Diverticular Disease of the Colon Clinical Practice Guidelines (ESCP, 2020)

European Society of Coloproctology

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.

July 29, 2020

In July 2020, the European Society of Coloproctology published their recommendations for the management of diverticular disease of the colon.[1]

Risk Factors for Diverticular Disease and Its Complications

Risk factors for the development of diverticulosis include older age, genetic predisposition, and obesity. Lifestyle and medications (eg, nonsteroidal anti-inflammatory drugs, aspirin, acetaminophen, corticosteroids, and opioids) can affect the progression of diverticulosis to diverticulitis and its complications.

The first episode of complicated diverticulitis is associated with the greatest morbidity and mortality. The risk of severe complications decreases with the number of recurrences.

Initial Evaluation of Acute Diverticulitis

Because clinical findings correlate poorly with the severity of the disease, imaging is necessary to confirm the diagnosis of acute diverticulitis. The recommended imaging study for assessing suspected diverticulitis is computed tomography (CT). Alternative modalities are ultrasonography and magnetic resonance imaging.

Medical Management of Diverticulitis

Most patients with acute uncomplicated diverticulitis do not require antibiotics. Reserve antibiotic therapy for immunocompromised patients and those with sepsis. Nearly all patients who have radiologic evidence of complicated diverticulitis should receive antibiotics.

Outpatient treatment of uncomplicated diverticulitis appears to be a safe option for patients who have an adequate social network; can tolerate oral intake; and do not have sepsis, significant comorbidity, or immunosuppression.

An unrestricted diet is generally recommended if the patient is able to tolerate it. A high-fiber diet has not been shown to prevent recurrent episodes or persistent symptoms in patients with acute diverticulitis. Bed rest is not recommended because imposed physical inactivity may harm the patient’s general condition.

Mesalazine, rifaximin, and probiotics are not useful for the prevention of recurrences or persistent symptoms after an episode of acute diverticulitis.

Consider percutaneous drainage of abscesses larger than 3 cm in patients with acute diverticulitis. Reserve emergency surgery for patients in whom other nonsurgical treatments fail.

Follow-up After Acute Diverticulitis

Colonoscopy may not be required for patients who have no symptoms after a single episode of CT-verified uncomplicated diverticulitis. All other patients treated medically for acute diverticulitis should be followed up with an examination of the colon at least 6 weeks after the acute episode, unless a colonoscopy has been performed within the past 3 years.

Emergency Surgery for Acute Diverticulitis

Observation seems to be a safe option for immunocompetent, hemodynamically stable patients with acute diverticulitis even if radiologic signs of extraluminal air are present. Consider immediate surgery for patients with sepsis and those who are hemodynamically unstable.

Resection is the treatment of choice for patients with fecal peritonitis.

Resection is also recommended for patients with purulent (Hinchey stage III) peritonitis; however, laparoscopic lavage is another option in selected patients.

Primary anastomosis with or without diverting ileostomy is a safe option for hemodynamically stable, immunocompetent patients with Hinchey III or IV diverticulitis.

Elective Surgery for Diverticulitis

The decision whether to recommend surgery after a patient recovers from an episode of acute diverticulitis should be individualized on the basis of the frequency of recurrences, the duration and severity of post-episode symptoms, and the presence of comorbid conditions. The goal of elective surgery is to improve quality of life.

Elective resection is not warranted for patients who have no radiologic or endoscopic signs of ongoing inflammation, stenosis, or fistulas.

The recommended surgical treatment of fistulas or persistent abscesses is laparoscopic or open resection of the diseased bowel with or without anastomosis.

Elective colon resection for diverticulitis should be performed laparoscopically whenever possible.

Technical Considerations

An air leak test of the colorectal anastomosis during surgery for sigmoid diverticulitis is recommended.

In an emergency resection and primary anastomosis, sigmoid resection down to the rectum with colorectal anastomosis should be performed, and the proximal margin should be in healthy colon.

If cancer is not suspected, inferior mesenteric artery-preserving surgery can be performed to optimize preservation of the vascularization and the autonomic nerves.

Ureteral stenting may be appropriate in selected patients with severe complicated disease but is not routinely recommended, owing to increased costs and operative time.

Partial or full mobilization of the splenic flexure might facilitate the creation of an anastomosis from soft and compliant descending colon.

For more information, please go to Diverticulitis and Imaging in Diverticulitis of the Colon.

For more Clinical Practice Guidelines, please go to Guidelines.

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