Diverticular Disease
Diverticulitis represents a broad spectrum of presentations ranging from mild left lower-quadrant pain to free perforation with peritonitis. A number of different modalities have been used to evaluate patients with suspected diverticular disease, but comp
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Key Concepts • The optimal diagnostic test to allow for optimal assessment of severity of diverticulitis is CT imaging. • The majority of patients with acute diverticulitis will respond to antibiotic therapy. • CT drainage of localized abscesses in diverticulitis will often avoid the need for emergency operations, even in patients who may not initially respond to medical therapy. • Hartmann’s resection can often be avoided in most patients requiring surgery for an acute attack. Resection with primary anastomosis, with or without proximal diversion (loop ileostomy), can be performed safely in the absence of physiologic instability. • The indications for elective resection after an acute attack of diverticulitis are evolving but should be considered in patients who remain symptomatic or develop a definite complication (stricture, fistula, etc.)
Introduction Colonic diverticula represent saccular outpouchings of the colonic wall. Most patients with diverticulosis are asymptomatic. Symptomatic diverticular disease represents a whole range of conditions ranging from mild abdominal pain and bloating to free perforation with peritonitis and sepsis. These presentations are stratified into complicated or uncomplicated diverticulitis. Patients with left-sided abdominal pain and sometimes fever and leukocytosis are considered to have uncomplicated diverticulitis. Complicated presentations are defined as episodes of free perforation, obstruction, stricture, fistula, or hemorrhage. Diverticular hemorrhage is associated with diverticulosis and not diverticulitis. Because of the wide range of clinical presentations and potential for significant morbidity/mortality, management of diverticular disease continues to represent a major challenge to clinicians. This chapter examines the current pathophysiology, evaluation, and
treatment of left-sided colonic diverticulosis and diverticulitis. The management of diverticula of the foregut and diverticular bleeding is left to other sources for discussion.
Incidence In the twentieth century, there has been a rising prevalence of diverticular disease in industrialized nations. Diverticulosis is rare in patients younger than age 30. The incidence of this colonic finding rises with age such that over 40% of patients develop diverticula by the age of 60 years. Over 60% of patients over 80 years have diverticular disease identified [1, 2]. In almost all cases (95%), diverticula involve the sigmoid and left colon. In some series, the number of diverticula increases proportionally with age. They are also found more proximally as age increases. This may explain why in the Western societies, right-sided diverticular disease is primarily identified in older patients with pan-diverticulosis [3, 4]. In Asian countries, however, diverticulosis occurs more commonly on the right side. Some authors estimate that in Asia, 70% of the diverticula isolated to the right side [5–7]. Ten to twenty-five percent of patients who develop diverticulosis will develop diverticulitis [8–12]. Administrative data sources suggest
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