AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review

Published:December 03, 2020DOI:
      Colonic diverticulitis is a painful gastrointestinal disease that recurs unpredictably and can lead to chronic gastrointestinal symptoms. Gastroenterologists commonly care for patients with this disease. The purpose of this Clinical Practice Update is to provide practical and evidence-based advice for management of diverticulitis. We reviewed systematic reviews, meta-analyses, randomized controlled trials, and observational studies to develop 14 best practices. In brief, computed tomography is often necessary to make a diagnosis. Rarely, a colon malignancy is misdiagnosed as diverticulitis. Whether patients should have a colonoscopy after an episode of diverticulitis depends on the patient’s history, most recent colonoscopy, and disease severity and course. In patients with a history of diverticulitis and chronic symptoms, alternative diagnoses should be excluded with both imaging and lower endoscopy. Antibiotic treatment can be used selectively rather than routinely in immunocompetent patients with mild acute uncomplicated diverticulitis. Antibiotic treatment is strongly advised in immunocompromised patients. To reduce the risk of recurrence, patients should consume a high-quality diet, have a normal body mass index, be physically active, not smoke, and avoid nonsteroidal anti-inflammatory drug use except aspirin prescribed for secondary prevention of cardiovascular disease. At the same time, patients should understand that genetic factors also contribute to diverticulitis risk. Patients should be educated that the risk of complicated diverticulitis is highest with the first presentation. An elective segmental resection should not be advised based on the number of episodes. Instead, a discussion of elective segmental resection should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits.


      Abbreviations used in this paper:

      AGA (American Gastroenterological Association), CT (computed tomography)
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        • Peery A.F.
        • Crockett S.D.
        • Murphy C.C.
        • et al.
        Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.
        Gastroenterology. 2019; 156: 254-272.e11
        • Bharucha A.E.
        • Parthasarathy G.
        • Ditah I.
        • et al.
        Temporal trends in the incidence and natural history of diverticulitis: a population-based study.
        Am J Gastroenterol. 2015; 110: 1589-1596
        • Kaise M.
        • Nagata N.
        • Ishii N.
        • et al.
        Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding.
        Dig Endosc. 2020; 32: 240-250
        • Kaiser A.M.
        • Jiang J.K.
        • Lake J.P.
        • et al.
        The management of complicated diverticulitis and the role of computed tomography.
        Am J Gastroenterol. 2005; 100: 910-917
        • Boostrom S.Y.
        • Wolff B.G.
        • Cima R.R.
        • et al.
        Uncomplicated diverticulitis, more complicated than we thought.
        J Gastrointest Surg. 2012; 16: 1744-1749
        • Daniels L.
        • Ünlü Ç.
        • de Korte N.
        • et al.
        Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis.
        Br J Surg. 2017; 104: 52-61
        • Lamps L.W.
        • Knapple W.L.
        Diverticular disease-associated segmental colitis.
        Clin Gastroenterol Hepatol. 2007; 5: 27-31
        • Andeweg C.S.
        • Knobben L.
        • Hendriks J.C.
        • et al.
        How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system.
        Ann Surg. 2011; 253: 940-946
        • Lameris W.
        • van Randen A.
        • van Gulik T.M.
        • et al.
        A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department.
        Dis Colon Rectum. 2010; 53: 896-904
        • Lameris W.
        • van Randen A.
        • Bipat S.
        • et al.
        Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy.
        Eur Radiol. 2008; 18: 2498-2511
        • Andeweg C.S.
        • Wegdam J.A.
        • Groenewoud J.
        • et al.
        Toward an evidence-based step-up approach in diagnosing diverticulitis.
        Scand J Gastroenterol. 2014; 49: 775-784
        • Meyer J.
        • Orci L.A.
        • Combescure C.
        • et al.
        Risk of colorectal cancer in patients with acute diverticulitis: a systematic review and meta-analysis of observational studies.
        Clin Gastroenterol Hepatol. 2019; 17: 1448-1456.e17
        • Chabok A.
        • Pahlman L.
        • Hjern F.
        • et al.
        Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis.
        Br J Surg. 2012; 99: 532-539
        • Drossman D.A.
        • Tack J.
        • Ford A.C.
        • et al.
        Neuromodulators for functional gastrointestinal disorders (disorders of gut-brain interaction): a Rome Foundation working team report.
        Gastroenterology. 2018; 154: 1140-1171.e1
        • Stam M.A.W.
        • Draaisma W.A.
        • van de Wall B.J.M.
        • et al.
        An unrestricted diet for uncomplicated diverticulitis is safe: results of a prospective diverticulitis diet study.
        Colorectal Dis. 2017; 19: 372-377
        • Stollman N.
        • Smalley W.
        • Hirano I.
        American Gastroenterological Association Institute Guideline on the management of acute diverticulitis.
        Gastroenterology. 2015; 149: 1944-1949
        • Hall J.
        • Hardiman K.
        • Lee S.
        • et al.
        The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the treatment of left-sided colonic diverticulitis.
        Dis Colon Rectum. 2020; 63: 728-747
        • Sartelli M.
        • Weber D.G.
        • Kluger Y.
        • et al.
        2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.
        World J Emerg Surg. 2020; 15: 32
        • Francis N.K.
        • Sylla P.
        • Abou-Khalil M.
        • et al.
        EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice.
        Surg Endosc. 2019; 33: 2726-2741
        • Au S.
        • Aly E.H.
        Treatment of uncomplicated acute diverticulitis without antibiotics: a systematic review and meta-analysis.
        Dis Colon Rectum. 2019; 62: 1533-1547
        • Rottier S.J.
        • Van Dijk S.T.
        • Ünlü Ç.
        • et al.
        Complicated disease course in initially computed tomography-proven uncomplicated acute diverticulitis.
        Surg Infect. 2019; 20: 453-459
        • van Dijk S.T.
        • Daniels L.
        • Nio C.Y.
        • et al.
        Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis.
        Int J Colorectal Dis. 2017; 32: 1693-1698
        • Swanson S.M.
        • Strate L.L.
        Acute colonic diverticulitis.
        Ann Intern Med. 2018; 168: Itc65-Itc80
        • Solomkin J.S.
        • Mazuski J.E.
        • Bradley J.S.
        • et al.
        Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.
        Surg Infect (Larchmt). 2010; 11: 79-109
        • Young-Fadok T.M.
        N Engl J Med. 2018; 379: 1635-1642

      Supplementary References

        • Humes D.J.
        • Fleming K.M.
        • Spiller R.C.
        • et al.
        Concurrent drug use and the risk of perforated colonic diverticular disease: a population-based case-control study.
        Gut. 2011; 60: 219-224
        • Broersen L.H.A.
        • Horvath-Puho E.
        • Pereira A.M.
        • et al.
        Corticosteroid use and mortality risk in patients with perforated colonic diverticular disease: a population-based cohort study.
        BMJ Open Gastroenterol. 2017; 4e000136
        • Biondo S.
        • Borao J.L.
        • Kreisler E.
        • et al.
        Recurrence and virulence of colonic diverticulitis in immunocompromised patients.
        Am J Surg. 2012; 204: 172-179
        • Biondo S.
        • Trenti L.
        • Elvira J.
        • et al.
        Outcomes of colonic diverticulitis according to the reason of immunosuppression.
        Am J Surg. 2016; 212: 384-390
        • Strate L.L.
        • Morris A.M.
        Epidemiology, pathophysiology, and treatment of diverticulitis.
        Gastroenterology. 2019; 156: 1282-1298.e1
        • Strate L.L.
        • Keeley B.R.
        • Cao Y.
        • et al.
        Western dietary pattern increases, and prudent dietary pattern decreases, risk of incident diverticulitis in a prospective cohort study.
        Gastroenterology. 2017; 152: 1023-1030.e2
        • Strate L.L.
        • Liu Y.L.
        • Syngal S.
        • et al.
        Nut, corn, and popcorn consumption and the incidence of diverticular disease.
        JAMA. 2008; 300: 907-914
        • Strate L.L.
        • Liu Y.L.
        • Aldoori W.H.
        • et al.
        Physical activity decreases diverticular complications.
        Am J Gastroenterol. 2009; 104: 1221-1230
        • Hjern F.
        • Wolk A.
        • Hakansson N.
        Smoking and the risk of diverticular disease in women.
        Br J Surg. 2011; 98: 997-1002
        • Ma W.
        • Jovani M.
        • Liu P.H.
        • et al.
        Association between obesity and weight change and risk of diverticulitis in women.
        Gastroenterology. 2018; 155: 58-66.e4
        • Strate L.L.
        • Liu Y.L.
        • Huang E.S.
        • et al.
        Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding.
        Gastroenterology. 2011; 140: 1427-1433
        • Jovani M.
        • Ma W.
        • Joshi A.D.
        • et al.
        Menopausal hormone therapy and risk of diverticulitis.
        Am J Gastroenterol. 2019; 114: 315-321
        • Camilleri M.
        • Sandler R.S.
        • Peery A.F.
        Etiopathogenetic mechanisms in diverticular disease of the colon.
        Cell Mol Gastroenterol Hepatol. 2020; 9: 15-32
        • Granlund J.
        • Svensson T.
        • Olen O.
        • et al.
        The genetic influence on diverticular disease--a twin study.
        Aliment Pharmacol Ther. 2012; 35: 1103-1107
        • Strate L.L.
        • Erichsen R.
        • Baron J.A.
        • et al.
        Heritability and familial aggregation of diverticular disease: a population-based study of twins and siblings.
        Gastroenterology. 2013; 144 (quiz e14): 736-742.e1
        • Maguire L.H.
        • Handelman S.K.
        • Du X.
        • et al.
        Genome-wide association analyses identify 39 new susceptibility loci for diverticular disease.
        Nat Genet. 2018; 50: 1359-1365
        • Sigurdsson S.
        • Alexandersson K.F.
        • Sulem P.
        • et al.
        Sequence variants in ARHGAP15, COLQ and FAM155A associate with diverticular disease and diverticulitis.
        Nat Commun. 2017; 8: 15789
        • Schafmayer C.
        • Harrison J.W.
        • Buch S.
        • et al.
        Genome-wide association analysis of diverticular disease points towards neuromuscular, connective tissue and epithelial pathomechanisms.
        Gut. 2019; 68: 854-865
        • Carter F.
        • Alsayb M.
        • Marshall J.K.
        • et al.
        Mesalamine (5-ASA) for the prevention of recurrent diverticulitis.
        Cochrane Database Syst Rev. 2017; 10: Cd009839
        • Ojetti V.
        • Petruzziello C.
        • Cardone S.
        • et al.
        The use of probiotics in different phases of diverticular disease.
        Rev Recent Clin Trials. 2018; 13: 89-96
        • Strate L.L.
        • Peery A.F.
        • Neumann I.
        American Gastroenterological Association Institute technical review on the management of acute diverticulitis.
        Gastroenterology. 2015; 149: 1950-1976.e12
        • Humes D.J.
        • West J.
        Role of acute diverticulitis in the development of complicated colonic diverticular disease and 1-year mortality after diagnosis in the UK: population-based cohort study.
        Gut. 2012; 61: 95-100
        • Aquina C.T.
        • Becerra A.Z.
        • Xu Z.
        • et al.
        Population-based study of outcomes following an initial acute diverticular abscess.
        Br J Surg. 2019; 106: 467-476
        • Strassle P.D.
        • Kinlaw A.C.
        • Chaumont N.
        • et al.
        Rates of elective colectomy for diverticulitis continued to increase after 2006 guideline change.
        Gastroenterology. 2019; 157: 1679-1681.e11
        • van de Wall B.J.M.
        • Stam M.A.W.
        • Draaisma W.A.
        • et al.
        Surgery versus conservative management for recurrent and ongoing left-sided diverticulitis (DIRECT trial): an open-label, multicentre, randomised controlled trial.
        Lancet Gastroenterol Hepatol. 2017; 2: 13-22
        • Bolkenstein H.E.
        • Consten E.C.J.
        • van der Palen J.
        • et al.
        Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial).
        Ann Surg. 2019; 269: 612-620
        • Thornblade L.W.
        • Simianu V.V.
        • Davidson G.H.
        • et al.
        Elective surgery for diverticulitis and the risk of recurrence and ostomy [published online ahead of print October 22, 2019]. Ann Surg.
        • Egger B.
        • Peter M.K.
        • Candinas D.
        Persistent symptoms after elective sigmoid resection for diverticulitis.
        Dis Colon Rectum. 2008; 51: 1044-1048
        • Andeweg C.
        • Peters J.
        • Bleichrodt R.
        • et al.
        Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease.
        World J Surg. 2008; 32: 1501-1506
        • von Strauss Und Torney M.
        • Moffa G.
        • Kaech M.
        • et al.
        Risk of emergency surgery or death after initial nonoperative management of complicated diverticulitis in Scotland and Switzerland.
        JAMA Surg. 2020; 155: 600-606