Clinical Practice Guidelines on the Treatment of Left-Sided Colonic Diverticulitis (ASCRS, 2020)

American Society of Colon and Rectal Surgeons

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 29, 2020

Clinical practice guidelines for the treatment of left-sided colonic diverticulitis were released in June 2020 by the American Society of Colon and Rectal Surgeons.[1]

Acute Diverticulitis Initial Evaluation

For the initial evaluation of suspected acute diverticulitis, include (1) a problem-specific history, (2) physical examination, and (3) appropriate laboratory evaluations.

The most appropriate initial imaging modality for assessing suspected diverticulitis is an abdominal and pelvic CT scan.

If CT scanning is contraindicated or unavailable, useful alternatives include ultrasonography and MRI.

Acute Diverticulitis Medical Management

In selected patients diagnosed with uncomplicated diverticulitis, treatment can be initiated without antibiotics.

In other patients, nonoperative treatment of diverticulitis may include antibiotics.

The typically recommended procedure for stable patients with abscesses larger than 3 cm is image-guided percutaneous drainage.

Recommended interventions that may potentially reduce the risk of developing diverticulitis include cessation of tobacco use, reduction of meat intake, increased physical activity, and weight loss.

Agents that are not typically recommended to reduce the risk of diverticulitis recurrence, but may be helpful for reducing chronic symptoms, include mesalamine, rifaximin, and probiotics.

Evaluation Post Acute Diverticulitis Recovery

After a patient recovers from an episode of acute complicated diverticulitis, the typical next step is to endoscopically evaluate the colon to confirm the diagnosis in the absence of a recent colonoscopy.

Acute Diverticulitis Elective Surgery

If a patient is successfully treated nonoperatively for a diverticular abscess, typically, elective resection should be considered.

If the patient's diverticulitis was complicated by obstruction, fistula, or stricture, elective colectomy is typically recommended.

It is not recommended to base the elective resection decision on younger age at presentation.

The decision whether to recommend elective sigmoid colectomy after a patient recovers from uncomplicated acute diverticulitis should be individualized on a case-by-case basis.

Additionally, whether to offer sigmoid colectomy after recovery from uncomplicated acute diverticulitis in patients who are immunosuppressed also should be individualized.

Acute Diverticulitis Emergency Surgery

In patients with diffuse peritonitis or patients in whom nonoperative management of acute diverticulitis fails, it is typically advised they undergo urgent sigmoid colectomy.

Following resection, issues to consider regarding the decision to restore bowel continuity should include patient factors, surgeon preference, and intraoperative factors.

Laparoscopic Lavage

It is not recommended to perform laparoscopic lavage in patients with feculent peritonitis; typically in this situation, the recommended procedure is colectomy.

Colectomy is also preferred over laparoscopic lavage in patients with purulent peritonitis, owing to higher rates of secondary intervention with laparoscopic lavage versus colectomy.

Technical Considerations

For elective resection, the extent should include the entire sigmoid colon, with margins of healthy colon and rectum.

If the expertise is available, the preferred approach for colectomy in diverticulitis is a minimally invasive approach.

For more information see Diverticulitis and Imaging in Diverticulitis of the Colon.

For more Clinical Practice Guidelines, go to Guidelines.

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