Pressure on hospital beds and an ageing population means the revisiting of ‘diverticulitis’ as a clinical entity is worthwhile.

By Dr Nigel Barwood, Colorectal Surgeon, Murdoch

All attacks of diverticulitis require antibiotics?

Current evidence suggests uncomplicated diverticulitis is more inflammation than infection. Mild episodes get better as quickly without antibiotics. Antibiotics are only needed for severe attacks (e.g. fever), complications (e.g. abscess) or in compromised patients.

Acute diverticulitis requires hospital admission?

Traditionally diverticulitis is admitted under general surgery with IV antibiotics and bowel rest. Current evidence suggests this is only needed in unwell patients (with severe attacks as outlined above).

Perforated diverticulitis requires surgery?

There is a huge difference between localised micro perforation (very common, localised tenderness blebs of free gas around the sigmoid diverticulitis on CT) versus free perforation (generalised peritonitis free gas/fluid on CT). Both are usually reported as ‘perforation’ on CT. Only free perforation requires urgent surgery.

Recurrent diverticulitis attacks make perforation more likely?

Current evidence suggests diverticulitis is not a progressive condition. The first episode is usually the worst attack. Most will continue to have similar attacks with complications of diverticulitis being relatively rare.

Avoid nuts and seeds?

Current evidence is strongly against this – both are fibre rich and hence probably beneficial.

Diverticulitis is one clinical entity?

There are two variants of mild uncomplicated diverticulitis SCAD (segmental colitis associated with diverticulitis) and SUDD (symptomatic uncomplicated diverticular disease) which has overlap with irritable bowel syndrome.

Changing diet and drugs are useful to prevent attacks?

Surprisingly, these are generally disappointing. While evidence suggests a high fibre, diet leads to a lower incidence of diverticulitis, there is no evidence that instituting a high fibre diet reduces recurrent attacks.

All diverticulitis requires a follow up colonoscopy?

This remains controversial. The incidence of colon cancer masquerading as diverticulitis is much less than originally reported. Patients with colonic wall thickening on CT should have a colonoscopy to exclude cancer or colitis. My practice is to individualise for each patient but with a general recommendation for colonoscopy unless performed recently.

Asymptomatic diverticulosis is of concern?

Diverticulosis is a very common finding on CT or colonoscopy with prevalence approaching the patient’s age (e.g. 35% at age 45, and 70% over 85 years). Very few patients experience symptoms in their lifetime – a high fibre diet probably reduces this risk

Two or more attacks means resection?

Diverticulitis surgery is often technically demanding and best left to colorectal surgeons. Despite lap surgery reducing inpatient stays to a few days, the indications for elective surgery have tightened significantly. Complicated diverticulitis (i.e. abscesses over 4 cm, fistulae and strictures) generally require surgery in good risk patients. Micro perforations, phlegmons and small abscesses indicate more significant disease, but don’t necessarily need surgery. The current approach is individualised patient risk versus benefit.

Author competing interests: nil relevant. Questions? Contact the editor.

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