Clinical Pearls & Morning Reports
Diverticular disease is the eighth-most-frequent outpatient gastrointestinal diagnosis in the United States, with 2.7 million associated health care visits annually. Read the latest NEJM Clinical Practice here.
Q: How is diverticulitis classified?
A: Diverticulitis is classified as simple (uncomplicated) or complicated. Complicated diverticulitis refers to abscess, fistula, stricture, or free perforation, and simple diverticulitis describes inflammation without these features. This classification does not predict severity or the need for surgery. Simple diverticulitis does not necessarily mean that surgical intervention will not be indicated (e.g., a microperforation may not become “walled off” in an immunosuppressed patient), and complicated diverticulitis may not require surgery (e.g., treatment with antibiotic agents may be sufficient for a small abscess that is not amenable to drainage).
Q: Are oral antibiotics required for outpatient management of diverticulitis?
A: Simple diverticulitis reflects localized inflammation and accounts for approximately 75% of cases of diverticulitis. In the absence of high fever, clinically significant laboratory or radiologic abnormalities, or immunosuppression, the condition can be managed on an outpatient basis. Randomized trials have shown no significant benefit of intravenous over oral antibiotics. Moreover, two trials evaluating routine antibiotic treatment as compared with no antibiotic treatment have shown no significant difference in outcomes. Despite the lack of data to confirm benefits, oral antibiotics are routinely prescribed in the United States.
A: Sigmoid resection with colostomy creation remains the safest and most widely used surgical procedure for perforated diverticulitis. Because more than 30% of these procedures result in a permanent colostomy, two alternative approaches that might reduce this risk have been proposed — laparoscopic lavage and resection with primary anastomosis. Randomized trials comparing lavage with emergency resection, however, yielded inconsistent results. Laparoscopic lavage of perforated diverticulitis remains controversial and should not be performed outside of a randomized trial. Resection and primary anastomosis with loop ileostomy requires two operations (resection of the perforated sigmoid, anastomosis, and diverting ileostomy first, followed by closure of the ileostomy). The procedure has not been widely adopted.
A: The decision to pursue elective surgery after an episode of diverticulitis that was treated nonsurgically is challenging. Many patients will not have another attack after an initial episode of uncomplicated diverticulitis, and only 3 to 5% have complicated recurrence after uncomplicated diverticulitis. Whereas older guidelines from the American Society of Colon and Rectal Surgeons recommended surgery after two attacks of uncomplicated diverticulitis, current guidelines recommend that decisions regarding elective surgery should not be driven by the number of episodes but rather should be individualized. Considerations include the severity and frequency of attacks, coexisting conditions, patient preference (or aversion) regarding surgery, and quality of life. It is helpful to compare the estimated risk of perforation from another attack (which is likely to be similar in severity to previous episodes) with the risk of surgical complications (estimated on the basis of coexisting conditions). Patients with immunosuppression, collagen vascular disease, glucocorticoid use, malnutrition, or obesity are at increased risk for recurrence and perforation but also have increased surgical risks, and tailored decision making is necessary. Elective surgery can be laparoscopic or open. Although a Cochrane review of three randomized trials comparing laparoscopic and open surgery for diverticulitis was inconclusive, the quality of the available data was considered to be low, and a meta-analysis of 25 randomized trials comparing open and laparoscopic colon resection for any indication showed superior outcomes with laparoscopy (i.e., less pain, lower rates of hospitalization and complications, lower costs, and better quality of life).