Updated recommendations on the management of acute left-sided colonic diverticulitis (ALCD) were released in May 2020 by the World Society of Emergency Surgery (WSES). In addition to including recent changes in the management of ALCD, there is a section about advances in acute right-sided colonic diverticulitis (ARCD), a condition that is more common than ALCD in certain regions of the world.
There is no single classification system for ALCD that has been conclusively proven to be superior in predicting patient outcomes. Thus, the WSES does not provide a specific recommendation on which of the many existing classifications should be used in patients with ALCD.
WSES classification: Uncomplicated versus complicated
The WSES classification divides acute diverticulitis into uncomplicated acute diverticulitis, in which the infection only involves the colon and does not extend to the peritoneum, and complicated acute diverticulitis, in which the infectious process extends beyond the colon.
Uncomplicated acute diverticulitis has a single stage, as follows:
0: Diverticula, wall thickening, increased pericolic fat density
Complicated acute diverticulitis is divided into four stages, based on the extension of the infectious process, as follows:
1A: Pericolic air bubbles or a small amount of pericolic fluid without abscess (within 5 cm from inflamed bowel segment)
1B: Abscess ≤4 cm
2A: Abscess >4 cm
2B: Distant gas (>5 cm from inflamed bowel segment)
3: Diffuse fluid without distant free gas
4: Diffuse fluid with distant free gas
In patients with suspected ALCD, WSES suggests the following (weak recommendations):
Performing a complete patient assessment, including clinical history, signs, laboratory inflammation markers, and radiologic findings
Not making the diagnosis on the sole basis of clinical examination
Imaging in Suspected ALCD
Contrast-enhanced abdominal computed tomography (CT) scanning is the suggested imaging modality of first choice for cases of suspected ALCD (weak recommendation).
Ultrasonography (US) performed by an expert operator is suggested in the initial evaluation of suspected ALCD, as it has wide availability and easy accessibility. A step-up approach with CT scanning performed after an inconclusive or negative US may be a safe approach for patients suspected of acute diverticulitis (weak recommendation).
Immunocompromised ALCD Patients
It is suggested that immunocompromised patients with ALCD be considered at high risk for failure of standard, nonoperative treatment (weak recommendation).
Antibiotics in Uncomplicated Acute Diverticulitis
In immunocompetent patients with uncomplicated diverticulitis without signs of systemic inflammation, antibiotic therapy is not recommended (strong recommendation).
In patients requiring antibiotic therapy, oral (PO) administration is recommended whenever possible, primarily, because an early switch from intravenous (IV) to PO therapy may facilitate a shorter inpatient length of stay (strong recommendation).
Outpatient management is suggested for patients with uncomplicated ALCD and no comorbidities, with reevaluation suggested within 7 days. Reevaluate patients earlier in the setting of a deteriorating clinical condition (weak recommendation).
Best Treatment for Acute Diverticulitis With CT Findings of Pericolic Gas
In patients with CT scan findings of pericolic extraluminal gas, a trial of nonoperative treatment with antibiotic therapy is suggested (weak recommendation).
Best Treatment for Small (< 4-5 cm) or Large Diverticular Abscesses
For patients with a small (< 4-5 cm) diverticular abscess, WSES suggests an initial trial of nonoperative treatment with antibiotics alone (weak recommendation).
For patients with large abscesses, WSES suggests combination treatment with percutaneous drainage and antibiotics; whenever percutaneous drainage of the abscess is not feasible or not available, it is suggested to initially treat patients with large abscesses with antibiotic therapy alone, clinical conditions permitting. Alternatively, an operative intervention is required (weak recommendation).
Early Colonic Evaluation
In patients with diverticular abscesses treated nonoperatively, planning an early colonic evaluation (4-6 weeks) is suggested (weak recommendation).
In patients with CT-proven uncomplicated diverticulitis treated nonoperatively, routine colonic evaluation is not recommended (weak recommendation).
Role of Nonoperative Treatment When CT Scans Show Distant Gas Without Diffuse Intra-abdominal Fluid
In patients with CT scan findings of distant free gas without diffuse intra-abdominal fluid, WSES suggests a nonoperative treatment in selected patients only if a close follow-up can be performed (weak recommendation).
Diffuse Peritonitis Due to Diverticular Perforation
WSES suggests performing laparoscopic peritoneal lavage and drainage only in very selected patients with generalized peritonitis. It is not considered the first-line treatment in patients with peritonitis from acute colonic diverticulitis (weak recommendation).
A Hartmann procedure is recommended for managing diffuse peritonitis from diverticular perforation in critically ill patients and in selected patients with multiple comorbidities (strong recommendation).
In clinically stable patients with diffuse peritonitis due to diverticular perforation who have no comorbidities, WSES suggests primary resection with anastomosis with or without a diverting stoma (weak recommendation).
In patients with diffuse peritonitis due to perforated diverticulitis, WSES suggests performing an emergency laparoscopic sigmoidectomy only if technical skills and equipment are available (weak recommendation).
Acute Peritonitis Due to Diverticular Perforation
WSES suggests damage control surgery (DCS) with staged laparotomies in selected unstable patients with diffuse peritonitis due to diverticular perforation (weak recommendation).
Planning Elective Resection in Acute Diverticulitis Treated Nonoperatively
WSES suggests evaluating patient-related factors and not the number of previous diverticulitis episodes in planning elective sigmoid resection (weak recommendation).
After an episode of conservatively treated ALCD, WSES suggests planning an elective sigmoid resection in high-risk patients (eg, immunocompromised patients) (weak recommendation).
Optimal Antibiotic Therapy and Duration for Diffuse Peritonitis Due to Diverticular Perforation
Selection of an empirically designed antibiotic regimen is suggested on the basis of the patient’s underlying clinical condition, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns (strong recommendation).
WSES suggests a 4-day period of postoperative antibiotic therapy in complicated ALCD if source control has been adequate (weak recommendation).
Acute Right-Sided Colonic Diverticulitis: Treatment Principles
All the statements for ALCD are suggested to also apply to ARCD. WSES indicates that although studies have shown that the percentage of complications requiring surgery is higher in patients with ALCD than in those with ARCD, the principles of diagnosis and treatment of patients with ARCD are similar to those of patients with ALCD.
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Cite this: Acute Colonic Diverticulitis Clinical Practice Guidelines (WSES, 2020) - Medscape - Jul 29, 2020.