of rationale for drug use in patients with asymptomatic diverticulosis, but there are limited indications to suggest an increase in dietary fibre to reduce risk of DD. To achieve symptomatic relief in SUDD patients, several therapeutic strategies with fibre, probiotics, rifaximin and mesalazine have been proposed even if a standard therapeutic approach remained to be defined. Agreement has been reached for the management of AD, since recent guidelines showed that antibiotics can be used selectively, rather than routinely in uncomplicated AD, although use of antibiotics remained crucial in the management of complicated cases. With regard to treatment for the primary and secondary prevention of AD, the efficacy of rifaximin and mesalazine has been proposed although with discordant recommendations among guidelines.ConclusionTreatment of DD represented an important challenge in clinical practice, especially concerning management of SUDD and the primary and secondary prevention of AD.

Divertikulitis

Increasing interest in diverticular disease by the scientific community in the last 10-15years has resulted in an increased number of publications. Among other things, nonevidence-based therapeutic paradigms were tested in randomized, controlled therapy studies. The importance of surgery in the therapy of diverticulitis has diminished in recent years; in particular, it has no role in the treatment of diverticulitis types 1a, 1b, and 2a according to the Classification of Diverticular Disease (CDD) treated successfully by conservative means. Surgery has only a subordinate role in recurrent type 3b diverticulitis according to the CDD. Diverticulitis is therefore increasingly treated using conservative or drug therapy. However, only the classic, established antibiotics are currently available as effective drugs for the treatment of diverticular disease. However, these are also decreasing in significance. Over 90% of patients with type 1a/1b diverticulitis can be safely treated according to current data without the use of antibiotics. It is possible that type 2a diverticulitis will also be successfully treated without antibiotics in the future. Substances such as rifaximin, mesalazine, or probiotics, which were tested above all in patients with chronic recurrent forms (CDD type 3a/3b), have not yet been established.

Diverticular disease: myths and realities

Diverticulosis and diverticular disease of the colon are common conditions in Western countries. The incidence and prevalence of these diseases are increasing and becoming significant for health systems. A growing body of knowledge is shifting the paradigm of the pathogenesis and treatment of diverticular disease. Low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to diverticular disease. The risk of developing diverticulitis among individuals with diverticulosis is lower than 10 to 25%. Studies indicate that diverticular disease may become a chronic disorder in some patients, not merely an acute illness. Contrary to the advice from international guidelines, studies have not shown that a high-fiber diet protects against diverticulosis. The evidence about the use of antibiotics in uncomplicated diverticulitis is sparse and of low quality. In relation to surgery, studies support a more conservative approach to prophylactic surgery in patients with recurrent disease or chronic symptoms. Finally, new pathophysiological knowledge suggests that other treatments may be useful (mesalamine, rifaximin and probiotics). However, more research is necessary to validate the safety, effectiveness and cost-effectiveness of these strategies.

DIVERTICULAR DISEASE OF THE COLON: RESOLVED AND UNRESOLVED ISSUES

The article is devoted to the classification and treatment of diverticular disease of the colon, which is by its prevalence, nature, clinical manifestations, complications is not only a medical but also a huge socio-economic problem. The article elaborates various domestic and foreign classification approaches with the reflection of the merits and costs requiring appropriate changes in the modern Russian guidelines for the diagnosis and treatment of adult patients with diverticular disease of the colon for the development of treatment and preventive measures in different forms of the disease. The place and the analysis of the effectiveness of different therapy regimens with the use of the effect of rifaximin-α (Alfa Normix), mesalazine, dietary fiber, particularly psyllium in the treatment of diverticular disease without clinical manifestations (asymptomatic diverticulosis); DB with clinical manifestations, including recurrent form (symptomatic uncomplicated diverticulosis); in the treatment of acute uncomplicated diverticulitis and for prevention of recurrence of acute diverticulitis (term and permanent treatment) are established.

Treatment of Diverticular Disease With Aminosalicylates: The Evidence.

Colonic diverticulosis is an increasingly common condition in Western industrialized countries. About 20% of patients develop symptoms, including abdominal pain, bloating, changes in bowel habits, and, eventually, diverticulitis or other complications. The management of symptomatic uncomplicated diverticular disease (SUDD) and the prevention of acute diverticulitis remains a challenge for the clinician. The rationale for the use of aminosalicylates, such as mesalazine, is based on the assumption of low-grade inflammation in SUDD and symptoms generation, whereas an overt inflammation may induce diverticulitis in patients with diverticular disease. Clinical scenarios in which the efficacy and safety of mesalazine have been studied include SUDD, prevention of diverticulitis, and of recurrent diverticulitis. Data from uncontrolled studies suggest a benefit of mesalazine on patients with SUDD, whereas data from randomized controlled trials showed some evidence of improvement of symptoms, although contrasting results are reported. The largest study so far published on the efficacy of mesalamine in the prevention of recurrence of diverticulitis showed that mesalamine was not superior to placebo. At this time, the role of mesalazine in the prevention of acute diverticulitis remains to be defined with many issues open and unresolved.

COMPLICATED DIVERTICULAR DISEASE: CONTEMPORARY CONCEPT OF TREATMENT (review)

The review respresents contemporary trends in treatment of diverticular disease. The basement of optimal decision making for these patients are clear diagnostic criteria, relevant diagnostic methods and comprehensive universal classification. The spectrum of therapies for diverticular disease includes conservative treatment for uncomplicated forms, percutaneous drainage for abscesses, resection for peritonitis. A possibility of primary anastomosis in case of resection for free perforation with or without protective stoma is discussed. Laparoscopic technologies for chronic complications of diverticular disease is a main trend to improve short, late and functional results in elective surgery.

Probiotics in the Treatment of Diverticular Disease. A Systematic Review.

Diverticular disease is a common gastrointestinal condition. Low-grade inflammation and altered intestinal microbiota have been identified as factors contributing to abdominal symptoms. Probiotics may lead to symptoms improvement by modifying the gut microbiota and are promising treatments for diverticular disease. The aim of this study was to systematically review the efficacy of probiotics in diverticular disease in terms of remission of abdominal symptoms and prevention of acute diverticulitis. According to PRISMA, we identified studies on diverticular disease patients treated with probiotics (Pubmed, Embase, Cochrane). The quality of these studies was evaluated by the Jadad scale. Main outcomes measures were remission of abdominal symptoms and prevention of acute diverticulitis. 11 studies (2 double-blind randomized placebo-controlled, 5 open randomized, 4 non-randomized open studies) were eligible. Overall, diverticular disease patients were 764 (55.1% females, age 58-75 years). Three studies included patients with symptomatic uncomplicated diverticular disease, 4 studies with symptomatic uncomplicated diverticular disease in remission, 4 studies with complicated or acute diverticulitis. Mainly (72.7%) single probiotic strains had been used, most frequently Lactobacilli. Follow-up ranged from 1 to 24 months. Interventions were variable: in 8 studies the probiotic was administered together with antibiotic or anti-inflammatory agents and compared with the efficacy of the drug alone; in 3 studies the probiotic was compared with a high-fibre diet or used together with phytoextracts. As an outcome measure, 4 studies evaluated the occurrence rate of acute diverticulitis, 6 studies the reduction of abdominal symptoms, and 6 studies the recurrence of abdominal symptoms. Meta-analysis on the efficacy of probiotics in diverticular disease could not be performed due to the poor quality of retrieved studies. This systematic review showed that high-quality data on the efficacy of probiotics in diverticular disease are scant: the available data do not permit conclusions. Further investigation is required to understand how probiotics can be employed in this condition.

Role of minimally invasive surgery in the treatment of diverticular disease: an evidence-based analysis.

The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. While the presence of diverticula is common, symptomatic diverticulitis is relatively uncommon, occurring in an estimated 10-30 % of patients. There is continued debate as to whether patients should undergo elective resection for diverticular disease and regarding the role of minimally invasive surgery. Since the first publication on laparoscopic colorectal procedures, the interest in minimally invasive surgery has kept growing. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. However, it still remains unclear whether laparoscopy should be recommended also for complicated sigmoid diverticulitis. The potential benefits of reduced pain and analgesic requirements, smaller scars, and shorter hospital stay but longer operative times are appealing to both patients and surgeons. Nevertheless, there many concerns regarding the time and the type of surgery. Although the role of minimally invasive surgery in the treatment of colonic diseases is progressively increased, current randomized controlled trials should demonstrate whether laparoscopic lavage, Hartmann's procedure or resection and anastomosis achieve the best results for patients. This review aimed to analyze the results of laparoscopic colonic resection for patients with uncomplicated and complicated forms of sigmoid diverticular disease and to determine what stages profit from a laparoscopic procedure and whether the approach can be performed with a low complication rate even for patients with complicated forms of the disease.

Diverticular disease: evolving concepts in classification, presentation, and management.

Diverticular disease is the most commonly reported finding at the time of colonoscopy and one of the most common gastrointestinal indications for hospitalization. Much of our previous understanding of diverticular disease has recently been challenged. There is emerging evidence that the long-accepted hypothesis of diverticulosis as a consequence of fiber deficiency may be more complex than commonly thought, with recent evidence suggesting that high-fiber diet and frequent bowel movements are associated with a greater and not lower prevalence of diverticular disease. There is also emerging support for the concept of low-grade inflammation in symptomatic uncomplicated diverticular disease (SUDD), and the role of anti-inflammatory treatment with mesalamine is being actively investigated. Additionally, elective 'prophylactic' surgery after diverticulitis, previously considered after a second confirmed diverticulitis episode, is being increasingly deferred. The pathogenesis of diverticular disease is likely multifactorial and complex. More studies are needed to evaluate the role of fiber in the pathogenesis and treatment of diverticular disease. The search for an effective medical therapy for SUDD and to prevent recurrent diverticulitis is being actively investigated. The efficacy of mesalamine does not appear to be strong data supported.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines.

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research. MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient. Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence. Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.