Diverticulitis Clinical Trials, Diagnosis, and Treatment

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Diverticulitis

Diverticulitis is a common digestive disease particularly found in the large intestine. Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed.

Current Research

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Causes

The development of colonic diverticulum is thought to be a result of raised intraluminal colonic pressures. The sigmoid colon (Section 4) has the smallest diameter of any portion of the colon, and therefore the portion which would be expected to have the highest intraluminal pressure. The postulate that low dietary fiber, particularly non-soluble fiber* (also known in older parlance as "roughage") predisposes individuals to diverticular disease is supported within the medical literature.

It is thought that mechanical blockage of a diverticulum, possibly by a piece of feces or food particles, leads to infection of the diverticulum.

Presentation

Patients often present with the classic triad of left lower quadrant pain, fever, and leukocytosis (an elevation of the white cell count in blood tests). Patients may also complain of nausea or diarrhea; others may be constipated.

Less commonly, an individual with diverticulitis may present with right-sided abdominal pain. This may be due to the less prevalent right-sided diverticula or a very redundant sigmoid colon.

Symptoms

Diverticulitis

The most common symptom of diverticulitis is abdominal pain. The most common sign is tenderness around the left side of the lower abdomen. If infection is the cause, fever, nausea, vomiting, chills, cramping, and constipation may occur as well. The severity of symptoms depends on the extent of the infection and complications.

Diverticulosis

Most people with diverticulosis do not have any discomfort or symptoms; however, symptoms may include mild cramps, bloating, and constipation. Other diseases such as irritable bowel syndrome (IBS) and stomach ulcers cause similar problems, so these symptoms do not always mean a person has diverticulosis.

Diagnosis

The differential diagnosis includes colon cancer, inflammatory bowel disease, ischemic colitis, and irritable bowel syndrome, as well as a number of urological and gynecological processes. Some patients report bleeding from the rectum.

Patients with the above symptoms are commonly studied with a computed tomography, or CT scan. The CT scan is very sensitive (98%) in diagnosing diverticulitis. In order to extract the most information possible about the patient's condition, thin section (5mm) transverse images are obtained through the entire abdomen and pelvis after the patient has been administered oral and intravascular contrast. Images reveal localized thickening and hyperemia (increased blood flow) involving a segment of the colon wall, with inflammatory changes extending into the fatty tissues surrounding the colon. The diagnosis of acute diverticulitis is made confidently when the involved segment contains diverticulae. CT may also identify patients with more complicated diverticulitis, such as those with an associated abscess. It may even allow for radiologically guided drainage of an associated abscess, sparing a patient from immediate surgical intervention.

Other studies, such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.

Treatment

An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest (ie, nothing by mouth), IV fluid resuscitation, and broad-spectrum antibiotics which cover anaerobic bacteria and gram-negative rods. However, recurring acute attacks or complications, such as peritonitis, abscess, or fistula may require surgery, either immediately or on an elective basis.

Upon discharge patients may be placed on a low residue diet. This low-fiber diet gives the colon adequate time to heal without needing to be overworked. Later, patients are placed on a high-fiber diet. There is some evidence this lowers the recurrence rate.

In some cases surgery may be required to remove the area of the colon with the diverticula. Patients suffering their first attack of diverticulitis are typically not encouraged to undergo the surgery, unless the case is severe. Patients suffering repeated episodes may benefit from the surgery. In such cases the risks of complications from the diverticulitis outweigh the risks of complications from surgery.

Complications

In complicated diverticulitis, bacteria may subsequently infect the outside of the colon if an inflamed diverticulum bursts open. If the infection spreads to the lining of the abdominal cavity, (peritoneum), this can cause a potentially fatal peritonitis. Sometimes inflamed diverticula can cause narrowing of the bowel, leading to an obstruction. Also, the affected part of the colon could adhere to the bladder or other organ in the pelvic cavity, causing a fistula, or abnormal connection between an organ and adjacent structure or organ, in this case the colon and an adjacent organ.

Bowel obstruction
Peritonitis
Abscess
Fistula
Bleeding
Strictures

Epidemiology

Diverticulitis most often affects middle-aged and elderly persons, though it can strike younger patients as well. Central obesity may be associated with diverticulitis in younger patients, with some being as young as 20 years old.
In Western countries, diverticular disease most commonly involves the sigmoid colon - section 4 - (95% of patients). The prevalence of diverticular disease has increased from an estimated 10% in the 1920s to between 35 and 50% by the late 1960s. 65% of those currently 85 years of age and older can be expected to have some form of diverticular disease of the colon. Less than 5% of those aged 40 years and younger may also be affected by diverticular disease.
Left-sided diverticular disease (involving the sigmoid colon) is most common in the West, while right-sided diverticular disease is more prevalent in Asia and Africa. Among patients with diverticulosis, 10-25% patients will go on to develop diverticulitis within their lifetimes.
Peanuts and seeds may aggravate diverticulitis.

Controversy

There is no scientific evidence that suggests the avoidance of nuts and seeds prevents the progression of diverticulosis to an acute case of diverticulitis, and as such the widely held belief that small undigestable foods like seeds becoming lodged in the diverticula appears to be nothing more than an 'old wives' tale. Further, in a survey of fellows of The American Society of Colon and Rectal Surgeons at least half of the surgeons responding to the survey saw no value in avoiding such foods.

Celebrity Cases

Grace Slick, member of Jefferson Airplane, Jefferson Starship
John Wooden, Basketball Coach
Billy Graham, evangelist
Fidel Castro, leader of Cuba (reported)
James K. Polk, 11th President of the United States
Ken Griffey, Jr., baseball player
Kwame Kilpatrick, Mayor of Detroit (2002-present)
Craig Venter
Dilma Rousseff
Amitabh Bachchan
"Buzz Burbank", news man of the nationally syndicated Don and Mike Show.
Desi Arnaz, Ricky Ricardo from I Love Lucy
Glenn Frey, The Eagles
Jack Wagner, Actor, Singer, Celebrity Golfer
Buckminster Fuller ate mostly steak, in response to a tendency to diverticulitis.
Cher

(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Diverticulitis)

Findings From Current Research

A Single Training Center's Experience with 200 Consecutive Cases of Diverticulitis: Can All Patients be Approached Laparoscopically?

Authors: Garrett KA, Champagne BJ, Valerian BT, Peterson D, Lee EC.

Department of General Surgery, Albany Medical Center, 47 New Scotland Avenue, MC-61, Albany, NY, 12208, USA, garretk@mail.amc.edu.

BACKGROUND: This study aimed to evaluate the outcomes for consecutive patients with diverticular disease who underwent elective laparoscopic sigmoid colectomy. METHODS: Data for this patient population were collected by chart review and analyzed retrospectively. RESULTS: Between December 2001 and March 2007, 200 consecutive patients (93 men and 107 women) with an average age of 55 years were identified. All cases were managed by one of two colorectal surgeons. Of the 200 patients, 158 had recurrent diverticulitis, 20 had fistulas, 12 had abscesses, 8 had strictures, 1 had a mass, and 1 had a bleed. The mean operative time was 159 min, and the conversion rate was 8%. A total of 30 early postoperative complications occurred for 26 patients including wound infection (n = 9), ileus (n = 8), Clostridium difficile colitis (n = 3), urinary retention (n = 3), pelvic abscess (n = 2), deep vein thrombosis and pulmonary embolism (n = 1), pneumonia (n = 1) urinary tract infection (n = 1), anastomotic leak (n = 1), and small bowel obstruction (n = 1). Late complications experienced by 11 patients included Clostridium difficile colitis (n = 3), incisional hernia (n = 3), wound infection (n = 3), wound hematoma (n = 1), and intraabdominal hemorrhage (n = 1). CONCLUSIONS: The authors believe it is feasible to offer elective laparoscopic sigmoid colectomy to all patients with symptomatic diverticular disease despite preoperative risk factors.

Journal: Surg Endosc. 2008 Mar 18
Adapted from PubMed; click here to access full journal article.

Operative Treatment of Recurrent or Complicated Diverticulitis

Authors: Dozois EJ.

Division of Colon and Rectal Surgery, Mayo Clinic, Gonda 9S, 200 First Street SW, Rochester, MN, 55902, USA, dozois.eric@mayo.edu.

Sigmoid diverticulosis remains a common disease in developed Western countries, and surgeons are frequently asked to manage diverticulitis and its complications. When to offer elective surgery to patients with uncomplicated, but recurrent, diverticulitis should be individualized, and practice recommendations by national societies continues to be debated. Complicated diverticulitis remains a surgically treated disease, and new technology such as colonic stents (for obstruction) and computed-tomography-guided percutaneous drainage (for abscess) have become bridging techniques to avoid two-stage operations in selected patients. Minimally invasive surgery for elective sigmoid resection has been shown to be safe and feasible and confers many patient-related short-term over traditional open surgery.

Journal: J Gastrointest Surg. 2008 Feb 16
Adapted from PubMed; click here to access full journal article.

Long-Term Experience with the Laparoscopic Approach to Perforated Diverticulitis plus Generalized Peritonitis

Authors: Franklin ME Jr, Portillo G, Treviño JM, Gonzalez JJ, Glass JL.

Texas Endosurgery Institute, 4242 East Southcross, Suite 1, San Antonio, Texas, 78222, USA.

BACKGROUND: The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique. In patients with complicated acute diverticulitis and peritonitis without gross fecal contamination, laparoscopic peritoneal lavage, inspection of the colon, and intraoperative drain placement of the peritoneal cavity appears to alleviate morbidity and improve the outcome. In this article, we report our experience of a laparoscopic peritoneal lavage technique with delayed definitive resection when necessary. METHOD AND MATERIALS: Records of patients who underwent intraoperative peritoneal lavage for purulent diverticulitis at the Texas Endosurgery Institute from April 1991 to September 2006 were retrospectively reviewed. RESULTS: Forty patients were included in the study, with a male/female ratio of 26:14. The average age was 60 years. Many had associated co-morbidities. The average operating time was 62 minutes. There were no conversions to an open procedure. Apart from mild postoperative paralytic ileus in six patients and chest infections in two, there were no significant peroperative or postoperative complications. Just over 50% underwent elective interval laparoscopic sigmoid colectomy. During the mean follow-up of 96 months, none of the other patients required further surgical intervention. CONCLUSION: Laparoscopic lavage of the peritoneal cavity and drainage is a safe alternative to the current standard of treatment for the management of perforated diverticulitis with or without gross fecal contamination. It is associated with a decrease in the overall cost of treatment; the use of a colostomy is avoided; patient improvement is immediate; and there is a reduction in mortality and morbidity as definitive laparoscopic resection can be performed in a nonemergent fashion. Perhaps the most important benefit, other than avoiding a colostomy, is the association of fewer wound complications such as dehiscence, wound infection, and the high risk of hernia formation. Laparoscopic lavage and drainage should be considered in all patients in whom medical and/or percutaneous treatment is not feasible. It carries minimal morbidity and should be considered the standard of care.

Journal: World J Surg. 2008 Feb 9
Adapted from PubMed; click here to access full journal article.

Laparoscopic Diverticular Resection with Situs Inversus Totalis (SIT): Report of A Case

Authors: Jobanputra S, Safar B, Wexner SD.

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA.

Situs inversus totalis (SIT) is a rare condition where the abdominal and thoracic cavity structures are opposite of their usual position. Laparoscopic colonic surgery for this patient population is not well described, with only 2 reported cases. Our patient was a 62-year-old female with a history of SIT who underwent a laparoscopic sigmoid colectomy for recurrent diverticulitis. The procedure included the use of 4 ports. The sigmoid colon was noted on the right side. Laparoscopic resection with stapled anastomosis was performed. The patient tolerated the procedure well and was discharged home on postoperative day 5 without complications. We present a third case of laparoscopic colectomy for diverticulitis in a patient with SIT and a description of the operative procedure.

Journal: Surg Innov. 2007 Dec;14(4):284-6.
Adapted from PubMed; click here to access full journal article.

Does a 48-hour Rule Predict Outcomes in Patients with Acute Sigmoid Diverticulitis?

Authors: Evans J.

Surgery University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030, USA. jessicahartford2003@yahoo.com

INTRODUCTION: Sigmoid diverticulitis is an infection that resolves with conservative management in 70-85% of patients. Some patients require prolonged hospitalization or surgery during their admission. It has been taught that one should expect clinical improvement within 48 h. In this study, we examined whether basic clinical parameters (the maximum temperature and leukocyte count) of patients would predict improvement and discharge as expected, or prolonged hospitalization. MATERIALS AND METHODS: Data was acquired from 198 patients admitted with acute sigmoid diverticulitis as confirmed by computed tomography (CT) scanning and physical exam. One hundred sixty-five patients recovered without surgery with an average hospital stay of 4 days: 120 were discharged within 4 days, whereas 45 patients required longer stays. Nineteen patients underwent surgery early during their admission (within 48 h). Fourteen patients did not improve over time and required surgery later during their hospital stay. The daily maximum temperature and leukocyte count of patients with prolonged stays was compared to the patients who were discharged within 4 days using analysis of variance analysis. RESULTS: The average maximum temperature and leukocyte count on admission were not statistically different between the groups; therefore, maximum temperature and leukocyte count on admission alone are not predictive. After the first 24 h, however, one could see a statistically significant difference in maximum temperature (p=0.004). The leukocyte count responded significantly by hospital day 2 (p=0.003). Both trends were significant through hospital day 4. DISCUSSION: Patients with a noticeable drop in leukocyte count and maximum temperature over the first 48 h of medical management were predictably discharged early on oral antibiotics. Patients failing to improve at 48 h required prolonged stays or surgery. CONCLUSION: By observing early trends in leukocyte count and maximum temperature of patients with diverticulitis, one can predict whether they will recover quickly as expected or if they will likely require prolonged IV antibiotics and/or surgery.

Journal: J Gastrointest Surg. 2008 Mar;12(3):577-82. Epub 2008 Jan 3.
Adapted from PubMed; click here to access full journal article.

Case Series: Diverticulitis in the Young

Authors: Cole CD, Wolfson AB.

University of Pittsburgh Affiliated Residency in Emergency Medicine, Pittsburgh, Pennsylvania 15213, USA.

Diverticulitis has long been regarded as a disease of the elderly, but its incidence has been increasing in those under age 40. Younger patients with diverticulitis are more likely to be male and obese. They often have atypical presentations, and 25% may have right lower quadrant pain. Not surprisingly, the condition is often misdiagnosed, resulting in unnecessary surgery. An abdominal CT scan is the modality of choice for diagnosis, but the most important diagnostic step is simply to include diverticulitis on the differential diagnosis of a young person with lower abdominal pain.

Journal: J Emerg Med. 2007 Nov;33(4):363-6. Epub 2007 May 30.
Adapted from PubMed; click here to access full journal article.

Is Primary Anastomosis Safe in the Surgical Management of Complications of Acute Diverticulitis?

Authors: Stumpf MJ, Vinces FY, Edwards J.

Department of Surgery, St. Barnabas Hospital, Bronx, New York 10457, USA. Michael.stumpf@yahoo.com

The purpose of this article is to determine whether primary anastomosis is a safe option in the surgical management of complications of acute diverticulitis in low-risk patients. Over the past century, the management of diverticulitis has evolved from a three-stage procedure to resection and primary anastomosis. In the beginning of the century, Mayo described drainage and proximal colostomy, a three-stage procedure. This was done by performing a diverting colostomy but leaving the diseased segment of colon, hoping that the inflammation would subside. Later, the patient went back for resection of the diseased segment. Then a third procedure was performed for reversal of the colostomy. Around the late 1970s to early 1980s, it was found that patients had better outcomes if the diseased segment was resected during the first operation-the Hartman procedure. During the late 1990s to early 2000s, some surgeons began performing resection and primary anastomosis in selected groups of patients with diverticulitis. There have been a number of studies published showing that resection and primary anastomosis has an acceptable morbidity and mortality. However, most of these studies are retrospective and do not achieve statistical significance. They also do not attempt to establish guidelines to help decide which patients are good candidates for resection and primary anastomosis. The goal of this study is to establish safe and reasonable practice guidelinesthat can be applied to a selected group of (low-risk) patients. This study is a retrospective review of all the patients treated surgically for complications of acute diverticulitis from 1998 to 2003 at United Hospital Medical Center in Port Chester, New York. Patients were classified as high or low risk based on their age, APACHE II score, American Society of Anesthesiologists class, and Hinchey score. There were a total of 66 patients operated on for complications of acute diverticulitis (left-sided) over this 5-year period. Thirty-six of them underwent resection and primary anastomosis and 30 underwent the Hartman procedure. Of the 36 who underwent resection and primary anastomosis, 19 were considered low risk. There were no complications in this low-risk group who underwent primary anastomosis. Patients who were low risk based on the mentioned criteria can safely undergo resection and primary anastomosis.

Journal: Am Surg. 2007 Aug;73(8):787-90; discussion 790-1.
Adapted from PubMed; click here to access full journal article.

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