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Review |

Sigmoid Diverticulitis:  A Systematic Review FREE

Arden M. Morris, MD, MPH1; Scott E. Regenbogen, MD, MPH1; Karin M. Hardiman, MD, PhD1; Samantha Hendren, MD, MPH1
[+] Author Affiliations
1Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor
JAMA. 2014;311(3):287-297. doi:10.1001/jama.2013.282025.
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Published online

Importance  Diverticulitis is a common disease. Recent changes in understanding its natural history have substantially modified treatment paradigms.

Objective  To review the etiology and natural history of diverticulitis and recent changes in treatment guidelines.

Evidence Review  We searched the MEDLINE and Cochrane databases for English-language articles pertaining to diagnosis and management of diverticulitis published between January 1, 2000, and March 31, 2013. Search terms applied to 4 thematic topics: pathophysiology, natural history, medical management, and indications for surgery. We excluded small case series and articles based on data accrued prior to 2000. We hand searched the bibliographies of included studies, yielding a total of 186 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines.

Findings  Eighty articles met criteria for analysis. The pathophysiology of diverticulitis is associated with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment. Several studies examined histologic commonalities with inflammatory bowel disease and irritable bowel syndrome but were focused on associative rather than causal pathways. The natural history of uncomplicated diverticulitis is often benign. For example, in a cohort study of 2366 of 3165 patients hospitalized for acute diverticulitis and followed up for 8.9 years, only 13.3% of patients had a recurrence and 3.9%, a second recurrence. In contrast to what was previously thought, the risk of septic peritonitis is reduced and not increased with each recurrence. Patient-reported outcomes studies show 20% to 35% of patients managed nonoperatively progress to chronic abdominal pain compared with 5% to 25% of patients treated operatively. Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought and that mesalamine might be useful. Surgical therapy for chronic disease is not always warranted.

Conclusions and Relevance  Recent studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.

Figures in this Article

Before effective broad-spectrum antibiotics were available, diverticulitis was a devastating disease associated with substantial morbidity and mortality. Now, most cases resolve with antibiotic therapy. Because of the fear of complications associated with perforation, if multiply recurrent disease occurs, surgical resection of the involved colon is performed.1 However, recent advances in the understanding of the disease’s pathophysiology and natural history have led to substantial changes in diverticulitis treatment guidelines.

Over the past decade, 4 key innovations have changed the thinking about and management of diverticulitis: complicated diverticulitis (ie, with perforation, abscess, or phlegmon) is now reliably distinguished from uncomplicated disease by computed tomography (CT)2; large clinical and administrative databases have facilitated more complete follow-up of large populations, resulting in changes in the understanding of the natural history of diverticulitis, clinical and behavioral risk factors for the disease, and what the indications and outcomes of its treatments are; similarities exist between the physiology and inflammatory processes for diverticulitis, irritable bowel syndrome, and inflammatory bowel disease. These insights led to new approaches to managing chronic disease and preventing recurrent diverticulitis.3 Surgeons now pursue less invasive intervention, increasing the use of percutaneous drainage, intraperitoneal lavkage, and minimally invasive surgical techniques.4

Diverticulitis treatments are rapidly evolving. This review summarizes recent medical literature describing the pathophysiology and natural history of chronic and recurrent sigmoid diverticulitis and reviews new recommendations for the medical management and indications for surgery. Four key questions are addressed: (1) What is known about the pathophysiology of diverticulitis? How do diverticula become inflamed, and what are associated risk factors? (2) How have large observational trials clarified the natural history of diverticulitis that is managed nonoperatively? (3) What are the proposed mechanisms, options, and outcomes of medical therapy for diverticulitis? and (4) What are the indications for surgical treatment of diverticulitis?

Data Sources

We performed a systematic review of the MEDLINE and Cochrane databases, using separate search terms for each of the 4 key questions (eAppendix in the Supplement), for articles published between January 1, 2000, and March 31, 2013. Broad search terms for question 1 included (pathophysiology or etiology or pathogenesis) and diverticulitis; for question 2, broad search terms were (natural history or outcome) and diverticulitis; for questions 3 and 4, broad search terms were (chronic or acute or smoldering or recurrent) and diverticulitis and (management or treatment). Searches were limited to English language articles published since 2000 that addressed diverticulitis in adult humans. All articles were then combined into a single list, and duplicates were excluded, resulting in 1383 abstracts and articles for review.

Study Selection

We reviewed abstracts and excluded commentary or opinion pieces, review articles that reported data present in other included references, articles based on data accrued before 2000, and articles containing primary data duplicated in another included article. In the case of duplicate presentation of data, we selected articles with the most recent analyses. We excluded small case series with fewer than 30 patients, except for the search of articles for question 1 regarding pathophysiology. We supplemented our automated search by manually searching additional references from the bibliographies of included studies, yielding a total of 186 articles for full review.

Data Extraction

Studies selected for inclusion were reviewed according to guidelines from the Strengthening the Reporting of Observational Studies in Epidemiology.5 We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines.6 We compared the resulting recommendations with those of the most comprehensive recent clinical practice guidelines on management of diverticulitis.4

Eighty articles were selected from the 186 reviewed. Articles were excluded if there was an absence of data regarding the topic of interest, if the majority of data accrued prior to 2000, and if it was a small case series. Articles were organized into 4 categories consistent with the study questions and summarized below.

Pathophysiology and Risk Factors

Twenty-five articles fulfilled criteria and were included in this review of the pathophysiology of diverticulitis. Although colonic diverticulum refers specifically to a thin-walled outpouching of the mucosa and serosa, absent the muscularis, and diverticulosis refers to the presence of many diverticula, diverticulitis is distinguished by the presence of inflammation. If untreated, diverticular inflammation may resolve, become chronic, or progress, leading to bacterial translocation or even perforation of the colon wall at the inflamed site.

The prevailing explanation for colonic diverticula formation posits that altered bowel motility leading to increased intraluminal pressure causes mucosal outpouching adjacent to the vasa recta. Whether diverticula, once formed, can spontaneously resolve is unknown. The mechanism by which asymptomatic diverticula become inflamed and perforate (diverticulitis) is still under investigation but is plausibly associated with altered gut motility and increased pressure combined with a deranged colonic microenvironment. In recent series, when ex vivo colonic tissue from patients with diverticulitis was exposed to chemicals that contract or relax smooth muscle, the response was significantly abnormal with increased hypercontractility and lower maximum relaxation responses.79 These findings are consistent with neuropeptide abnormalities and the altered histologic appearance of muscle and nerves in the bowel wall of patients with diverticulitis compared with healthy patients. For example, reduced serotonin transporter expression and fewer interstitial cells of Cajal were found among patients with diverticulitis but not among those with normal colons or with noninflamed diverticula.1012 Moreover, patients who ingest calcium channel blockers, which reduce smooth muscle contractility, appear to have a reduced risk of perforated diverticulitis compared with patients who do not take calcium blockers.13

Recurrent or chronic diverticulitis displays chemical and histological similarities to inflammatory bowel disease and irritable bowel syndrome.14,15 These diagnoses may be concurrent, sequential, or entirely separate. Although the mechanisms of inflammation are unknown, higher levels of histamine, tumor necrosis factor α (TNF-α), and matrix metalloproteinases have been identified in colonic biopsies from patients with irritable bowel syndrome, inflammatory bowel disease, and diverticulitis.1618 Other common evidence of chronic inflammation includes the presence of granulomas and infiltrating lymphocytes. Ultimately, however, there were minimal mechanistic data to support or refute a common or related pathway and key distinguishing features of each persist. For example, a hallmark of irritable bowel syndrome is relief of crampy pain upon defecation; inflammatory bowel disease is characterized by mucosal injury frequently resulting in bloody diarrhea; diverticulitis is by definition associated with diverticula.

Lifestyle risk factors such as diet, smoking, and medication use have long been considered important in the etiology of diverticular disease. A prospective UK population-based cohort study found a relative risk of 0.69 (95% CI, 0.55-0.86) of diverticular disease among vegetarians compared with meat eaters.19 The relationship between dietary fiber and diverticula is not clear, however. A large cohort study of patients undergoing colonoscopy found that those who reported the highest fiber intake were at highest risk of diverticulosis.20 A longitudinal survey of 47 228 health professionals recently reported that incident diverticulitis was not associated with nut, corn, or popcorn ingestion and that increased nut intake was associated with lower risk of diverticulitis.21 Smoking and obesity have been linked to diverticulitis and to complicated diverticulitis in several large cohort studies,2226 whereas increased physical activity is associated with decreased risk.27,28 Nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids have been convincingly associated with increased risk of perforated diverticulitis.2932 A unifying hypothesis to integrate these diverse lifestyle effects and their contribution to pathophysiology has not been advanced.

Natural History

We defined the natural history of diverticulitis as the longitudinal outcomes for patients whose disease was managed nonoperatively. Six articles fulfilled criteria and were reviewed. Most of the data regarding natural history were focused on nonoperative outcomes and specifically on risk of recurrence, that is, subsequent acute diverticulitis after an asymptomatic interval, rather than on chronic disease in which there is no asymptomatic interval.

Risk of Recurrence

Two large multicenter studies33,34 confirmed that recurrence is rare and is a relatively benign process for the substantial majority of patients. Broderick-Villa et al34 reported on 2366 of 3165 patients (75%) hospitalized with acute diverticulitis and treated nonoperatively in the Kaiser Permanente system. Eighty-six percent of those patients required no further inpatient care for diverticulitis over the 8.9 years of follow-up. Recurrence occurred in only 13.3% of patients and only 3.9% had a second recurrence. No patient with a second recurrence required an operation, and repeat recurrences plateaued after 4 episodes. Although the risk for a second recurrence increased to 29% among those with a first recurrence, the authors concluded that recurrence overall is rare and therefore does not warrant elective colectomy.

Binda et al33 obtained complete follow-up for 320 patients treated with antibiotics in 17 Italian hospitals after admission for acute diverticulitis. Over a mean period of 10.7 years, 61% of patients required no further inpatient care. Twenty-two percent of patients had persistent or recurrent symptoms requiring hospitalization, and 17% had a recurrent episode resulting in an emergency operation. In adjusted analyses, the risk of recurrence was greatest among patients younger than 50 years and among those with at least 3 previous episodes. The authors noted that unlike other studies of recurrence, episodes were not clustered into the first 2 years or even the first 5 years following the index diagnosis.

Complications of Diverticulitis

A large population-based study linked primary care and hospital-based data to examine patterns of morbidity associated with complicated diverticulitis among 2950 patients hospitalized in the United Kingdom.35 Seventy-two percent of patients had no antecedent episodes of diverticulitis, and 2 or more prior episodes were not associated with abscess or stricture formation, although they were associated with increased risk of fistula. Although most serious complications of diverticulitis were linked to the first episode, not to recurrence, they were consequential. Compared with age- and sex-matched cases in the general population, patients with perforation or abscess had 4.5-fold increased risk of death in the ensuing year.

Shifting Morphology

Morphologic characteristics of recurrent diverticulitis may differ considerably from the first episode. A single institution study36 of 60 patients with recurrent disease after initial medical management of uncomplicated diverticulitis compared CT scans from the index and second admission. At the time of recurrence, 6 patients (10%) had complicated diverticulitis and 3 underwent an urgent Hartmann procedure. Among the 54 patients with a CT-defined recurrence that was uncomplicated, 19 (35%) had a morphologically distinct recurrence of diverticulitis at an average of 8 cm from the previous site.

Chronic Pain

Nelson et al37 analyzed a cohort of 99 patients with complicated diverticulitis whose care was managed nonoperatively with follow-up over 76 months. Forty-six patients had recurrent disease and 20 underwent an elective resection more than 6 months after the initial episode. Unlike Binda et al, the authors found no difference between recurrence or need for emergency operation based on age. Although about half of the patients had recurrent or chronic disease, none died of complications of diverticulitis. Similarly, a longitudinal survey of 124 patients with diverticular disease who were managed medically over 7 years reported that 34% continued to experience abdominal pain for 3.5 days per month. Odds of chronic pain were increased 4-fold among those who had been previously diagnosed with diverticulitis.38

Until recently, recommendations for management and prevention of diverticulitis were well-established. Patients with perforation, abscess, fistula, or stricture were managed definitively with an urgent or elective sigmoid colon resection. Those with uncomplicated disease were managed with antibiotics and bowel rest. In the event of a recurrence or failure to resolve, patients were scheduled for an elective sigmoid colectomy. The rationale for elective surgery was largely preventive, based on concerns that recurrence would result in progressively increased risk of sepsis or the need for a colostomy. More recently, emerging medical therapies are under investigation as a potentially lower-risk means of prevention.

Emerging Medical Therapies

The goals of medical therapy for diverticulitis are to decrease inflammation acutely, to prevent recurrence, and to manage chronic symptoms. With the advantage of more current pathophysiologic data and large database-derived studies of natural history, new medical approaches toward these goals have been proposed. A total of 14 articles on existent or emerging medical therapies met criteria for review (Table 1); however, the quality of most available evidence was poor (level B or C) and only 1 article met level A criteria.

Table Graphic Jump LocationTable 1.  Medical Management of Chronic and Recurrent Diverticulitis
Fiber

The traditional approach to prevention of recurrence of diverticulitis has been to increase dietary or supplemental fiber. Ünlü et al53 recently published a systematic review of the evidence supporting this longstanding recommendation. The authors found 4 studies on treatment and no studies on prevention of recurrence that met inclusion criteria. One randomized trial showed no treatment effect of fiber ingestion on resolution of symptoms, whereas the other 3 studies did show a significant treatment advantage with fiber ingestion. The authors concluded that recommendations for ingestion for dietary fiber are based on inconsistent level 2 and level 3 evidence. None of the studies examined met criteria for inclusion in our study because the data were collected prior to 2000. A systematic review40 of 4 trials of fiber vs rifaximin plus fiber found that the combined therapy was slightly but significantly more effective in obtaining symptom relief and preventing complications at 1 year. Two of the 4 studies were based on data from prior to 2000, the third was not explicitly about diverticulitis, and the fourth did not state what years data were collected.

Antibiotic Therapy

A major change in the approach to the management of acute uncomplicated diverticulitis is the progressively reduced use of antibiotics. Specifically, prospective randomized and open trials have shown no advantage of intravenous over oral antibiotics, and therefore have recommended outpatient management.39,4750 In addition, more recent data indicate equivalent efficacy of a 4-day vs 7-day course of an appropriately broad-spectrum antibiotic.54 This study recommended short-course therapy with ertapenem but rifaximin has also been favored for chronic or recurrent diverticulitis due to limited gut absorption and low cost.52 A Cochrane review51 of antibiotic use in acute uncomplicated diverticulitis found that, in spite of published guidelines, the best available data42 do not support use of antibiotics. A more inclusive systematic review44 and a retrospective cohort study46 have also found that antibiotic use has no effect on complications, need for surgery, or recurrence rate. Thus, newer data support a noninterventional policy for treatment of uncomplicated diverticulitis.

Probiotics

The rationale for use of probiotics in diverticular disease is based on the theory that a deranged colonic microenvironment, including abnormal gut flora, precipitates chronic inflammation and recurrent disease. One study of probiotics met inclusion criteria.45 The authors randomized 83 consecutive patients, whose index episode was resolved after treatment with rifaximin or ciprofloxacin, to receive an oral polybacterial lysate suspension or placebo twice daily for 2 weeks every month within 3 months after an acute attack. Complete follow-up data were available for 76 patients. The probiotic group reported significantly less abdominal pain, bloating, and fever, but there was no significant difference in recurrence rates (2 of 41 vs 5 of 35).

Anti-inflammatory Medication

A recent appreciation of chronic mucosal inflammation has sparked interest in alterations of the colonic microenvironment and the potential for use of anti-inflammatory medication. A head-to-head comparison of anti-inflammatory treatment using mesalamine vs antibiotic therapy with rifaximin demonstrated significantly reduced symptoms after 6 to 12 months of high-dose cyclic mesalamine.43 A nonrandomized comparison52 of rifaximin and mesalazine vs rifaximin alone showed 3% recurrence in the combined medication group and 13% recurrence in the rifaximin alone group over 1 year. A cohort study from the same authors41 showed that combined mesalamine and rifaximin followed by mesalamine alone led to resolution of symptoms for nearly all patients but recurrent disease among 2% at 8 weeks. The duration of follow-up for this study was notably short; most studies of recurrence require a minimum asymptomatic period of 3 to 6 months from the time of the index diagnosis before the next symptom onset.

Current Indications for Surgical Treatment

Surgery for acute diverticulitis is indicated for patients who present with sepsis and diffuse peritonitis and for patients whose condition did not improve with medical therapy, percutaneous drainage, or both.4,55 Surgical options include simple colostomy formation in the setting of profound inflammation, traditional sigmoid resection with colostomy (Hartmann procedure), and sigmoid resection with a primary colocolonic or colorectal anastomosis with or without a diverting loop ileostomy. Based on selection criteria, we identified 35 relevant articles describing indications for surgical therapy (in the Supplement). Most articles met only level B or C criteria and none met level A criteria, thereby limiting the conclusions that can be drawn.

Urgent Setting

In 2 cohort studies, the presence of complicated diverticulitis, abscess, free intraperitoneal air on computed tomography alone, or all 3 did not mandate an urgent operation among hemodynamically stable patients.56,57 Still, up to 25% of patients with evidence of abscess, perforation, or both underwent surgery during the acute index hospitalization.5860 Elective surgery after successful nonoperative management of an episode of complicated diverticulitis was often recommended due to rates of recurrence, hospital readmission, and need for elective resection as high as 50 to 70,34,5861 especially among those with a pelvic or paracolic abscess that required percutaneous drainage.59 However, few of these patients needed an emergency operation.37,62

Preoperative Colonoscopy

Elective evaluation of patients who recovered from an episode of acute diverticulitis was controversial. Some authors advocated colonoscopy to confirm the diagnosis and exclude malignancy.63,64 Others reported no increased detection of advanced neoplasia in patients with a typical presentation of acute diverticulitis.6568

Recurrent Diverticulitis

Among studies comparing surgical with nonsurgical management, several important considerations challenged routine elective surgical therapy for recurrent or chronic diverticulitis. First, complicated recurrence after recovery from an uncomplicated episode of diverticulitis occurred in fewer than 5% of patients whose care was managed nonoperatively.62,6973 Second, the occurrence of multiple subsequent episodes did not increase the risk of major complications of diverticulitis.74 Third, complicated diverticulitis most commonly occurred during the first episode, rather than during recurrent episodes.7578 Fourth, 5% to 25% of postoperative patients had recurrent or unresolved abdominal symptoms.33,7984

Patient Characteristics

Although several articles found modestly higher rates of recurrence and need for resection among patients younger than 50 years,71,72,85,86 most did not document a greater likelihood of perforation or worse outcomes among this cohort.8793 Young patients do have a longer life expectancy (thus, increased potential for future episodes and more to gain from prevention) and lower operative risk.9496 In general, however, the data supported decision making for operative therapy based on the severity of symptoms and complexity of the disease rather than the age of the patient.72,85 Exceptions to the current rule are immunosuppressed patients, such as those with solid organ transplants, collagen vascular diseases, steroid use, malnutrition, and chronic renal failure, who had 5-fold greater risk of complicated recurrence and perforation compared with nonimmunosuppressed patients (36% vs 7%).97,98 Thus, the threshold for immunosuppressed patients to proceed with elective resection after 1 or more episodes is lower, provided that the surgical risk due to these same comorbidities is not prohibitive.94

Sigmoid diverticulitis is an increasingly common and costly disease endemic in industrialized nations. Between 1998 and 2005, US hospital admissions for diverticulitis increased by 26% and elective operations by 29%.99 As incidence rates are increasing, the understanding and management of sigmoid diverticulitis is evolving. Collectively, several recent studies indicate a pathogenetic role for inflammation in diverticulitis that may be similar to that of irritable bowel syndrome, inflammatory bowel disease, or both, based on common histologic findings such as granulomas, infiltrating lymphocytes, TNF-α, histamine, and matrix metalloproteinases. However, studies of the etiology and pathophysiology of diverticulitis were limited by a focus on associative rather than causal pathways. Similarly, while lifestyle alterations were often recommended in response to the first incidence of diverticulitis, we found no studies testing the effect of lifestyle modifications on the disease course.

The risk of recurrence among patients with uncomplicated diverticulitis was approximately 13% to 36% and the risk of future emergency surgery was approximately 4% to 7%. Therefore, the available data do not support a routine policy of prophylactic sigmoidectomy on clinical grounds alone (Figure). In addition, given the possibility of shifting morphology,36 a prophylactic resection may actually miss the site of future inflammation, although these data should be confirmed in a larger cohort. Recent data also suggest that combination medical therapy, particularly rifaximin and mesalamine, may contribute to reduced symptoms in chronic disease. Further investigation into commonalities with irritable bowel syndrome and inflammatory bowel disease may provide insight and more opportunities for crossover of medical therapies.

Place holder to copy figure label and caption
Figure.
Clinical Outcomes Based on Current Treatment Standards for a Hypothetical Cohort of 1000 Patients Presenting With Acute Diverticulitis

Data derived from the following studies of diverticulitis outcomes: Ambrosetti et al,59 Broderick-Villa et al,34 Nelson et al,37 Kaiser et al,60Dharmarajan et al,57 Anaya et al,71 and Hall et al.70aComplicated diverticulitus refers to the presence of perforation, abscess, or phlegmon.

Graphic Jump Location

Whether and when to perform elective surgery for chronic or recurrent episodes of uncomplicated diverticulitis remain controversial topics. The traditional recommendation for surgical resection after 2 such episodes was based on outdated evidence suggesting that the success of nonoperative treatment diminished with each subsequent recurrence.100 Patients were told that an elective operation would permit primary anastomosis, whereas a potential emergency would necessitate fecal diversion with a colostomy. This recommendation has been challenged by more recent natural history information and recent studies of operative vs nonoperative management.

The current clinical practice guidelines4,101,102 were largely written for a surgical audience and may be oriented toward the patient population seen by surgeons (Table 2 and Table 3). However, no corresponding clinical practice guideline specifically targets primary care clinicians who encounter a different spectrum of disease in the primary care setting. Despite current clinical guidelines, we found minimal data to support the prevention of recurrence with fiber ingestion. We found that immunocompromised patients did not have a higher risk of mortality with recurrence. Nor did elective surgery always prevent recurrence or treat chronic disease. Up to 25% of patients who underwent an operation for chronic diverticulitis had no sustained postoperative symptom relief. Finally, we found mixed data regarding the utility of routine postinflammation colonoscopy. In spite of these data, practice parameters from surgical societies4,103 stipulate flexible endoscopy to distinguish diverticulitis from other causes of segmental colitis (eg, cancer, Crohn disease, and ischemic colitis).

Table Graphic Jump LocationTable 2.  Level of Recommendation for Systematic Review of Recent Literature Compared to Current Practice Guidelines for Prevention of Recurrent Sigmoid Diverticulitis
Table Graphic Jump LocationTable 3.  Level of Recommendation for Systematic Review of Recent Literature vs Current Practice Guidelines for Management of Chronic Sigmoid Diverticulitis

Our review is subject to a number of limitations which should be noted. Throughout the review, the level of evidence was lower grade, thereby limiting our interpretation and conclusions. Most importantly, studies of diverticulitis were limited by the lack of a standard terminology for aspects of the disease, which resulted in some difficulty commenting across studies. For example, some articles clearly distinguished between complicated and uncomplicated diverticulitis while others did not. Some referred only to diverticular disease and did not discuss diverticulitis per se. Very few studies included outpatient data, and therefore we were unable to draw conclusions about resolution or recurrence of symptoms in this population.

In spite of these limitations, population-based data indicate that peritonitis and sepsis are rare complications of incident diverticulitis and are even more rare complications of recurrent disease. Therefore, although septic peritonitis remains a clear indication for urgent operation, there are few other indications for an urgent colectomy with or without colostomy formation. Moreover, several recommendations meant to reduce the risk of recurrence were based on associations with an index episode and have not been tested longitudinally. Future studies of causality and interventions to reduce recurrence are needed, especially given the increasing incidence of diverticulitis.

In summary, although decision making should be based on individual clinical characteristics and patient preferences, the current data support a substantially reduced role for aggressive antibiotic and surgical intervention in recurrent and chronic diverticulitis.

Section Editor: Mary McGrae McDermott, MD, Senior Editor.
Submissions:We encourage authors to submit papers for consideration as a Review. Please contact Mary McGrae McDermott, MD, at mdm608@northwestern.edu.

Corresponding Author: Arden M. Morris, MD, MPH, Division of Colorectal Surgery, Department of Surgery, University of Michigan, 1500 E Medical Center Dr, TC-2124, Ann Arbor, MI 48109-5343 (ammsurg@med.umich.edu).

Author Contributions: Dr Morris had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Morris, Regenbogen, Hardiman.

Acquisition of data: Morris, Regenbogen, Hardiman.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: All authors.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed   |  Link to Article
von Rahden  BH, Kircher  S, Thiery  S,  et al.  Association of steroid use with complicated sigmoid diverticulitis: potential role of activated CD68+/CD163+ macrophages. Langenbecks Arch Surg. 2011;396(6):759-768.
PubMed   |  Link to Article
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PubMed
Binda  GA, Arezzo  A, Serventi  A,  et al; Italian Study Group on Complicated Diverticulosis (GISDIC).  Multicentre observational study of the natural history of left-sided acute diverticulitis [published correction appears in Br J Surg. 2012;99(4):600]. Br J Surg. 2012;99(2):276-285.
PubMed   |  Link to Article
Broderick-Villa  G, Burchette  RJ, Collins  JC, Abbas  MA, Haigh  PI.  Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005;140(6):576-581.
PubMed   |  Link to Article
Humes  DJ, 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(1):95-100.
PubMed   |  Link to Article
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PubMed   |  Link to Article
Nelson  RS, Ewing  BM, Wengert  TJ, Thorson  AG.  Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J Surg. 2008;196(6):969-972.
PubMed   |  Link to Article
Humes  DJ, Simpson  J, Neal  KR, Scholefield  JH, Spiller  RC.  Psychological and colonic factors in painful diverticulosis. Br J Surg. 2008;95(2):195-198.
PubMed   |  Link to Article
Alonso  S, Pera  M, Parés  D,  et al.  Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2010;12(10 online):e278-e282.
PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed
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PubMed   |  Link to Article
Dughera  L, Serra  AM, Battaglia  E, Tibaudi  D, Navino  M, Emanuelli  G.  Acute recurrent diverticulitis is prevented by oral administration of a polybacterial lysate suspension. Minerva Gastroenterol Dietol. 2004;50(2):149-153.
PubMed
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PubMed   |  Link to Article
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Shabanzadeh  DM, Wille-Jørgensen  P.  Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092.
PubMed
Tursi  A, Brandimarte  G, Daffinà  R.  Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon. Dig Liver Dis. 2002;34(7):510-515.
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Ünlü  C, Daniels  L, Vrouenraets  BC, Boermeester  MA.  A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis. 2012;27(4):419-427.
PubMed   |  Link to Article
Schug-Pass  C, Geers  P, Hügel  O, Lippert  H, Köckerling  F.  Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis. 2010;25(6):751-759.
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Regenbogen  SE, Hardiman  KM, Hendren  S, Morris  AM, .  Surgery for diverticulitis in the 21st century: a systematic review. JAMASurg. 10.1001/jamasurg.2013.5477.
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Dharmarajan  S, Hunt  SR, Birnbaum  EH, Fleshman  JW, Mutch  MG.  The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54(6):663-671.
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Ambrosetti  P.  Value of CT for acute left-colonic diverticulitis: the surgeon’s view. Dig Dis. 2012;30(1):51-55.
PubMed   |  Link to Article
Ambrosetti  P, Chautems  R, Soravia  C, Peiris-Waser  N, Terrier  F.  Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum. 2005;48(4):787-791.
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Kaiser  AM, Jiang  JK, Lake  JP,  et al.  The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005;100(4):910-917.
PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed   |  Link to Article
Bar-Meir  S, Lahat  A, Melzer  E.  Role of endoscopy in patients with diverticular disease. Dig Dis. 2012;30(1):60-63.
PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed   |  Link to Article
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PubMed   |  Link to Article
Eglinton  T, Nguyen  T, Raniga  S, Dixon  L, Dobbs  B, Frizelle  FA.  Patterns of recurrence in patients with acute diverticulitis. Br J Surg. 2010;97(6):952-957.
PubMed   |  Link to Article
Hall  JF, Roberts  PL, Ricciardi  R,  et al.  Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011;54(3):283-288.
PubMed   |  Link to Article
Anaya  DA, Flum  DR.  Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg. 2005;140(7):681-685.
PubMed   |  Link to Article
Guzzo  J, Hyman  N.  Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum. 2004;47(7):1187-1190.
PubMed   |  Link to Article
Janes  S, Meagher  A, Frizelle  FA.  Elective surgery after acute diverticulitis. Br J Surg. 2005;92(2):133-142.
PubMed   |  Link to Article
Chapman  JR, Dozois  EJ, Wolff  BG, Gullerud  RE, Larson  DR.  Diverticulitis: a progressive disease? do multiple recurrences predict less favorable outcomes? Ann Surg. 2006;243(6):876-830.
PubMed   |  Link to Article
Issa  N, Dreznik  Z, Dueck  DS,  et al.  Emergency surgery for complicated acute diverticulitis. Colorectal Dis. 2009;11(2):198-202.
PubMed   |  Link to Article
Pittet  O, Kotzampassakis  N, Schmidt  S, Denys  A, Demartines  N, Calmes  JM.  Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis? World J Surg. 2009;33(3):547-552.
PubMed   |  Link to Article
Ritz  JP, Lehmann  KS, Frericks  B, Stroux  A, Buhr  HJ, Holmer  C.  Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery. 2011;149(5):606-613.
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Chapman  J, Davies  M, Wolff  B,  et al.  Complicated diverticulitis: is it time to rethink the rules? Ann Surg. 2005;242(4):576-581.
PubMed
Andeweg  C, Peters  J, Bleichrodt  R, van Goor  H.  Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease. World J Surg. 2008;32(7):1501-1506.
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Ambrosetti  P, Francis  K, Weintraub  D, Weintraub  J.  Functional results following elective laparoscopic sigmoidectomy after CT-proven diagnosis of acute diverticulitis evaluation of 43 patients and review of the literature. J Gastrointest Surg. 2007;11(6):767-772.
PubMed   |  Link to Article
Egger  B, Peter  MK, Candinas  D.  Persistent symptoms after elective sigmoid resection for diverticulitis. Dis Colon Rectum. 2008;51(7):1044-1048.
PubMed   |  Link to Article
Forgione  A, Leroy  J, Cahill  RA,  et al.  Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg. 2009;249(2):218-224.
PubMed   |  Link to Article
Käser  SA, Glauser  PM, Basilicata  G, Müller  DA, Maurer  CA.  Timing of rectosigmoid resection for diverticular disease: the patient’s view. Colorectal Dis. 2012;14(3):e111-e116.
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Pasternak  I, Wiedemann  N, Basilicata  G, Melcher  GA.  Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease. Int J Colorectal Dis. 2012;27(6):781-787.
PubMed   |  Link to Article
Faria  GR, Almeida  AB, Moreira  H, Pinto-de-Sousa  J, Correia-da-Silva  P, Pimenta  AP.  Acute diverticulitis in younger patients: any rationale for a different approach? World J Gastroenterol. 2011;17(2):207-212.
PubMed   |  Link to Article
Lahat  A, Menachem  Y, Avidan  B,  et al.  Diverticulitis in the young patient—is it different? World J Gastroenterol. 2006;12(18):2932-2935.
PubMed
Biondo  S, Parés  D, Martí Ragué  J, Kreisler  E, Fraccalvieri  D, Jaurrieta  E.  Acute colonic diverticulitis in patients under 50 years of age. Br J Surg. 2002;89(9):1137-1141.
PubMed   |  Link to Article
Hjern  F, Josephson  T, Altman  D, Holmström  B, Johansson  C.  Outcome of younger patients with acute diverticulitis. Br J Surg. 2008;95(6):758-764.
PubMed   |  Link to Article
Kotzampassakis  N, Pittet  O, Schmidt  S, Denys  A, Demartines  N, Calmes  JM.  Presentation and treatment outcome of diverticulitis in younger adults: a different disease than in older patients? Dis Colon Rectum. 2010;53(3):333-338.
PubMed   |  Link to Article
Lopez-Borao  J, Kreisler  E, Millan  M,  et al.  Impact of age on recurrence and severity of left colonic diverticulitis. Colorectal Dis. 2012;14(7):e407-e412.
PubMed   |  Link to Article
Mäkelä  JT, Kiviniemi  HO, Laitinen  ST.  Acute sigmoid diverticulitis in young patients. Hepatogastroenterology. 2009;56(94-95):1382-1387.
PubMed
Nelson  RS, Velasco  A, Mukesh  BN.  Management of diverticulitis in younger patients. Dis Colon Rectum. 2006;49(9):1341-1345.
PubMed   |  Link to Article
Ritz  JP, Lehmann  KS, Stroux  A, Buhr  HJ, Holmer  C.  Sigmoid diverticulitis in young patients—a more aggressive disease than in older patients? J Gastrointest Surg. 2011;15(4):667-674.
PubMed   |  Link to Article
Pessaux  P, Muscari  F, Ouellet  JF,  et al.  Risk factors for mortality and morbidity after elective sigmoid resection for diverticulitis: prospective multicenter multivariate analysis of 582 patients. World J Surg. 2004;28(1):92-96.
PubMed   |  Link to Article
Oomen  JL, Engel  AF, Cuesta  MA.  Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors. Colorectal Dis. 2006;8(2):112-119.
PubMed   |  Link to Article
Lidsky  ME, Thacker  JK, Lagoo-Deenadayalan  SA, Scarborough  JE.  Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis. Surgery. 2012;152(3):465-472.
PubMed   |  Link to Article
Klarenbeek  BR, Samuels  M, van der Wal  MA, van der Peet  DL, Meijerink  WJ, Cuesta  MA.  Indications for elective sigmoid resection in diverticular disease. Ann Surg. 2010;251(4):670-674.
PubMed   |  Link to Article
Yoo  PS, Garg  R, Salamone  LF, Floch  MH, Rosenthal  R, Longo  WE.  Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis. Am J Surg. 2008;196(5):710-714.
PubMed   |  Link to Article
Etzioni  DA, Mack  TM, Beart  RW  Jr, Kaiser  AM.  Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg. 2009;249(2):210-217.
PubMed   |  Link to Article
Parks  TG.  Natural history of diverticular disease of the colon: a review of 521 cases. BMJ. 1969;4(5684):639-642.
PubMed   |  Link to Article
Society for Surgery of the Alimentary Tract. Patient care guidelines. http://www.ssat.com/cgi-bin/divert.cgi. Board approved October 8, 2007. Accessed April 4, 2013.
World Gastroenterology Organisation. Practice guidelines—diverticular disease. http://www.worldgastroenterology.org/diverticular-disease.html. Accessed April 4, 2013.
Fozard  JB, Armitage  NC, Schofield  JB, Jones  OM; Association of Coloproctology of Great Britain and Ireland.  ACPGBI position statement on elective resection for diverticulitis. Colorectal Dis. 2011;13(suppl 3):1-11.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Clinical Outcomes Based on Current Treatment Standards for a Hypothetical Cohort of 1000 Patients Presenting With Acute Diverticulitis

Data derived from the following studies of diverticulitis outcomes: Ambrosetti et al,59 Broderick-Villa et al,34 Nelson et al,37 Kaiser et al,60Dharmarajan et al,57 Anaya et al,71 and Hall et al.70aComplicated diverticulitus refers to the presence of perforation, abscess, or phlegmon.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Medical Management of Chronic and Recurrent Diverticulitis
Table Graphic Jump LocationTable 2.  Level of Recommendation for Systematic Review of Recent Literature Compared to Current Practice Guidelines for Prevention of Recurrent Sigmoid Diverticulitis
Table Graphic Jump LocationTable 3.  Level of Recommendation for Systematic Review of Recent Literature vs Current Practice Guidelines for Management of Chronic Sigmoid Diverticulitis

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Strate  LL, Liu  YL, Syngal  S, Aldoori  WH, Giovannucci  EL.  Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907-914.
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Dobbins  C, Defontgalland  D, Duthie  G, Wattchow  DA.  The relationship of obesity to the complications of diverticular disease. Colorectal Dis. 2006;8(1):37-40.
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Hjern  F, Wolk  A, Håkansson  N.  Obesity, physical inactivity, and colonic diverticular disease requiring hospitalization in women: a prospective cohort study. Am J Gastroenterol. 2012;107(2):296-302.
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Rosemar  A, Angerås  U, Rosengren  A.  Body mass index and diverticular disease: a 28-year follow-up study in men. Dis Colon Rectum. 2008;51(4):450-455.
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Strate  LL, Liu  YL, Aldoori  WH, Syngal  S, Giovannucci  EL.  Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. 2009;136(1):115-122.
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Hjern  F, Wolk  A, Håkansson  N.  Smoking and the risk of diverticular disease in women. Br J Surg. 2011;98(7):997-1002.
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Strate  LL, Liu  YL, Aldoori  WH, Giovannucci  EL.  Physical activity decreases diverticular complications. Am J Gastroenterol. 2009;104(5):1221-1230.
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Williams  PT.  Incident diverticular disease is inversely related to vigorous physical activity. Med Sci Sports Exerc. 2009;41(5):1042-1047.
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Morris  CR, Harvey  IM, Stebbings  WS, Speakman  CT, Kennedy  HJ, Hart  AR.  Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease. Br J Surg. 2003;90(10):1267-1272.
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Strate  LL, Liu  YL, Huang  ES, Giovannucci  EL, Chan  AT.  Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology. 2011;140(5):1427-1433.
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von Rahden  BH, Kircher  S, Thiery  S,  et al.  Association of steroid use with complicated sigmoid diverticulitis: potential role of activated CD68+/CD163+ macrophages. Langenbecks Arch Surg. 2011;396(6):759-768.
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Goh  H, Bourne  R.  Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Ann R Coll Surg Engl. 2002;84(2):93-96.
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Binda  GA, Arezzo  A, Serventi  A,  et al; Italian Study Group on Complicated Diverticulosis (GISDIC).  Multicentre observational study of the natural history of left-sided acute diverticulitis [published correction appears in Br J Surg. 2012;99(4):600]. Br J Surg. 2012;99(2):276-285.
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Broderick-Villa  G, Burchette  RJ, Collins  JC, Abbas  MA, Haigh  PI.  Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005;140(6):576-581.
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Humes  DJ, 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(1):95-100.
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Gervaz  P, Platon  A, Widmer  L, Ambrosetti  P, Poletti  PA.  A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2. Colorectal Dis. 2012;14(4):463-468.
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Nelson  RS, Ewing  BM, Wengert  TJ, Thorson  AG.  Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J Surg. 2008;196(6):969-972.
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Humes  DJ, Simpson  J, Neal  KR, Scholefield  JH, Spiller  RC.  Psychological and colonic factors in painful diverticulosis. Br J Surg. 2008;95(2):195-198.
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Alonso  S, Pera  M, Parés  D,  et al.  Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2010;12(10 online):e278-e282.
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Bianchi  M, Festa  V, Moretti  A,  et al.  Long-term therapy with rifaximin in the management of uncomplicated diverticular disease. Aliment Pharmacol Ther. 2011;33(8):902-910.
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Brandimarte  G, Tursi  A.  Rifaximin plus mesalazine followed by mesalazine alone is highly effective in obtaining remission of symptomatic uncomplicated diverticular disease. Med Sci Monit. 2004;10(5):PI70-PI73.
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Chabok  A, Påhlman  L, Hjern  F, Haapaniemi  S, Smedh  K; AVOD Study Group.  Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99(4):532-539.
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Comparato  G, Fanigliulo  L, Cavallaro  LG,  et al.  Prevention of complications and symptomatic recurrences in diverticular disease with mesalazine: a 12-month follow-up. Dig Dis Sci. 2007;52(11):2934-2941.
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de Korte  N, Unlü  C, Boermeester  MA, Cuesta  MA, Vrouenreats  BC, Stockmann  HB.  Use of antibiotics in uncomplicated diverticulitis. Br J Surg. 2011;98(6):761-767.
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Dughera  L, Serra  AM, Battaglia  E, Tibaudi  D, Navino  M, Emanuelli  G.  Acute recurrent diverticulitis is prevented by oral administration of a polybacterial lysate suspension. Minerva Gastroenterol Dietol. 2004;50(2):149-153.
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Hjern  F, Josephson  T, Altman  D,  et al.  Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory? Scand J Gastroenterol. 2007;42(1):41-47.
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Mizuki  A, Nagata  H, Tatemichi  M,  et al.  The out-patient management of patients with acute mild-to-moderate colonic diverticulitis. Aliment Pharmacol Ther. 2005;21(7):889-897.
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Moya  P, Arroyo  A, Pérez-Legaz  J,  et al.  Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis. Tech Coloproctol. 2012;16(4):301-307.
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Ribas  Y, Bombardó  J, Aguilar  F,  et al.  Prospective randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicillin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Colorectal Dis. 2010;25(11):1363-1370.
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Ridgway  PF, Latif  A, Shabbir  J,  et al.  Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis. 2009;11(9):941-946.
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Shabanzadeh  DM, Wille-Jørgensen  P.  Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092.
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Tursi  A, Brandimarte  G, Daffinà  R.  Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon. Dig Liver Dis. 2002;34(7):510-515.
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Ünlü  C, Daniels  L, Vrouenraets  BC, Boermeester  MA.  A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis. 2012;27(4):419-427.
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Schug-Pass  C, Geers  P, Hügel  O, Lippert  H, Köckerling  F.  Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis. 2010;25(6):751-759.
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Regenbogen  SE, Hardiman  KM, Hendren  S, Morris  AM, .  Surgery for diverticulitis in the 21st century: a systematic review. JAMASurg. 10.1001/jamasurg.2013.5477.
Costi  R, Cauchy  F, Le Bian  A, Honart  JF, Creuze  N, Smadja  C.  Challenging a classic myth: pneumoperitoneum associated with acute diverticulitis is not an indication for open or laparoscopic emergency surgery in hemodynamically stable patients: a 10-year experience with a nonoperative treatment. Surg Endosc. 2012;26(7):2061-2071.
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Dharmarajan  S, Hunt  SR, Birnbaum  EH, Fleshman  JW, Mutch  MG.  The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54(6):663-671.
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Ambrosetti  P.  Value of CT for acute left-colonic diverticulitis: the surgeon’s view. Dig Dis. 2012;30(1):51-55.
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Ambrosetti  P, Chautems  R, Soravia  C, Peiris-Waser  N, Terrier  F.  Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum. 2005;48(4):787-791.
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Kaiser  AM, Jiang  JK, Lake  JP,  et al.  The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005;100(4):910-917.
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Poletti  PA, Platon  A, Rutschmann  O,  et al.  Acute left colonic diverticulitis: can CT findings be used to predict recurrence? AJR Am J Roentgenol. 2004;182(5):1159-1165.
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Shaikh  S, Krukowski  ZH.  Outcome of a conservative policy for managing acute sigmoid diverticulitis. Br J Surg. 2007;94(7):876-879.
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Lahat  A, Yanai  H, Sakhnini  E, Menachem  Y, Bar-Meir  S.  Role of colonoscopy in patients with persistent acute diverticulitis. World J Gastroenterol. 2008;14(17):2763-2766.
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Lau  KC, Spilsbury  K, Farooque  Y,  et al.  Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? Dis Colon Rectum. 2011;54(10):1265-1270.
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Bar-Meir  S, Lahat  A, Melzer  E.  Role of endoscopy in patients with diverticular disease. Dig Dis. 2012;30(1):60-63.
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Lam  TJ, Meurs-Szojda  MM, Gundlach  L,  et al.  There is no increased risk for colorectal cancer and adenomas in patients with diverticulitis: a retrospective longitudinal study. Colorectal Dis. 2010;12(11):1122-1126.
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Schmilovitz-Weiss  H, Yalunin  E, Boaz  M,  et al.  Does a colonoscopy after acute diverticulitis affect its management? a single center experience. J Clin Gastroenterol. 2012;46(4):317-320.
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Westwood  DA, Eglinton  TW, Frizelle  FA.  Routine colonoscopy following acute uncomplicated diverticulitis. Br J Surg. 2011;98(11):1630-1634.
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Eglinton  T, Nguyen  T, Raniga  S, Dixon  L, Dobbs  B, Frizelle  FA.  Patterns of recurrence in patients with acute diverticulitis. Br J Surg. 2010;97(6):952-957.
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Hall  JF, Roberts  PL, Ricciardi  R,  et al.  Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011;54(3):283-288.
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Anaya  DA, Flum  DR.  Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg. 2005;140(7):681-685.
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Guzzo  J, Hyman  N.  Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum. 2004;47(7):1187-1190.
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Janes  S, Meagher  A, Frizelle  FA.  Elective surgery after acute diverticulitis. Br J Surg. 2005;92(2):133-142.
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Chapman  JR, Dozois  EJ, Wolff  BG, Gullerud  RE, Larson  DR.  Diverticulitis: a progressive disease? do multiple recurrences predict less favorable outcomes? Ann Surg. 2006;243(6):876-830.
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Issa  N, Dreznik  Z, Dueck  DS,  et al.  Emergency surgery for complicated acute diverticulitis. Colorectal Dis. 2009;11(2):198-202.
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Pittet  O, Kotzampassakis  N, Schmidt  S, Denys  A, Demartines  N, Calmes  JM.  Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis? World J Surg. 2009;33(3):547-552.
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Ritz  JP, Lehmann  KS, Frericks  B, Stroux  A, Buhr  HJ, Holmer  C.  Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery. 2011;149(5):606-613.
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Chapman  J, Davies  M, Wolff  B,  et al.  Complicated diverticulitis: is it time to rethink the rules? Ann Surg. 2005;242(4):576-581.
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Andeweg  C, Peters  J, Bleichrodt  R, van Goor  H.  Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease. World J Surg. 2008;32(7):1501-1506.
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Ambrosetti  P, Francis  K, Weintraub  D, Weintraub  J.  Functional results following elective laparoscopic sigmoidectomy after CT-proven diagnosis of acute diverticulitis evaluation of 43 patients and review of the literature. J Gastrointest Surg. 2007;11(6):767-772.
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Egger  B, Peter  MK, Candinas  D.  Persistent symptoms after elective sigmoid resection for diverticulitis. Dis Colon Rectum. 2008;51(7):1044-1048.
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Forgione  A, Leroy  J, Cahill  RA,  et al.  Prospective evaluation of functional outcome after laparoscopic sigmoid colectomy. Ann Surg. 2009;249(2):218-224.
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Käser  SA, Glauser  PM, Basilicata  G, Müller  DA, Maurer  CA.  Timing of rectosigmoid resection for diverticular disease: the patient’s view. Colorectal Dis. 2012;14(3):e111-e116.
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Pasternak  I, Wiedemann  N, Basilicata  G, Melcher  GA.  Gastrointestinal quality of life after laparoscopic-assisted sigmoidectomy for diverticular disease. Int J Colorectal Dis. 2012;27(6):781-787.
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Faria  GR, Almeida  AB, Moreira  H, Pinto-de-Sousa  J, Correia-da-Silva  P, Pimenta  AP.  Acute diverticulitis in younger patients: any rationale for a different approach? World J Gastroenterol. 2011;17(2):207-212.
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Lahat  A, Menachem  Y, Avidan  B,  et al.  Diverticulitis in the young patient—is it different? World J Gastroenterol. 2006;12(18):2932-2935.
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Biondo  S, Parés  D, Martí Ragué  J, Kreisler  E, Fraccalvieri  D, Jaurrieta  E.  Acute colonic diverticulitis in patients under 50 years of age. Br J Surg. 2002;89(9):1137-1141.
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Hjern  F, Josephson  T, Altman  D, Holmström  B, Johansson  C.  Outcome of younger patients with acute diverticulitis. Br J Surg. 2008;95(6):758-764.
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Kotzampassakis  N, Pittet  O, Schmidt  S, Denys  A, Demartines  N, Calmes  JM.  Presentation and treatment outcome of diverticulitis in younger adults: a different disease than in older patients? Dis Colon Rectum. 2010;53(3):333-338.
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Lopez-Borao  J, Kreisler  E, Millan  M,  et al.  Impact of age on recurrence and severity of left colonic diverticulitis. Colorectal Dis. 2012;14(7):e407-e412.
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Mäkelä  JT, Kiviniemi  HO, Laitinen  ST.  Acute sigmoid diverticulitis in young patients. Hepatogastroenterology. 2009;56(94-95):1382-1387.
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Nelson  RS, Velasco  A, Mukesh  BN.  Management of diverticulitis in younger patients. Dis Colon Rectum. 2006;49(9):1341-1345.
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Ritz  JP, Lehmann  KS, Stroux  A, Buhr  HJ, Holmer  C.  Sigmoid diverticulitis in young patients—a more aggressive disease than in older patients? J Gastrointest Surg. 2011;15(4):667-674.
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Pessaux  P, Muscari  F, Ouellet  JF,  et al.  Risk factors for mortality and morbidity after elective sigmoid resection for diverticulitis: prospective multicenter multivariate analysis of 582 patients. World J Surg. 2004;28(1):92-96.
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Oomen  JL, Engel  AF, Cuesta  MA.  Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors. Colorectal Dis. 2006;8(2):112-119.
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Lidsky  ME, Thacker  JK, Lagoo-Deenadayalan  SA, Scarborough  JE.  Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis. Surgery. 2012;152(3):465-472.
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Klarenbeek  BR, Samuels  M, van der Wal  MA, van der Peet  DL, Meijerink  WJ, Cuesta  MA.  Indications for elective sigmoid resection in diverticular disease. Ann Surg. 2010;251(4):670-674.
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Yoo  PS, Garg  R, Salamone  LF, Floch  MH, Rosenthal  R, Longo  WE.  Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis. Am J Surg. 2008;196(5):710-714.
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Etzioni  DA, Mack  TM, Beart  RW  Jr, Kaiser  AM.  Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg. 2009;249(2):210-217.
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