Review

Mild to Moderate Diverticulitis: What’s New in Diagnostic Approach, Treatment, and Prevention of Recurrence?

Nancy Lutwak, MD
Curt Dill, MD
Volume 21 - Number 7 - July 2013

Affiliations:

Department of Emergency Medicine, VA New York Harbor Healthcare System, New York University School of Medicine, New York, NY

Abstract: Diverticular disease, including diverticulitis, is common in geriatric patients and may be chronic, resulting in recurrent episodes of abdominal pain, bloating, cramping, and constipation or diarrhea. These symptoms may cause substantial emotional distress, anxiety, and depression, leading to poor quality of life. Diverticular disease is also associated with several complications, including abscess and perforation, which can increase the risk of morbidity and mortality. Heightened understanding of diverticular disease is resulting in changes to guidelines for diagnosing, treating, and preventing recurrences. In this article, the authors discuss the latest findings and recommendations regarding diverticulitis, which are transitioning care away from more invasive strategies to more conservative ones.

Key words: Diverticulitis, diverticular disease, diverticulosis, gastrointestinal disorder, abdominal pain, preventive medicine, nutrition, nutritional deficiency, computed tomography scanning, antibiotics, probiotics.
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Diverticular disease, also known as diverticulosis, is thought to occur when weaknesses of the muscle layers in the colon wall cause small pouches to form that bulge outward through the colon or large intestine. These pockets are known as diverticula, and when they become inflamed or infected because of trapped feces, the condition is called diverticulitis. As people age, the risk of diverticular disease increases. The condition is estimated to affect between 50% and 66% of patients aged 80 years and older and is especially common in Western societies, possibly due to the high consumption of low-fiber diets.1,2 In many cases, there are no symptoms of diverticular disease, but it is an incidental finding on routine colonoscopy.

 In many cases, when diverticular disease becomes symptomatic, the symptoms are pronounced enough for patients to seek medical care, increasing financial costs to the healthcare system.2,3 Symptoms most commonly include a variety of chronic abdominal problems, such as bloating, nausea, pain, diarrhea, and constipation, which are punctuated by acute severe episodes. The chronicity and recurrent bouts may result in poor quality of life, emotional distress, depression, and anxiety.3-7 When diverticular disease manifests as diverticulitis with an associated abscess, phlegmon, fistula, stricture, obstruction, bleeding, or perforation, the condition is deemed complicated.8 
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Over the past decade, there has been a shift away from the previously held dogma about diverticular disease, which is leading to changes in the standards of care for diagnosing, treating, and preventing recurrences of this condition.3-7 Evidence now suggests that diverticulitis mimics inflammatory bowel disease, which has resulted in the identification of new effective medical management approaches and new thinking regarding surgical and dietary management approaches, particularly with regard to preventing recurrences.3,9,10 Understanding these latest recommendations is essential to improving patient care. Therefore, in this article, we review the current views on diagnostic testing, treatment options, and the prevention of recurrent diverticulitis.

New Views on Diagnostic Testing

Multiple authors have stated that clinical acumen is sufficient to accurately diagnose some causes of abdominal pain without obtaining an immediate computed tomography (CT) scan, particularly if there is a history of diverticular disease, thus decreasing patients’ exposure to harmful radiation while reducing healthcare costs.11-13 This approach is sometimes taken in ambulatory settings, where patients receive a clinical diagnosis of mild diverticulitis and are then discharged to their homes to start bowel rest and antimicrobial therapy.14 Clinical judgment in the setting of specific parameters or use of ultrasonography may be reasonable and safer alternatives to immediate CT scanning.12,15 A 2010 study by Laméris and colleagues16 identified several parameters that may be helpful in accurately diagnosing mild diverticulitis, including localized left lower-quadrant tenderness, no vomiting, and elevated C-reactive protein levels; when all of these parameters are met, CT imaging may not be necessary.

Stollman and Raskin2 advocate that patients can be safely discharged to home with a presumptive diagnosis of mild diverticulitis if they present with localized left lower-quadrant tenderness without peritoneal signs, are able to tolerate oral antibiotics, have no significant comorbidities, and can be trusted to return to their healthcare provider if their symptoms worsen. These patients would be instructed to follow bowel rest and take antimicrobials, if necessary; this approach is advocated particularly for individuals with a history of documented diverticulitis.2 This care plan has also been espoused for patients who will have rapid follow-up or will reliably return for a CT scan within 48 hours if their condition worsens.6 Tursi and Papagrigoriadis6 suggest that if there are subsequent questions about the accuracy of the diagnosis, a CT scan can be performed after a short interval of treatment and observation. If an underlying malignancy is suspected or the patient has not had a colonoscopy within the previous 5 years, a colonoscopy is recommended after the patient’s acute symptoms improve and he or she is clinically stable.4-6

In contrast, CT scans of the abdomen and pelvis would be the appropriate immediate diagnostic tool for obese, elderly, and immunosuppressed patients with abdominal pain who may present atypically and for whom the condition cannot be reliably diagnosed clinically. Likewise, patients with diffuse abdominal pain of unknown etiology, septic patients, or patients demonstrating peritoneal signs on physical examination would require an immediate CT scan since this presentation is less likely to represent localized diverticulitis and requires a rapid definitive diagnosis to prevent greater morbidity and mortality.6

Although immediate CT scans are only necessary for certain patient populations, as previously described, they are often routinely ordered, increasing patient exposure to radiation without having clear benefits. Some physicians requesting this diagnostic study might underestimate radiation doses from these scans. Radiation exposure from abdominal and pelvic CT scans averages 11.8 millisievert (mSv) compared with a chest radiograph that averages 0.34  mSv.17 Studies have estimated that 1.5% to 2% of all cancers in the United States are attributable to radiation exposure from CT scans.18,19

To avoid the risks of and unnecessary exposure to medical radiation, Brenner18 suggests that CT scans may be reasonably replaced with other radiological imaging tests, such as ultrasonography or magnetic resonance imaging, and that developing and using new guidelines for diagnosis and treatment would decrease unnecessary CT scans. In addition, the cost effectiveness of CT scans has only been demonstrated in patients clinically suspected of having acute appendicitis.11 Ultrasonography may be a suitable initial diagnostic test in patients with acute abdominal pain, decreasing medical costs and preventing radiation exposure.20 Ultrasonography can be helpful in accurately diagnosing mild to moderate diverticulitis and in monitoring response to treatment, and it is available in clinic settings and in emergency departments. Studies have demonstrated an overall sensitivity for diagnosing acute colonic diverticulitis of 92% for ultrasonography versus 94% for CT scanning, and an overall specificity of 90% for ultrasonography versus 99% for CT scanning.20,21 Reliability for ultrasonography, however, is somewhat dependent on the technical skill of the person performing the examination. As stated previously, its use would help reduce costs and radiation exposure and, therefore, should be considered for determining the diagnosis of patients strongly suspected of having mild to moderate diverticulitis.12 Clinicians must determine on a case-by-case basis whether ultrasonography examination is sufficiently reliable to diagnose diverticulitis. In 2013, Radiologic Clinics of North America referenced a study on this topic, indicating that transabdominal ultrasonography is highly sensitive and specific for diagnosing uncomplicated acute diverticulitis and the primary complication of pericolic abscess.22

New Views on Treatment

The medical, surgical, and dietary approaches for the effective treatment of diverticulosis are evolving rapidly. These changes reflect new thinking about the epidemiology of diverticular disease, which focuses on inflammation, visceral hypersensitivity, changes in gut flora, and dysmotility. This is in opposition to the long-held theory that weakened muscles walls lead to diverticular disease, and this greater understanding must be reflected in patient care.Studies have demonstrated that more conservative medical and surgical treatment can be safe and effective.23,24

Medical Treatment of Uncomplicated Diverticulitis
As stated previously, a greater understanding of the epidemiology of diverticular disease is leading toward innovative treatment strategies for chronic and recurrent diverticulitis and away from the traditional approach of supportive care accompanied by antimicrobials, which are typically given as a 7- to 10-day course.Studies published in 2011 and 2012 have demonstrated that it is possible to treat patients who have mild to moderate diverticulitis without peritoneal signs with a short course of antibiotics for 5 days or no antibiotics at all24,25; however, the optimum duration of antimicrobial administration remains unclear.2,26,27 In addition, current guidelines on the choice of antibiotics are primarily based on tradition, clinical consensus, and indirect evidence, rather than prospective, randomized trials.

Astudy by Schug-Pass and associates28 compared the efficacy of 4 days of ertapenem therapy with 7 days of standard antibiotic therapy in the management of uncomplicated sigmoid diverticulitis. The overall success rates at 1 month following treatment were similar among the two treatment groups: 94% versus 96.2%, respectively. Furthermore, multiple studies have indicated that ambulatory treatment of simple diverticulitis is effective and safe, provided patients can tolerate oral medication and have adequate family support.27,29-31

Antispasmodic and anticholinergic agents have also been used in the treatment of uncomplicated diverticular disease. Antispasmodics are used to relax the muscles around the digestive tract, whereas anticholinergics inhibit acetylcholine, which blocks parasympathetic nerve impulses and reduces smooth muscle contractions. The observed hypermotility of the sigmoid colon in many patients with symptomatic disease has served as the rationale for using these agents, despite no well-controlled studies proving their clinical efficacy for these patients.2,32

Treatment of Diverticulitis With Abscesses
According to the American Society of Colon and Rectal Surgeons, approximately 15% of patients with diverticulitis will develop an abscess, either within the mesenteric leaves or in the pelvis.33 There has been ongoing debate regarding the size of abscess that can be treated effectively with antibiotics alone (oral or intravenous) versus those that require drainage.34-36 A study from 2006 compared two groups of patients with abscesses; the first group had 6-cm abscesses (median size) treated with percutaneous drainage, and the second group had 4-cm abscesses (median size) treated with antimicrobials alone.37 The failure rate in the first group was higher than that in the second group (33% vs 19%, respectively), despite the first group receiving more aggressive treatment.

In 2009, a study by Martin and colleagues38 reported that patients (mean age, 55 years) with abscesses smaller than 3 cm responded well to oral antibiotics, with this treatment demonstrating a success rate of almost 95%; only 4 of the 74 patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration. Based on their findings, the authors concluded that ambulatory conservative management was a safe and effective treatment for their patient population and that this approach reduced the need for hospitalization and lowered costs.38

A more recent study from 2011 demonstrated an overall success rate of more than 90% in treating patients with complicated diverticulitis nonoperatively, some of whom had abscesses larger than 4 cm or free air distant from the site of perforation.39 The study authors conclude that “nonoperative management of acute complicated diverticulitis is highly effective” and that “nonoperative management is able to convert an emergent situation into an elective one in 93% of cases.”

Based on such studies, the need for interventional radiologists to drain small abscesses is in debate and needs clarification. Until there are more definitive answers, physicians need to use their clinical judgment. For example, if a patient has a small abscess but has continued pain or fever, then interventional radiology should drain it.

Surgical Management: Taking a More Conservative Approach
Surgical approaches to diverticular disease are also in transition. There are now studies negating the role of surgical resection to prevent recurrence of diverticulitis. Historically, it was generally recommended that patients undergo elective resection after two documented episodes of uncomplicated diverticulitis or after one episode of complicated diverticulitis that did not require emergency surgery.40 It was also accepted that people older than 50 years and persons with a history of solid organ transplants could receive elective resection after their first episode of uncomplicated diverticulitis. The rationale behind this approach was that recurrent episodes would increase the risk of more pronounced complications and mortality; however, more recent evidence indicates that it is prudent to decide on a case-by-case basis whether to proceed with elective surgery for a patient with uncomplicated diverticulitis.41 It is also recognized that most mortality related to diverticular disease is tied to perforation, yet many patients with perforated diverticulitis have no previous history of diverticular disease. It has been reported that anywhere from 78% to 89.5% of patients with perforation have no known history of this disease.41,42 In addition, elective surgery has been shown to have little impact on the subsequent need to perform urgent surgery or on the ability to predict perforation.40,41 A retrospective study that assessed the records of 337 patients hospitalized for complicated diverticulitis found an overall mortality rate of 6.5%, which was considerably lower than the mortality rate of 10% or higher reported in earlier literature.41 When the authors excluded cases of perforated diverticulitis, the overall mortality rate for their study population was less than 1.6%.Based on their findings, the authors conclude that prophylactic colectomy is unlikely to prevent complicated diverticulitis and that “investigation is needed to identify who is at risk for the development of perforated diverticulitis as the initial manifestation of diverticular disease.”41

Several studies have shed light on factors that increase the risk of perforation and mortality. One study from the United Kingdom indicated that older age (>65 years), preexisting renal disease, and use of nonsteroidal anti-inflammatory drugs (NSAIDs) were associated with the highest rate of perforated diverticulitis.43 In another study, steroid use, female sex, older age (mean age, 78.9 years), and immune system compromise were associated with increased risk of perforation and subsequent mortality.41 In a Swedish study, colonic diverticular perforation was associated with the use of several medications, including NSAIDs, opioids, corticosteroids, and calcium channel blockers.44 When surgical management is needed to treat diverticulitis, including perforated diverticulitis, laparoscopic lavage has been reported to be a reasonable alternative to resection.45 The need for laparotomy in all cases of perforated diverticulitis has been called into question by numerous reports in the literature.4-6,13,27,34,35,45,46  

Pathophysiology: Guiding Recommendations for Prevention of Recurrence
More recent theories of the epidemiology of chronic diverticular disease, which include inflammation, shifts in gut microflora, dysmotility, and visceral hypersensitivity, have shed light on nonsurgical interventions that might prevent recurrences and reduce the risk of complications. When inflammation occurs, it may be microscopic or macroscopic; however, its extent may not be reflected in symptom severity. There may be changes in enteric innervation in patients with diverticular disease, resulting in increased pain. In addition, a colon affected by this illness has dysfunctional motility and abnormal contractile activity.3

As diverticular disease is becoming better understood, common overlapping clinical findings with inflammatory bowel disease have been identified; thus, the use of 5-aminosalicylic acid (5-ASA) and probiotics are being investigated as potential treatments. The inflammation of diverticula seems to be the result of greater production of pro-inflammatory cytokines, greater intramucosal nitric oxide production, and less anti-inflammatory cytokine synthesis. There is evidence that a fiber-deficient diet results in changes in colonic microflora, leading to an increase in pathogenic bacteria.28 The combination of rifaximin, a broad-spectrum antibiotic, and mesalamine, an anti-inflammatory agent, seem to prevent disease recurrence by deactivating the inflammatory cascade caused by alterations in the colonic microecology.47 In addition, probiotics, rifaximin, and mesalamine seem to down-regulate the inflammatory cascade caused by bacterial overgrowth, with resultant increased mucosal levels of interleukin-1 and tumor necrosis factor alpha.4-6,27,35

Dietary Approaches
Previous recommendations have suggested that patients avoid corn, nuts, and seeds, but these recommendations were not based on clinical trials. More recent literature has shown no evidence that these foods are contributory.9 Therefore, patients do not need to avoid these foods unless they find them bothersome; however, patients should be advised to chew all of their foods properly before swallowing them and to remain adequately hydrated, both of which can prevent constipation, which has been associated with diverticula formation and can exacerbate pain.

There is also no evidence that a high-fiber diet influences subsequent outcome, although vegetarians have been shown to have a lower risk of diverticular disease.10 Nevertheless, a high-fiber diet prevents constipation and helps maintain healthy gut flora. Therefore, it should continue to be recommended when a patient is not on bowel rest.

Conclusion

Diverticular disease is common in the elderly population and can cause chronic bouts of abdominal problems, which are punctuated by acute severe episodes, reducing quality of life and increasing the risk of anxiety and depression. The diagnostic and treatment recommendations for mild to moderate diverticulitis are in transition, as many of the currently accepted approaches are being questioned by new scientific evidence. Historically, CT scans have been routinely ordered when patients present with abdominal symptoms, but this diagnostic modality exposes patients to potentially harmful levels of radiation. In some cases, clinical judgment or use of ultrasonography may be reasonable, safer alternatives to immediate CT scanning. With regard to treatment, shorter duration of antibiotic administration or foregoing this treatment altogether in cases of simple diverticulitis may be clinically safe. Bowel rest to effectively treat mild to moderate diverticulitis has been shown to be effective. Although elective surgery was once recommended after a specific number of documented diverticulitis episodes, the decision to surgically treat the condition is best made on a case-by-case basis, with laparoscopic lavage preferred over laparotomy in most cases, including for perforated diverticulitis. In addition, as the pathophysiology of the disease becomes clearer, probiotics, rifaximin, and 5-ASA may become part of the armamentarium to prevent recurrences.

Our review of the most recent body of literature regarding diverticulitis indicates that more conservative strategies are not only proving to be safe and effective, but appear to be superior to more invasive ones. As research continues and the condition becomes better understood, patient care and outcomes will continue to improve. In addition, diagnosis and treatment will be based on scientific studies, not unsubstantiated dogma.

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Disclosures: The authors report no relevant financial relationships.

Address correspondence to: Nancy Lutwak, MD, Department of Emergency Medicine, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010; nancy.lutwak@va.gov