The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
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Diagnosis and Treatment of Colon Diverticulitis

대장게실염의 진단 및 치료

  • Seo, Geom Seog (Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine) ;
  • Choi, Suck Chei (Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine)
  • 서검석 (원광대학교 의과대학 내과학교실, 소화기질환연구소) ;
  • 최석채 (원광대학교 의과대학 내과학교실, 소화기질환연구소)
  • Published : 2013.12.01
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Abstract

Colonic diverticular disease is the common conditions in industrialized and westernized countries, but it is relatively rare in areas such as Asia. Colonic diverticula are asymptomatic in most cases, only 10-25% develop diverticulitis and 1% finally gets surgery. The location of colonic diverticulitis are significantly different in Western countries and Asia. Left-sided diverticulitis is common in Western countries, while in Asians, right-sided diverticulitis is more prevalent. A CT scans is commonly used to diagnose diverticulitis and its complication such as abscess, obstruction, fistula and perforation. It also has been used in percutaneous drainage of diverticular abscess and predicting the success of medical therapy. After resolution of clinical attack of diverticulitis, colonoscopy can be performed to exclude colon cancer. The current therapeutic approaches for colonic diverticulitis are relieving symptoms and preventing complications. Uncomplicated diverticulitis is successfully treated with antibiotics, bowel rest and pain control, while complicated diverticulitis require surgical consultation. Treatment strategy of recurrent diverticulitis depends on age and comorbid diseases as well as the frequency and severity of subsequent attacks.

Keywords

References

  1. Young-Fadok TM, Roberts PL, Spencer MP, Wolff BG. Colonic diverticular disease. Curr Probl Surg 2000;37:457-514.
  2. Hildebrand P, Kropp M, Stellmacher F, Roblick UJ, Bruch HP, Schwandner O. Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period. Langenbecks Arch Surg 2007;392:143-147. https://doi.org/10.1007/s00423-006-0109-6
  3. Sugihara K, Muto T, Morioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan: a review of 615 cases. Dis Colon Rectum 1984;27:531-537. https://doi.org/10.1007/BF02555517
  4. Lee IK. Right colonic diverticulitis. J Korean Soc Coloproctol 2010;26:241-245. https://doi.org/10.3393/jksc.2010.26.4.241
  5. Kim SY, Oh TH, Seo JY, et al. The clinical factors for predicting severe diverticulitis in Korea: a comparison with Western countries. Gut Liver 2012;6:78-85. https://doi.org/10.5009/gnl.2012.6.1.78
  6. Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR. Epidemiology of perforated colonic diverticular disease. Postgrad Med J 2002;78:654-658. https://doi.org/10.1136/pmj.78.925.654
  7. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004;363:631-639. https://doi.org/10.1016/S0140-6736(04)15597-9
  8. Biondo S, Golda T, Kreisler E, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg 2013 May 31 [Epub]. http://dx.doi.org/1097/SLA.0b013e3182965a11.
  9. O'Connor ES, Leverson G, Kennedy G, Heise CP. The diagnosis of diverticulitis in outpatients: on what evidence? J Gastrointest Surg 2010;14:303-308. https://doi.org/10.1007/s11605-009-1098-x
  10. Martin ST, Stocchi L. New and emerging treatments for the prevention of recurrent diverticulitis. Clin Exp Gastroenterol 2011;4:203-212.
  11. Chen SC, Chang KJ, Wei TC, Yu SC, Wang SM. Can cecal diverticulitis be differentiated from acute appendicitis? J Formos Med Assoc 1994;93:263-265.
  12. Shyung LR, Lin SC, Shih SC, Kao CR, Chou SY. Decision making in right-sided diverticulitis. World J Gastroenterol 2003;9:606-608. https://doi.org/10.3748/wjg.v9.i3.606
  13. Shin JH, Son BH, Kim H. Clinically distinguishing between appendicitis and right-sided colonic diverticulitis at initial presentation. Yonsei Med J 2007;48:511-516. https://doi.org/10.3349/ymj.2007.48.3.511
  14. Longstreth GF, Iyer RL, Chu LH, et al. Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients. Aliment Pharmacol Ther 2012;36:886-894. https://doi.org/10.1111/apt.12047
  15. Sher ME, Agachan F, Bortul M, Nogueras JJ, Weiss EG, Wexner SD. Laparoscopic surgery for diverticulitis. Surg Endosc 1997;11:264-267. https://doi.org/10.1007/s004649900340
  16. Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg 1999; 65:632-635.
  17. Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100:910-917. https://doi.org/10.1111/j.1572-0241.2005.41154.x
  18. Ambrosetti P. Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg 2008;12:1318-1320. https://doi.org/10.1007/s11605-008-0489-8
  19. Al-Sahaf O, Al-Azawi D, Fauzi MZ, El-Masry S, Gillen P. Early discharge policy of patients with acute colonic diverticulitis following initial CT scan. Int J Colorectal Dis 2008;23:817-820. https://doi.org/10.1007/s00384-008-0492-2
  20. Destigter KK, Keating DP. Imaging update: acute colonic diverticulitis. Clin Colon Rectal Surg 2009;22:147-155. https://doi.org/10.1055/s-0029-1236158
  21. Schwerk WB, Schwarz S, Rothmund M. Sonography in acute colonic diverticulitis: a prospective study. Dis Colon Rectum 1992;35:1077-1084. https://doi.org/10.1007/BF02252999
  22. Pradel JA, Adell JF, Taourel P, Djafari M, Monnin-Delhom E, Bruel JM. Acute colonic diverticulitis: prospective comparative evaluation with US and CT. Radiology 1997;205: 503-512. https://doi.org/10.1148/radiology.205.2.9356636
  23. Liljegren G, Chabok A, Wickbom M, Smedh K, Nilsson K. Acute colonic diverticulitis: a systematic review of diagnostic accuracy. Colorectal Dis 2007;9:480-488. https://doi.org/10.1111/j.1463-1318.2007.01238.x
  24. Ambrosetti P, Jenny A, Becker C, Terrier TF, Morel P. Acute left colonic diverticulitis: compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Dis Colon Rectum 2000;43:1363-1367. https://doi.org/10.1007/BF02236631
  25. Kircher MF, Rhea JT, Kihiczak D, Novelline RA. Frequency, sensitivity, and specificity of individual signs of diverticulitis on thin-section helical CT with colonic contrast material: experience with 312 cases. AJA Am J Roentgenol 2002;178:1313-1318. https://doi.org/10.2214/ajr.178.6.1781313
  26. Ambrosetti P, Becker C, Terrier F. Colonic diverticulitis: impact of imaging on surgical management: a prospective study of 542 patients. Eur Radiol 2002;12:1145-1149. https://doi.org/10.1007/s00330-001-1143-y
  27. Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum 2008;51:1810-1815. https://doi.org/10.1007/s10350-008-9330-4
  28. Ajaj W, Ruehm SG, Lauenstein T, et al. Dark-lumen magnetic resonance colonography in patients with suspected sigmoid diverticulitis: a feasibility study. Eur Radiol 2005; 15:2316-2322. https://doi.org/10.1007/s00330-005-2862-2
  29. Buckley O, Geoghegan T, McAuley G, Persaud T, Khosa F, Torreggiani WC. Pictorial review: magnetic resonance imaging of colonic diverticulitis. Eur Radiol 2007;17: 221-227. https://doi.org/10.1007/s00330-006-0236-z
  30. Öistämö E, Hjern F, Blomqvist L, Von Heijne A, Abraham- Nordling M. Cancer and diverticulitis of the sigmoid colon: differentiation with computed tomography versus magnetic resonance imaging: preliminary experiences. Acta Radiol 2013;54:237-241. https://doi.org/10.1258/ar.2012.120543
  31. Schout PJ, Spillenaar Bilgen EJ, Groenen MJ. Routine screening for colon cancer after conservative treatment of diverticulitis. Dig Surg 2012;29:408-411. https://doi.org/10.1159/000345332
  32. Oh KH, Han KH, Kim EJ, et al. Colon cancer after acute diverticulitis treatment. Ann Coloproctol 2013;29:167-171. https://doi.org/10.3393/ac.2013.29.4.167
  33. Almy TP, Howell DA. Medical progress: diverticular disease of the colon. N Engl J Med 1980;302:324-331. https://doi.org/10.1056/NEJM198002073020605
  34. Panish JF. Limitations and complications of colonoscopy. Gastrointest Endosc 1980;26(2 Suppl):20S-21S. https://doi.org/10.1016/S0016-5107(80)73332-1
  35. Elmi A, Hedgire SS, Pargaonkar V, Cao K, McDermott S, Harisinghani M. Is early colonoscopy beneficial in patients with CT-diagnosed diverticulitis? AJR Am J Roentgenol 2013;200:1269-1274. https://doi.org/10.2214/AJR.12.9539
  36. Lau KC, Spilsbury K, Farooque Y, et al. Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? Dis Colon Rectum 2011;54:1265-1270. https://doi.org/10.1097/DCR.0b013e31822899a2
  37. Holme O, Bretthauer M, de Lange T, et al. Risk stratification to predict pain during unsedated colonoscopy: results of a multicenter cohort study. Endoscopy 2013;45:691-696. https://doi.org/10.1055/s-0033-1344239
  38. Sakhnini E, Lahat A, Melzer E, et al. Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36:504-507. https://doi.org/10.1055/s-2004-814398
  39. Detry R, Jamez J, Kartheuser A, et al. Acute localized diverticulitis: optimum management requires accurate staging. Int J Colorectal Dis 1992;7:38-42. https://doi.org/10.1007/BF01647660
  40. Thompson WG, Patel DG. Clinical picture of diverticular disease of the colon. Clin Gastroenterol 1986;15:903-916.
  41. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999;42:470-475. https://doi.org/10.1007/BF02234169
  42. Weizman AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J Gastroenterol 2011;25:385-389. https://doi.org/10.1155/2011/795241
  43. Perkins JD, Shield CF 3rd, Change FC, Farha GJ. Acute diverticulitis: comparison of treatment in immunocompromised patient. Arch Surg 1991;126:855-858. https://doi.org/10.1001/archsurg.1991.01410310065009
  44. Roberts P, Abel M, Rosen L, et al. The standards task force of the American Society of Colon and Rectal Surgeons: practice parameters for sigmoid diverticulitis: supporting documentation. Dis Colon Rectum 1995;38:126-132. https://doi.org/10.1007/BF02052439
  45. Roberts PL, Veidenheimer MC. Current management of diverticulitis. Adv Surg 1994;27:189-208.
  46. Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med 1998;338:1521-1526. https://doi.org/10.1056/NEJM199805213382107
  47. Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis: supporting documentation: the Standards Task Force: the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000;43: 290-297. https://doi.org/10.1007/BF02258291
  48. Salem TA, Molloy RG, O'Dwyer PJ. Prospective, five-year follow-up study of patients with symptomatic uncomplicated diverticular disease. Dis Colon Rectum 2007;50:1460-1464. https://doi.org/10.1007/s10350-007-0226-5
  49. Collins D, Winter DC. Elective resection for diverticular disease: an evidence-based review. World J Surg 2008;32: 2429-2433. https://doi.org/10.1007/s00268-008-9705-7
  50. Laméris W, van Randen A, van Gulik TM, et al. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum 2010;53: 896-904. https://doi.org/10.1007/DCR.0b013e3181d98d86
  51. Buchs NC, Konrad-Mugnier B, Jannot AS, Poletti PA, Ambrosetti P, Gervaz P. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg 2013;100:976-979. https://doi.org/10.1002/bjs.9119
  52. Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939-944. https://doi.org/10.1007/s10350-006-0578-2
  53. Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010;251: 670-674. https://doi.org/10.1097/SLA.0b013e3181d3447d
  54. Faria GR, Almeida AB, Moreira H, Pinto-de-Sousa J, Correia-da-Silva P, Pimenta AP. Acute diverticulitis in younger patients: any rationale for a different approach? World J Gastroenterol 2011;17:207-212. https://doi.org/10.3748/wjg.v17.i2.207
  55. Song ME, Jung SA, Shim KN, et al. Clinical characteristics and treatment outcome of colonic diverticulitis in young patients. Korean J Gastroenterol 2013;61:75-81. https://doi.org/10.4166/kjg.2013.61.2.75
  56. Schauer PR, Ramos P, Ghiatas AA, Sirinek KR. Virulent diveticular disease in young obese men. Am J Surg 1992;164: 443-446. https://doi.org/10.1016/S0002-9610(05)81177-8
  57. Sheth AA, Longo W, Floch M. Diverticular disease and diverticulitis. Am J Gastroenterol 2008;103:1550-1556. https://doi.org/10.1111/j.1572-0241.2008.01879.x
  58. Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg 2009;249:210-217. https://doi.org/10.1097/SLA.0b013e3181952888
  59. Klarenbeek BR, Veenhof AA, Bergamaschi R, et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 2009;249:39-44. https://doi.org/10.1097/SLA.0b013e31818e416a
  60. Klarenbeek BR, Bergamaschi R, Veenhof AA, et al. Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial. Surg Endosc 2011;25:1121-1126. https://doi.org/10.1007/s00464-010-1327-0
  61. Kang JY, Hoare J, Tinto A, et al. Diverticular disease of the colon: on the rise: a study of hospital admission in England between 1989/1990 and 1999/2000. Aliment Pharmacol Ther 2003;17:1189-1195. https://doi.org/10.1046/j.1365-2036.2003.01551.x
  62. Schechter S, Eisenstat TE, Oliver GC, Rubin RJ, Salvati EP. Computerized tomographic scan-guided drainage of intra- abdominal abscesses: preoperative and postoperative modalities in colon and rectal surgery. Dis Colon Rectum 1994;37:984-988. https://doi.org/10.1007/BF02049309
  63. Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005;48:787-791. https://doi.org/10.1007/s10350-004-0853-z
  64. Woods RJ, Lavery IC, Fazio VW, Jagelman DG, Weakley FL. Internal fistulas in diverticular disease. Dis Colon Rectum 1988;31:591-596. https://doi.org/10.1007/BF02556792
  65. Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008;22:454-462. https://doi.org/10.1007/s00464-007-9453-z
  66. Keranen I, Lepistö A, Udd M, Halttunen J, Kylänpää L. Outcome of patients after endoluminal stent placement for benign colorectal obstruction. Scand J Gastroenterol 2010; 45:725-731. https://doi.org/10.3109/00365521003663696
  67. Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 1984;71:921-927. https://doi.org/10.1002/bjs.1800711202
  68. Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007;22:351-357. https://doi.org/10.1007/s00384-005-0059-4
  69. Kreis ME, Mueller MH, Thasler WH. Hartmann's procedure or primary anastomosis? Dig Dis 2012;30:83-85. https://doi.org/10.1159/000335726
  70. Herzog T, Janot M, Belyaev O, et al. Complicated sigmoid diverticulitis: Hartmann's procedure or primary anastomosis? Acta Chir Belg 2011;111:378-383. https://doi.org/10.1080/00015458.2011.11680777
  71. Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson JE Jr. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188:629-634. https://doi.org/10.1016/S1072-7515(99)00043-5
  72. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996;171:244-246. https://doi.org/10.1016/S0002-9610(97)89559-1
  73. Yang HR, Huang HH, Wang YC, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30:1929-1934. https://doi.org/10.1007/s00268-005-0746-x
  74. Stollman NH, Raskin JB. Diagnosis and management of diverticular disease of the colon in adults: Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:3110-3121. https://doi.org/10.1111/j.1572-0241.1999.01501.x
  75. Unlu C, Daniels L, Vrouenraets BC, Boermeester MA. A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis 2012;27:419-427. https://doi.org/10.1007/s00384-011-1308-3
  76. Dobbins C, Defontgalland D, Duthie G, Wattchow DA. The relationship of obesity to the complications of diverticular disease. Colorectal Dis 2006;8:37-40.
  77. Turunen P, Wikström H, Carpelan-Holmström M, Kairaluoma P, Kruuna O, Scheinin T. Smoking increases the incidence of complicated diverticular disease of the sigmoid colon. Scand J Surg 2010;99:14-17. https://doi.org/10.1177/145749691009900104
  78. Porta E, Germano A, Ferrieri A, Koch M. The natural history of diverticular disease of the colon: a role for antibiotics in preventing complications? a retrospective study. Riv Eur Sci Med Farmacol 1994;16:33-39.
  79. Tursi A, Brandimarte G, Daffinà R. Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon. Dig Liver Dis 2002;34:510-515. https://doi.org/10.1016/S1590-8658(02)80110-4
  80. Tursi A. New physiopathological and therapeutic approaches to diverticular disease of the colon. Expert Opin Pharmacother 2007;8:299-307. https://doi.org/10.1517/14656566.8.3.299
  81. Tursi A, Brandimarte G, Giorgetti GM, Elisei W, Aiello F. Balsalazide and/or high-potency probiotic mixture (VSL#3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon. Int J Colorectal Dis 2007; 22:1103-1108. https://doi.org/10.1007/s00384-007-0299-6