Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

Table 1 Comparison of medical and surgical professional society clinical practice guidelines for diverticular disease

	Medical society guidelines				Surgical society guidelines
	AGA[19], 2015	AAFP[16], 2013	ACP[17], 2022		ASCRS[18], 2020	SAGES[45], 2019	WSES[15], 2020
Diagnosis and medical management
Triage to outpatient	-	Recommend outpatient if uncomplicated and mild (level C)	Outpatient in uncomplicated disease as outpatients in absence of SIRS (conditional, low certainty)		-	Selective outpatient in immunocompetent host with uncomplicated diverticulitis (weak, moderate-quality)	Outpatient if uncomplicated without comorbidity, re-evaluate at 7 d (weak, moderate-quality)
Antibiotics
Use	Selective use in uncomplicated disease (conditional, low-quality)	Enteric coverage if inpatient. Use outpatient if persistent or worsening symptoms (level B)	Omit in healthy, immunocompetent outpatients with uncomplicated disease and no SIRS (conditional, low certainty)		Healthy patients with uncomplicated disease should not be treated with antibiotics (strong, high-quality). May use in non-operative strategies (strong, low-quality)	Selective use in immunocompetent patients with uncomplicated disease (weak, high-quality)	Advise against antibiotics in healthy patients with uncomplicated disease and no SIRS (strong, high-quality)
Duration	-	-	Insufficient data		-	-	-
Percutaneous drainage	-	Consider in presence of abscess. No size recommendation (level C)	Insufficient outcomes data with percutaneous drain		Recommend when abscess > 3 cm (strong, moderate-quality)	Abscess < 4 cm: Trial antibiotics, drain for failure. Abscess > 4 cm: Drain upfront (weak, low-quality)	Abscess 4-5 cm: Trial antibiotics, drain for failure (weak, low-quality). Abscess > 5 cm: Drain upfront (weak, low-quality)
Prevention	Fiber, physical activity (conditional, very low-quality)	Fiber intake, weight loss, smoking cessation	-		Tobacco cessation, limit red meat, physical activity weight loss (strong, low-quality)	-	-
Surgical management
Emergency surgery
Indications	-	-	-		Diffuse peritonitis, non-operative treatment failure (strong, low-quality)	Peritonitis - Hinchey class III and IV (strong, low-quality)
Stoma or no stoma	-	-	-		Restoration of continuity preferred, when possible, based on patient/OR factors, surgeon preference (strong, moderate-quality)	Hartmann’s if unstable, or immunocompromise. Sigmoid resection with primary anastomosis and proximal diversion over Hartmann’s (weak, moderate-quality)	Critically-ill or major comorbidities: Hartmann’s procedure (strong, low-quality). Stable without comorbidities: Primary resection ± diversion (weak, low-quality)
Laparoscopic lavage	-	-	-		Advise against in feculent peritonitis (strong, high-quality). Not preferred in purulent peritonitis (strong, high-quality)	Consider in select Hinchey III with appropriate expertise and intensive monitoring (weak, high-quality)	Reserve for highly selected patients with generalized peritonitis (weak, high-quality)
Elective surgery
Uncomplicated	Recommends against after single episode of acute diverticulitis, individualize (conditional, very low-quality)	-	-		Individualize, do not based on age or episodes (strong, moderate-quality)	Resect when symptomatic disease decreases-quality of life (strong, moderate-quality)	Recommend elective resection in high-risk patients (weak, very low-quality). Individualize, do not base on episodes (weak, low-quality)
Complicated	-	-	-		Consider when diverticular abscess resolved (strong, moderate-quality). Recommend for fistula, obstruction, or structure (strong, moderate-quality)	Minimum six weeks after complicated episode (weak, low-quality)	-

All professional societies agree workup should include a history and physical, laboratory studies, and imaging with contrast-enhanced abdominopelvic computed tomography (CT), if clinically indicated. Societies agree that ultrasound with regional expertise or magnetic resonance imaging are acceptable alternatives in patients in whom contrast-enhanced CT is contraindicated. Similarly, surgical societies agree that using minimally invasive surgery is preferable in emergent and elective surgery when expertise is available. AGA: American Gastroenterological Association; AAFP: American Academy of Family Physicians; ACP: American College of Physicians; ASCRS: American College of Colon and Rectal Surgeons; SAGES: Society of American Gastrointestinal and Endoscopic Surgeons; WSES: World Society of Emergency Surgery.