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- Clin Colon Rectal Surg
- v.34(2); 2021 Mar
- PMC7904335
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Clin Colon Rectal Surg. 2021 Mar; 34(2): 121–126.
Published online 2021 Feb 24. doi:10.1055/s-0040-1716704
PMCID: PMC7904335
PMID: 33642952
Diverticulitis
Guest Editor: Jason Hall, MD, MPH, FACS, FACRS
Elizabeth H. Wood, MD, MS,1 Michael M. Sigman, MD,1 and Dana M. Hayden, MD, MPH1
Author information Copyright and License information PMC Disclaimer
Abstract
Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old. It is responsible for ∼300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation.2It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circ*mstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum, right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circ*mstances.
Keywords: diverticulitis, giant diverticulum, right-sided diverticulitis, immunosuppression, multifocal disease
Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old.1It is responsible for ∼300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation.2It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circ*mstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum (GCD), right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circ*mstances.
Multifocal Disease
Epidemiology
Distribution of diverticula throughout the colon has been found to vary based on geographic location and race. Epidemiologic studies have indicated that patients from countries in the Western hemisphere tend to have diverticular disease in the left colon. In Asian countries, right-sided diverticula are more common, and this has been attributed to dietary and lifestyle differences.3However, other studies have attributed differences to nonenvironmental factors. In one population study, the distribution of diverticula varied significantly by race. Proximally located diverticula were more common in black patients compared with white patients living in the same geographic location.4This concurred with a previous study using barium enemas, which found that black patients were more likely to have proximal diverticula.5
In general, 90% of patients in Europe and North America with diverticular disease have involvement of the sigmoid colon and only 15% have right-sided disease. Seven percent of patients have pan-colonic diverticula, and only 4% of patients have diverticula limited to a segment of colon proximal to the sigmoid.6Since the vast majority of symptomatic diverticular disease occurs in the sigmoid or descending colon, the most frequent surgical intervention is sigmoid colectomy. A group from Mayo Clinic studied the natural history of diverticulosis after sigmoid resection and followed patients with barium enemas 5 to 9 years after surgery. The progression of disease to more proximal colon was found in only 14.7% of patients and the progression was minimal. About 11.4% of patients had recurrent episodes of diverticulitis in the remaining colon. The study concluded that it would not be beneficial to resect additional large bowel that contained diverticula as long as adequate resection of the sigmoid was performed since the progression of disease was minimal.7
Pathophysiology
It is believed that left-sided and right-sided diverticulosis may arise due to different mechanisms. Muscle thickening has been attributed to formation of diverticula in the left colon, and this is associated with perforation, acute inflammation, and diverticulitis. Left-sided diverticular disease has also been associated with increased intraluminal pressure as well as a weakened colonic wall that may occur during aging. A different form of diverticulosis has been attributed to a diffuse connective tissue abnormality resulting in pan-colonic or right-sided diverticulosis and associated bleeding.8
Treatment of incidentally found diverticulosis in an otherwise asymptomatic patient involves diet modification to increase fiber and decrease fat intake. Medical and surgical interventions may be required once diverticulosis is complicated by infection or bleeding. The majority of patients with symptomatic diverticular disease presents initially with pain, fever, and changes in bowel habits secondary to diverticulitis. Because the prevalence of the disease rises with increasing age, it was believed to be a progressive disease. However, a prospective study following asymptomatic patients with diverticular disease diagnosed on routine colonoscopy failed to detect significant risk of developing diverticulitis (4.8 cases per 1000 years).9
Complicated Multifocal Diverticular Disease
Multifocal diverticular disease is either incidentally identified on colonoscopy or at the time of computed tomography (CT) imaging obtained to evaluate abdominal pain or for other reasons, such as cancer surveillance. An extensive search of the current literature demonstrates only one case of multifocal diverticulitis where a patient initially presented with right-sided diverticulitis underwent a right hemicolectomy for symptoms and later presented with sigmoid and then transverse colon diverticulitis.10Because subsequent episodes of diverticulitis were uncomplicated, the patient was managed conservatively and did not undergo additional colon resection. Additionally, another case report described synchronous diverticular perforation that occurred in a patient who presented with peritonitis. Upon laparotomy, the patient was found to have both a perforated cecal diverticulum and a perforated sigmoid diverticulum. Right hemicolectomy as well as sigmoidectomy was performed resulting in two stapled primary anastomoses, which were protected by a diverting loop ileostomy.11
Conclusions
Multifocal diverticulosis or pan-colonic diverticulosis has been documented in the general population but multifocal diverticulitis, hemorrhage, or perforation is exceedingly rare and only reported as anecdotes. Management of this disease should be individualized to the patient. If a patient is found to have multiple areas of diverticulosis but is only symptomatic from a discrete part of the colon, treatment should follow the general principles of diverticulitis with attempted conservative management for uncomplicated disease and surgical or percutaneous intervention for more complicated disease. Extensive colon resections are usually not required for incidentally found asymptomatic multifocal diverticular disease.
Giant Colonic Diverticulum
A colonic diverticulum is considered giant when it measures greater than 4 cm. GCD generally present on the antimesenteric border of the colon are singular, and are most frequently found in the sigmoid colon but can be present throughout. GCD is usually found in patients in the sixth decade of life with equal prevalence in men and women.12The pathophysiology of GCD is unclear but several causes have been hypothesized. One is the “ball-valve” theory where a diverticulum is intermittently occluded allowing the entrance but not the exit of colonic gas into the diverticulum. Another theory hypothesizes that gas-forming bacteria are trapped in the diverticulum causing eventual enlargement.13
There are three types of GCDs defined by histology. Type I is a pseudodiverticulum and contains only muscularis mucosa and muscularis propria. These tend to be directly associated with diverticular disease. Type II is the most common and contains only reactive scar tissue. A type III GCD is a true diverticulum, involves all layers of the colonic wall, and may be a congenital duplication cyst.14
Diagnosis
When evaluating a patient with possible GCD, differential diagnoses that should be considered include giant duodenal diverticula, colonic volvulus, abdominal abscess, duplication cyst, giant Meckel's diverticulum, and pneumatosis cystoides intestinalis.15Clinical symptoms are generally nonspecific and past history of diverticulitis is not required. Patients typically present with abdominal pain, distention, vomiting, and constipation. Rarely presentations can include gastrointestinal bleeding, free perforation, or urinary obstruction due to mass effect. Diagnosis of GCD is usually made radiographically and CT scan is more sensitive than abdominal plain films.16A large air-filled cystic cavity may be seen on X-ray. On CT imaging, the cystic structure and its association with the colon can be seen. Barium enemas and colonoscopies are less useful given the potential for perforation.
The role of colonoscopy in diagnosis is also limited as the ostium connecting the diverticulum to the colon may be too small to detect.17In fact, 20% of GCD have no communication with the colon secondary to inflammation.18Still, colonoscopy is recommended to evaluate the extent of diverticular disease and to rule out possible malignancy. Endoscopy should be used judiciously since excessive insufflation may increase the likelihood of perforation.
Management
Treatment of GCD depends on size, organs involved, and associated inflammation. The majority of patients undergoes laparotomy with resection of the diverticulum with the associated colon followed by a primary anastomosis. In the event, the diverticulum is complicated by abscess formation, perforation, or inflammation, a Hartmann procedure with end colostomy or primary anastomosis with diverting ileostomy can be performed. Diverticulectomy is sometimes performed if adjacent colon is not inflamed and there is not extensive diverticular disease.18However, there have been reports of increased recurrence and leaks after this more limited procedure.19However, there have also been individual cases reported in the literature where percutaneous drainage or antibiotics alone have been sufficient treatment for complicated GCD in patients who may not be surgical candidates.20
Most recently, laparoscopic-assisted approaches to resection of the diverticulum have been described. Data are anecdotal but there have been minimal complications reported with laparoscopic resection.2122
Conclusions
GCD are extremely rare manifestations of diverticular disease. The current literature regarding the diagnosis and management of this pathology is comprised of case reports and small case series. The incidence of GCD is too low to conduct meaningful randomized trials comparing treatment options. At this time, management for GCD should be determined on an individualized basis by taking into consideration the patient's clinical characteristics, the symptomatology of the diverticulum, and the comfort of the surgeon with laparoscopic colon surgery.
Right-Sided Diverticulitis
Etiology
Very little is known about the natural history of right-sided diverticulitis. This is due in part to the fact that the majority of published information is derived from case reports and small series and most are derived from Asian or Asian-descent populations. Right-sided diverticulitis is a rare clinical entity in Western populations, with a reported rate of 1.5% of all diverticulitis cases. It is far more common in Asian countries where right-sided diverticulosis accounts for 20% of diverticular disease and 75% of cases of diverticulitis.2324Often grouped together as one clinical entity, right-sided diverticulitis may refer to large solitary diverticula or smaller numerous diverticula found in the appendix, cecum, or throughout the ascending colon. When solitary, they are thought to be congenital and true diverticula, consisting of all layers of the colonic wall. When multiple, they are typically acquired and considered false diverticula, similar to those more commonly seen in sigmoid diverticulitis.2526Cecal and right-sided diverticulitis patients present at a younger age than those with left-sided diverticulitis, and in some series there is a male predisposition in right-sided disease.24
Diagnosis
Historically, right-sided diverticulitis was discovered intraoperatively, as its presentation clinically mimics that of appendicitis. In the late 1990s, the routine use of CT for the diagnosis of appendicitis was shown to be cost-effective and since then, CT imaging has been used with greater than 90 to 95% sensitivity and specificity to accurately differentiate between the two.27Right-sided diverticulitis may often mimic other more common conditions including cholecystitis, gastritis, and peptic ulcer disease, mesenteric adenitis, ischemic colitis, pelvic inflammatory disease, pyelonephritis, and left-sided diverticulitis (with redundant sigmoid). Clinical findings that indicate right-sided diverticulitis versus appendicitis include lower incidence of nausea, emesis, and anorexia accompanying the abdominal pain as well as variable point of maximum tenderness to palpation on abdominal exam.2829
Findings on CT imaging consistent with a diagnosis of right colon diverticulitis are similar to those appreciated in left-sided disease: colonic wall thickening, presence of extraluminal mass, haziness and stranding of adjacent pericolic fat, and thickening of associated fascial planes.30Although CT has very high diagnostic specificity, right-sided diverticulitis may still be mistaken for appendicitis with abscess, Crohn's disease, omental infarction, or colon cancer.31
Treatment
The treatment of right-sided diverticulitis depends on severity of presentation and timing of diagnosis. Asymptomatic diverticula incidentally found on imaging do not require intervention.
With the exception of isolated cecal diverticulitis, there is no consensus for optimal treatment of patients with right-sided diverticulitis found incidentally at the time of operation. While some surgeons advocate no intervention, others recommend diverticulectomy if inflammation is minimal. Right hemicolectomy is recommended for extensive inflammation, perforation, or mass suspicious for carcinoma. In cases of isolated cecal diverticulitis, resection (diverticulectomy or ileocecectomy) is strongly recommended.3233If a preoperative diagnosis of uncomplicated diverticulitis is made, management should consist of bowel rest and intravenous antibiotics. It has been suggested that right-sided diverticulitis differs from left-colon diverticulitis as it has a more indolent course.34Several published series demonstrate long-term remission and control of disease with medical therapy alone. Komuta et al published a study demonstrating 99% of patients diagnosed with uncomplicated right colon diverticulitis were successfully treated with bowel rest and antibiotics alone. Over an average of 3 years, 20% experienced a recurrent attack of uncomplicated diverticulitis, all of which had resolved with medical therapy. Of the 20% with recurrent disease, 15% experienced a third attack, again all of which were treated successfully without operative intervention.34
Another study examined the management and outcome of 113 patients with right colon diverticulitis over a 10-year course. The authors demonstrated a 20% recurrence rate of uncomplicated disease.35Just as elective resection for uncomplicated left-sided diverticulitis does not have a specific number of episodes to indicate surgery, operative management of right-sided diverticulitis should be treated on a case-by-case basis, tailoring management to the specific patient and presentation.273637Elective resection should be considered in cases of frequent recurrence or worsening symptoms. One exception to medical therapy is isolated cecal diverticulitis. It occurs uncommonly and is rarely diagnosed preoperatively. Surgical treatment includes diverticulectomy with or without ileocecectomy or right colectomy depending on the degree of inflammation. Most surgeons advocate resection, since isolated cecal diverticulitis is thought to infrequently resolve with medical therapy and has a high rate of complicated recurrence.32
For patients who present with complicated right-sided diverticulitis, initial therapy should be similar to those with left-sided disease. Patients who present with abscess, but are otherwise hemodynamically stable, should be treated with percutaneous drainage, bowel rest, and intravenous antibiotics. Although uncommon, patients with overt perforation or those who are clinically unstable should be taken for urgent operation.
Diverticulitis in the Setting of Immunosuppression
The birth and expansion of visceral allograft transplantation techniques along with synthesis of immunosuppressive (IMS) drugs in the late 1960s in the United States witnessed complications relating to colonic perforation and virulent diverticulitis.3839The incidence of diverticulitis in Western populations is increasing along with an increasing incidence of presentation at a younger age.40Additionally, the population of patients with IMS has grown, due to an increased number of transplant recipients, extended indications for immunosuppressant medication and chemotherapy, patients with chronic renal failure on hemodialysis, and the prevalence of acquired immunodeficiency.
Complicated diverticulitis in IMS patients appears to be more aggressive. Compared with general population, diverticulitis occurs with a higher incidence (1 vs. 0.02%).414243IMS patients suffer from more severe index episodes with higher need for emergency surgery compared with immunocompetent patients. They also have a higher mortality compared with general population, both after surgical and medical management. IMS patients tend to have higher severity of disease when they recur, although recurrence rates overall are not increased when compared with immunocompetent patients.4445IMS patients may not mount a significant inflammatory response and may have only extraluminal gas on CT without other typical radiographic findings of diverticulitis. This can contribute both to delay in diagnosis and worse outcomes.
In the current American Society of Colon and Rectal Surgeons (ASCRS) guidelines for treatment of sigmoid diverticulitis, transplant patients and patients maintained on chronic corticosteroid therapy are identified as a subgroup of patients in which medical management is more likely to fail. IMS patients also have a higher mortality when compared with those treated with medical therapy alone.2Patients with chronic renal failure or collagen-vascular disease are also identified as having a significantly greater risk of recurrence and complicated disease requiring emergency surgery.
There is evidence that the natural history of acute diverticulitis can vary depending on the underlying cause of IMS. Kreisler et al published the results of a 20-year observational study in which IMS patients were grouped into those with chronic steroid use, transplant patients, those with extracolonic malignant neoplasms, chronic renal failure, and “other” (including myasthenia gravis, inflammatory bowel disease, pyoderma). The authors found that the chronic corticosteroid group had a higher rate of emergency surgery at the index admission.46However, only American Society of Anesthesiologist (ASA) score was significantly related to overall mortality in multivariate analysis.
Another study performed in 2014 looked at patients undergoing chemotherapy and incidence of diverticulitis. The authors found that patients who were currently or recently receiving chemotherapy did not present too differently from those who were not receiving chemotherapy in regard to severity of index case, failure of medical management, or recurrence rate. However, those undergoing chemotherapy did present with more severe disease at the recurrent episode were more likely to require emergent surgery and more likely to be diverted. Patients did not have worse perioperative outcomes; however, if they underwent interval colectomy, patients undergoing chemotherapy were more likely to suffer a postoperative complication.47
Current practice guidelines recommend a low threshold for operative intervention in IMS patients during their first hospitalization for acute diverticulitis, even if uncomplicated. However, given that the mortality and morbidity after prophylactic colectomy are not negligible and that previously held operative indications for uncomplicated diverticulitis are now increasingly based on patient factors, some authors suggest individualizing the decision for surgery.46A few studies have indicated that nonoperative management of uncomplicated diverticulitis in the immunocompromised may be safe and effective, even for recurrences.4849
For perforated or complicated diverticulitis or nonoperative failures in IMS patients, the most commonly performed operation is the Hartmann's procedure. Immunosuppression, acuity of operation, advanced Hinchey stage, and higher index of peritonitis have been found to predict a nonrestorative operation in large retrospective reviews.50However, it has been increasingly recognized that in immunocompetent patients, resection with primary anastomosis with or without diversion may be preferable to Hartmann's regardless of degree of peritonitis.5152It has not been fully elucidated whether this applies to IMS patients. Biondo et al studied all patients undergoing emergency surgery for perforated diverticulitis from 2004 to 2012 who were classified as immunocompromised versus immunocompetent. Operation, postoperative morbidity, and mortality were compared between the groups. The impact of peritonitis severity score (PSS) was also evaluated to determine its impact on the restoration of gastrointestinal continuity. The PSS and the Manhattan Peritonitis Index are validated systems for left colonic peritonitis based on routinely measured variables to allow stratification of patients according to mortality risk. Similar to the previously published results from the same group, resection with primary anastomosis and diversion was safe when compared with Hartmann's procedures except in IMS patient with the highest PSS.253
Diverticulitis in immunocompromised patients represents a unique challenge to the colorectal or general surgeon due to their increased severity, poorer outcomes, and delayed diagnosis. The decision for elective sigmoidectomy or primary anastomosis after resection in emergent surgery is best tailored to the individual patient by assessing risk factors like severity of disease or clinical presentation.
Footnotes
Conflict of Interest None declared.
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