Copyright
©The Author(s) 2021.
World J Gastroenterol. Mar 7, 2021; 27(9): 760-781
Published online Mar 7, 2021. doi: 10.3748/wjg.v27.i9.760
Published online Mar 7, 2021. doi: 10.3748/wjg.v27.i9.760
Table 1 Differential diagnosis for acute and chronic presentations of diverticulitis
Acute presentation | Chronic presentation |
Appendicitis | Malignancy |
Anastomotic leak (post-surgical) | IBS/SUDD |
Perforating malignancy | IBD |
Constipation | Constipation |
IBS | Post-surgical |
IBD | |
Ischemic colitis | |
Post-radiation enteritis | |
Urogynecological pathology (tubo-ovarian abscess, endometriosis, pyelonephritis, cystitis etc.) | |
Non-malignant viscus perforation (peptic ulcer) |
Table 2 Workup for acute and chronic presentations of diverticulitis
Acute | Chronic | |
History | Onset, progression, severity, location. Previous colon evaluation (< 2 yr). Previous episodes. Bowel habits | Recurrent attacks. Previous hospitalizations.Previous imaging. Previous colon evaluation (< 2 yr). Change in bowel habits |
Physical examination | Localized vs diffuse peritonitis? | Abdominal distension. Fistula |
Lab tests | WBC, CRP | Anemia? UTI? |
Imaging | CT with oral/rectal and intravenous contrast: (1) Phlegmon; (2) Abscess/contrast extravasation; (3) Free air; and (4) Findings suggestive of other diagnosis | CT with oral/rectal and intravenous contrast: (1) Wall thickening; (2) Extraluminal contrast/air; (3) Fistulization; (4) Proximal colon distention; and (5) Rule out cancer features |
Endoscopy | Avoid in acute phase, plan after 6 wk à rule out malignancy/IBD and/or synchronous pathology | Always à assess for mucosal pathology at target site and for synchronous pathology in the rest of the colon |
Additional | (1) Possible CT-guided abscess drainage; and (2) Possible water-soluble contrast enema | (1) If colon evaluation incomplete à CT colonography or barium double contrast enema; and (2) Potentially cystoscopy, colposcopy |
Table 3 Hinchey classification and modified Hinchey classification of acute diverticulitis
Hinchey classification[66] | Modified Hinchey classification[60,69,91] (imaging- or surgery-defined) | Comment | ||
I | Pericolic abscess or phlegmon | 0 | Mild clinical diverticulitis | LLQ pain, elevated WBC, fever, no confirmation by imaging or surgery |
I | Confined pericolic inflammation: Phlegmon | |||
I | Confined pericolic abscess | In immediate adjacency to inflamed bowel segment | ||
II | Pelvic, intra-abdominal or retroperitoneal abscess | II | Pelvic, distant intra-abdominal, or retroperitoneal abscess | |
III | Generalized purulent peritonitis | III | Generalized purulent peritonitis | No open communication with bowel lumen (ruptured abscess) |
IV | Generalized fecal peritonitis | IV | Fecal peritonitis | Free perforation, open communication with bowel lumen |
SMOL1 | Smoldering diverticulitis/peridiverticulitis | Recurrent/intermittent or chronic | ||
FIST2 | Colovesical/vaginal/enteric/cutaneous fistula | Chronic or acute | ||
OBST3 | Large and/or small bowel obstruction | Chronic or acute |
Table 4 Randomized controlled trials of antibiotics vs omission of antibiotics in the treatment of uncomplicated diverticulitis
Ref. | Number of patients | Antibiotics group | Control group | Primary outcome | Conclusions |
AVOD[86] | 623 | At least 10 d of Abx, IV initially, then PO after admission or upon discharge | IV fluids | Complications, length of stay, need for surgery | Complications: 1% in Abx arm, 1.9% in control group (P = 0.302). LOS: 3 d in both groups. Recurrent diverticulitis/readmission in 1 year: 16% in both groups (P = 0.881) |
DIABOLO[63] | 528 | 10 d course of Abx, IV for 2 d, then PO | Observation as outpatient if clinical criteria satisfied | Time to recovery | Median time (d) to recovery: Observation 14 (IQR 6-35); antibiotic 12 (7-30; HR 0.91; P = 0.151) |
Table 5 Randomized controlled trials comparing laparoscopic peritoneal lavage for perforated diverticulitis
Ref. | Number of patients | Morbidity (%) | Mortality (%) | Nonresolution (%) | Recurrence (%) | Elective resection (%) | No resection needed (%) |
LADIES/LOLA[154] | |||||||
-Laparoscopic lavage | 47 | 44 | 2 | 20 | 13 | 2 | 52 |
-Sigmoidectomy | 43 | 29 | 1 | N/A | N/A | 71 | N/A |
SCANDIV[155] | |||||||
-Laparoscopic lavage | 101 | 26 | 8 | Not recorded | Not recorded | Not recorded | Not recorded |
-Sigmoidectomy | 98 | 14 | 7 | N/A | N/A | Not recorded | N/A |
DILALA[156] | |||||||
-Laparoscopic lavage | 43 | 21 | 8 | Not recorded | 0 | 0 | Not recorded |
-Open Hartmann’s | 40 | 17 | 11 | N/A | N/A | Not recorded | N/A |
- Citation: Hanna MH, Kaiser AM. Update on the management of sigmoid diverticulitis. World J Gastroenterol 2021; 27(9): 760-781
- URL: https://www.wjgnet.com/1007-9327/full/v27/i9/760.htm
- DOI: https://dx.doi.org/10.3748/wjg.v27.i9.760