Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Management of diverticular disease

Nature Reviews Gastroenterology & Hepatology volume 12, pages 629–638 (2015)Cite this article

Subjects

Key Points

  • Diverticular disease comprises acute and chronic as well as uncomplicated and complicated disease courses

  • Classification is an inevitable requirement for appropriate management

  • Classification needs clinical examination and cross-sectional imaging by CT or ultrasonography

  • Antibiotics should be confined to treatment of more complicated disease

  • Uncomplicated diverticular disease is a case for conservative management and not for surgery

Abstract

Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Algorithm for the therapeutic management of diverticular disease.

Similar content being viewed by others

References

  1. Graser, E. Ueber multiple falsche Darmdivertikel in der Flexura sigmoidea [German]. Münchener Med. Wschr. 46, 721–723 (1899).

    Google Scholar 

  2. Peery, A. F. et al. A high-fiber diet does not protect against asymptomatic diverticulosis. Gastroenterology 142, 266–272.e1 (2012).

    Article  PubMed  Google Scholar 

  3. Stumpf, M. et al. Increased distribution of collagen type III and reduced expression of matrix metalloproteinase 1 in patients with diverticular disease. Int. J. Colorectal Dis. 16, 271–275 (2001).

    Article  CAS  PubMed  Google Scholar 

  4. Wess, L., Eastwood, M. A., Wess, T. J., Busuttil, A. & Miller, A. Cross linking of collagen is increased in colonic diverticulosis. Gut 37, 91–94 (1995).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Painter, N. S. & Burkitt, D. P. Diverticular disease of the colon: a deficiency disease of Western civilization. BMJ 2, 450–454 (1971).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Hjern, F., Johansson, C., Mellgren, A., Baxter, N. N. & Hjern, A. Diverticular disease and migration—the influence of acculturation to a Western lifestyle on diverticular disease. Aliment. Pharmacol. Ther. 23, 797–805 (2006).

    Article  CAS  PubMed  Google Scholar 

  7. Aldoori, W. H. et al. A prospective study of diet and the risk of symptomatic diverticular disease in men. Am. J. Clin. Nutr. 60, 757–764 (1994).

    Article  CAS  PubMed  Google Scholar 

  8. Manousos, O. et al. Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece. Gut 26, 544–549 (1985).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Gear, J. S. et al. Symptomless diverticular disease and intake of dietary fibre. Lancet 1, 511–514 (1979).

    Article  CAS  PubMed  Google Scholar 

  10. Normand, S. L. et al. Readers guide to critical appraisal of cohort studies: 3. Analytical strategies to reduce confounding. BMJ 330, 1021–1023 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  11. Mamdani, M. et al. Reader's guide to critical appraisal of cohort studies: 2. Assessing potential for confounding. BMJ 330, 960–962 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  12. Rochon, P. A. et al. Reader's guide to critical appraisal of cohort studies: 1. Role and design. BMJ 330, 895–897 (2005).

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jepsen, P., Johnsen, S. P., Gillman, M. W. & Sorensen, H. T. Interpretation of observational studies. Heart 90, 956–960 (2004).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Shelton, R. C., Jandorf, L., Ellison, J., Villagra, C. & DuHamel, K. N. The influence of sociocultural factors on colonoscopy and FOBT screening adherence among low-income Hispanics. J. Health Care Poor Underserved 22, 925–944 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  15. Painter, N. S. The aetiology of diverticulosis of the colon with special reference to the action of certain drugs on the behaviour of the colon. Ann. R. Coll. Surg. Engl. 34, 98–119 (1964).

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Painter, N. S., Truelove, S. C., Ardran, G. M. & Tuckey, M. Effect of morphine, prostigmine, pethidine, and probanthine on the human colon in diverticulosis studied by intraluminal pressure recording and cineradiography. Gut 6, 57–63 (1965).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Bassotti, G. et al. Alterations in colonic motility and relationship to pain in colonic diverticulosis. Clin. Gastroenterol. Hepatol. 3, 248–253 (2005).

    Article  PubMed  Google Scholar 

  18. Bassotti, G., Battaglia, E., Spinozzi, F., Pelli, M. A. & Tonini, M. Twenty-four hour recordings of colonic motility in patients with diverticular disease: evidence for abnormal motility and propulsive activity. Dis. Colon Rectum 44, 1814–1820 (2001).

    Article  CAS  PubMed  Google Scholar 

  19. Santin, B. J., Prasad, V. & Caniano, D. A. Colonic diverticulitis in adolescents: an index case and associated syndromes. Pediatr. Surg. Int. 25, 901–905 (2009).

    Article  PubMed  Google Scholar 

  20. Granlund, J. et al. The genetic influence on diverticular disease—a twin study. Aliment. Pharmacol. Ther. 35, 1103–1107 (2012).

    CAS  PubMed  Google Scholar 

  21. Stoss, F. & Meier-Ruge, W. Diagnosis of neuronal colonic dysplasia in primary chronic constipation and sigmoid diverticulosis endoscopic biopsy and enzyme-histochemical examination. Surg. Endosc. 5, 146–149 (1991).

    Article  CAS  PubMed  Google Scholar 

  22. Wedel, T. et al. Diverticular disease is associated with an enteric neuropathy as revealed by morphometric analysis. Neurogastroenterol. Motil. 22, 407–414.e93–e94 (2010).

    Article  CAS  PubMed  Google Scholar 

  23. Shahedi, K. et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin. Gastroenterol. Hepatol. 11, 1609–1613 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  24. Sandler, R. S. et al. The burden of selected digestive diseases in the United States. Gastroenterology 122, 1500–1511 (2002).

    Article  PubMed  Google Scholar 

  25. Everhart, J. E. & Ruhl, C. E. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterology 136, 376–386 (2009).

    Article  PubMed  Google Scholar 

  26. Peery, A. F. et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 143, 1179–1187.e1–e3 (2012).

    Article  PubMed  Google Scholar 

  27. Jeyarajah, S. et al. Diverticular disease hospital admissions are increasing, with poor outcomes in the elderly and emergency admissions. Aliment. Pharmacol. Ther. 30, 1171–1182 (2009).

    Article  CAS  PubMed  Google Scholar 

  28. Humes, D. J. et al. A population-based study of perforated diverticular disease incidence and associated mortality. Gastroenterology 136, 1198–1205 (2009).

    Article  PubMed  Google Scholar 

  29. Papagrigoriadis, S., Debrah, S., Koreli, A. & Husain, A. Impact of diverticular disease on hospital costs and activity. Colorectal Dis. 6, 81–84 (2004).

    Article  CAS  PubMed  Google Scholar 

  30. Gesundheitsberichterstattung des Bundes. Das Informationssystem der Gesundheitsberichterstattung des Bundes [online], (2015).

  31. Andersen, J. C. et al. Danish national guidelines for treatment of diverticular disease. Dan. Med. J. 59, C4453 (2012).

    PubMed  Google Scholar 

  32. Andeweg, C. S. et al. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig. Surg. 30, 278–292 (2013).

    Article  CAS  PubMed  Google Scholar 

  33. Kruis, W., Germer, C. T. & Leifeld, L. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral surgery. Digestion 90, 190–207 (2014).

    Article  PubMed  Google Scholar 

  34. Kohler, L., Sauerland, S. & Neugebauer, E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg. Endosc. 13, 430–436 (1999).

    Article  CAS  PubMed  Google Scholar 

  35. Hinchey, E. J., Schaal, P. G. & Richards, G. K. Treatment of perforated diverticular disease of the colon. Adv. Surg. 12, 85–109 (1978).

    CAS  PubMed  Google Scholar 

  36. Sher, M. E. et al. Laparoscopic surgery for diverticulitis. Surg. Endosc. 11, 264–267 (1997).

    Article  CAS  PubMed  Google Scholar 

  37. Wasvary, H., Turfah, F., Kadro, O. & Beauregard, W. Same hospitalization resection for acute diverticulitis. Am. Surg. 65, 632–635 (1999).

    CAS  PubMed  Google Scholar 

  38. Hansen, J. S. & Stock, W. Prophylaktische operation bei der divertikelkrankheit des kolons—stufenkonzept durch exakte stadieneinteilung [German]. Langenbecks Arch. Surg. (Suppl. II), 1257–1260 (1999).

  39. Kaiser, A. M. et al. The management of complicated diverticulitis and the role of computed tomography. Am. J. Gastroenterol. 100, 910–917 (2005).

    Article  PubMed  Google Scholar 

  40. Toorenvliet, B. R., Bakker, R. F., Breslau, P. J., Merkus, J. W. & Hamming, J. F. Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Colorectal Dis. 12, 179–186 (2010).

    Article  CAS  PubMed  Google Scholar 

  41. Hollerweger, A., Macheiner, P., Rettenbacher, T., Brunner, W. & Gritzmann, N. Colonic diverticulitis: diagnostic value and appearance of inflamed diverticula-sonographic evaluation. Eur. Radiol. 11, 1956–1963 (2001).

    Article  CAS  PubMed  Google Scholar 

  42. Puylaert, J. B. Ultrasound of colon diverticulitis. Dig. Dis. 30, 56–59 (2012).

    Article  PubMed  Google Scholar 

  43. Schwerk, W. B., Schwarz, S. & Rothmund, M. Sonography in acute colonic diverticulitis. A prospective study. Dis. Colon Rectum 35, 1077–1084 (1992).

    Article  CAS  PubMed  Google Scholar 

  44. Wilson, S. R. & Toi, A. The value of sonography in the diagnosis of acute diverticulitis of the colon. AJR Am. J. Roentgenol. 154, 1199–1202 (1990).

    Article  CAS  PubMed  Google Scholar 

  45. Lameris, W. et al. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur. Radiol. 18, 2498–2511 (2008).

    Article  PubMed  Google Scholar 

  46. Liljegren, G., Chabok, A., Wickbom, M., Smedh, K. & Nilsson, K. Acute colonic diverticulitis: a systematic review of diagnostic accuracy. Colorectal Dis. 9, 480–488 (2007).

    Article  CAS  PubMed  Google Scholar 

  47. Nielsen, K. et al. The limited role of ultrasound in the diagnostic process of colonic diverticulitis. World J. Surg. 38, 1814–1818 (2013).

    Google Scholar 

  48. Lahat, A., Yanai, H., Menachem, Y., Avidan, B. & Bar-Meir, S. The feasibility and risk of early colonoscopy in acute diverticulitis: a prospective controlled study. Endoscopy 39, 521–524 (2007).

    Article  CAS  PubMed  Google Scholar 

  49. Lahat, A., Yanai, H., Sakhnini, E., Menachem, Y. & Bar-Meir, S. Role of colonoscopy in patients with persistent acute diverticulitis. World J. Gastroenterol. 14, 2763–2766 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  50. Peery, A. F. et al. Constipation and a low-fiber diet are not associated with diverticulosis. Clin. Gastroenterol. Hepatol. 11, 1622–1627 (2013).

    Article  PubMed  Google Scholar 

  51. Crowe, F. L., Appleby, P. N., Allen, N. E. & Key, T. J. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ 343, d4131 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  52. Horner, J. L. Natural history of diverticulosis of the colon. Am. J. Dig. Dis. 3, 343–350 (1958).

    Article  CAS  PubMed  Google Scholar 

  53. Strate, L. L., Liu, Y. L., Syngal, S., Aldoori, W. H. & Giovannucci, E. L. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 300, 907–914 (2008).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Lin, O. S. et al. Dietary habits and right-sided colonic diverticulosis. Dis. Colon Rectum 43, 1412–1418 (2000).

    Article  CAS  PubMed  Google Scholar 

  55. Hjern, F., Wolk, A. & Hakansson, N. Smoking and the risk of diverticular disease in women. Br. J. Surg. 98, 997–1002 (2011).

    Article  CAS  PubMed  Google Scholar 

  56. Rosemar, A., Angeras, U. & Rosengren, A. Body mass index and diverticular disease: a 28-year follow-up study in men. Dis. Colon Rectum 51, 450–455 (2008).

    Article  PubMed  Google Scholar 

  57. Aldoori, W. H. et al. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann. Epidemiol. 5, 221–228 (1995).

    Article  CAS  PubMed  Google Scholar 

  58. Song, J. H. et al. Clinical characteristics of colonic diverticulosis in Korea: a prospective study. Korean J. Intern. Med. 25, 140–146 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  59. Tonnesen, H., Engholm, G. & Moller, H. Association between alcoholism and diverticulitis. Br. J. Surg. 86, 1067–1068 (1999).

    Article  CAS  PubMed  Google Scholar 

  60. Kopylov, U. et al. Obesity, metabolic syndrome and the risk of development of colonic diverticulosis. Digestion 86, 201–205 (2012).

    Article  PubMed  Google Scholar 

  61. Hjern, F., Wolk, A. & Hakansson, N. Obesity, physical inactivity, and colonic diverticular disease requiring hospitalization in women: a prospective cohort study. Am. J. Gastroenterol. 107, 296–302 (2012).

    Article  PubMed  Google Scholar 

  62. Strate, L. L., Liu, Y. L., Aldoori, W. H., Syngal, S. & Giovannucci, E. L. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology 136, 115–122 e1 (2009).

    Article  PubMed  Google Scholar 

  63. Aldoori, W. H. et al. Prospective study of physical activity and the risk of symptomatic diverticular disease in men. Gut 36, 276–282 (1995).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Strate, L. L., Liu, Y. L., Aldoori, W. H. & Giovannucci, E. L. Physical activity decreases diverticular complications. Am. J. Gastroenterol. 104, 1221–1230 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  65. Williams, P. T. Incident diverticular disease is inversely related to vigorous physical activity. Med. Sci. Sports Exerc. 41, 1042–1047 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  66. Rafferty, J., Shellito, P., Hyman, N. H. & Buie, W. D. Practice parameters for sigmoid diverticulitis. Dis. Colon Rectum 49, 939–944 (2006).

    Article  PubMed  Google Scholar 

  67. Wong, W. D. et al. Practice parameters for the treatment of sigmoid diverticulitis—supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis. Colon Rectum 43, 290–297 (2000).

    Article  CAS  PubMed  Google Scholar 

  68. Chabok, A., Pahlman, L., Hjern, F., Haapaniemi, S. & Smedh, K. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br. J. Surg. 99, 532–539 (2012).

    Article  CAS  PubMed  Google Scholar 

  69. de Korte, N. et al. Mild colonic diverticulitis can be treated without antibiotics. A case-control study. Colorectal Dis. 14, 325–330 (2012).

    Article  CAS  PubMed  Google Scholar 

  70. Hjern, F. et al. Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory? Scand. J. Gastroenterol. 42, 41–47 (2007).

    Article  PubMed  Google Scholar 

  71. Aldoori, W. H., Giovannucci, E. L., Rimm, E. B., Wing, A. L. & Willett, W. C. Use of acetaminophen and nonsteroidal anti-inflammatory drugs: a prospective study and the risk of symptomatic diverticular disease in men. Arch. Fam. Med. 7, 255–260 (1998).

    Article  CAS  PubMed  Google Scholar 

  72. Campbell, K. & Steele, R. J. Non-steroidal anti-inflammatory drugs and complicated diverticular disease: a case-control study. Br. J. Surg. 78, 190–191 (1991).

    Article  CAS  PubMed  Google Scholar 

  73. Corder, A. Steroids, non-steroidal anti-inflammatory drugs, and serious septic complications of diverticular disease. Br. Med. J. (Clin. Res. Ed.) 295, 1238 (1987).

    Article  CAS  Google Scholar 

  74. Goh, H. & Bourne, R. Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Ann. R. Coll. Surg. Engl. 84, 93–96 (2002).

    CAS  PubMed  PubMed Central  Google Scholar 

  75. Humes, D. J., Fleming, K. M., Spiller, R. C. & West, J. Concurrent drug use and the risk of perforated colonic diverticular disease: a population-based case-control study. Gut 60, 219–224 (2011).

    Article  PubMed  Google Scholar 

  76. Langman, M. J., Morgan, L. & Worrall, A. Use of anti-inflammatory drugs by patients admitted with small or large bowel perforations and haemorrhage. Br. Med. J. (Clin. Res. Ed.) 290, 347–349 (1985).

    Article  CAS  Google Scholar 

  77. Morris, C. R., Harvey, I. M., Stebbings, W. S. & Hart, A. R. Incidence of perforated diverticulitis and risk factors for death in a UK population. Br. J. Surg. 95, 876–881 (2008).

    Article  CAS  PubMed  Google Scholar 

  78. Morris, C. R. et al. Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease. Br. J. Surg. 90, 1267–1272 (2003).

    Article  CAS  PubMed  Google Scholar 

  79. Mpofu, S. et al. Steroids, non-steroidal anti-inflammatory drugs, and sigmoid diverticular abscess perforation in rheumatic conditions. Ann. Rheum. Dis. 63, 588–590 (2004).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  80. Piekarek, K. & Israelsson, L. A. Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers. Int. J. Colorectal Dis. 23, 1193–1197 (2008).

    Article  PubMed  Google Scholar 

  81. Strate, L. L., Liu, Y. L., Huang, E. S., Giovannucci, E. L. & Chan, A. T. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 140, 1427–1433 (2011).

    Article  CAS  PubMed  Google Scholar 

  82. Wilson, R. G., Smith, A. N. & Macintyre, I. M. Complications of diverticular disease and non-steroidal anti-inflammatory drugs: a prospective study. Br. J. Surg. 77, 1103–1104 (1990).

    Article  CAS  PubMed  Google Scholar 

  83. Wilson, R. G., Smith, A. N. & Macintyre, I. M. Non-steroidal anti-inflammatory drugs and complicated diverticular disease: a case-control study. Br. J. Surg. 78, 1148 (1991).

    Article  CAS  PubMed  Google Scholar 

  84. Davey, P. et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst. Rev. 4, CD003543 (2013).

    Google Scholar 

  85. Slimings, C. & Riley, T. V. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. J. Antimicrob. Chemother. 69, 881–891 (2014).

    Article  CAS  PubMed  Google Scholar 

  86. Chapman, J. et al. Complicated diverticulitis: is it time to rethink the rules? Ann. Surg. 242, 576–581 (2005).

    PubMed  PubMed Central  Google Scholar 

  87. Sheer, A. J. et al. Congestive heart failure and chronic obstructive pulmonary disease predict poor surgical outcomes in older adults undergoing elective diverticulitis surgery. Dis. Colon Rectum 54, 1430–1437 (2011).

    Article  PubMed  Google Scholar 

  88. Friend, K. & Mills, A. M. Is outpatient oral antibiotic therapy safe and effective for the treatment of acute uncomplicated diverticulitis? Ann. Emerg. Med. 57, 600–602 (2011).

    Article  PubMed  Google Scholar 

  89. Jaccard, C. et al. Prospective randomized comparison of imipenem-cilastatin and piperacillin-tazobactam in nosocomial pneumonia or peritonitis. Antimicrob. Agents Chemother. 42, 2966–2972 (1998).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  90. Malangoni, M. A., Song, J., Herrington, J., Choudhri, S. & Pertel, P. Randomized controlled trial of moxifloxacin compared with piperacillin-tazobactam and amoxicillin-clavulanate for the treatment of complicated intra-abdominal infections. Ann. Surg. 244, 204–211 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  91. Wacha, H., Warren, B., Bassaris, H. & Nikolaidis, P. Intra-Abdominal Infections Study Group. Comparison of sequential intravenous/oral ciprofloxacin plus metronidazole with intravenous ceftriaxone plus metronidazole for treatment of complicated intra-abdominal infections. Surg. Infect. (Larchmt) 7, 341–354 (2006).

    Article  Google Scholar 

  92. Brandt, D. et al. Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis. Colon Rectum 49, 1533–1538 (2006).

    Article  CAS  PubMed  Google Scholar 

  93. Kumar, R. R. et al. Factors affecting the successful management of intra-abdominal abscesses with antibiotics and the need for percutaneous drainage. Dis. Colon Rectum 49, 183–189 (2006).

    Article  PubMed  Google Scholar 

  94. Siewert, B. et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am. J. Roentgenol. 186, 680–686 (2006).

    Article  PubMed  Google Scholar 

  95. Durmishi, Y. et al. Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan. Surg. Endosc. 20, 1129–1133 (2006).

    Article  CAS  PubMed  Google Scholar 

  96. Ambrosetti, P., Grossholz, M., Becker, C., Terrier, F. & Morel, P. Computed tomography in acute left colonic diverticulitis. Br. J. Surg. 84, 532–534 (1997).

    Article  CAS  PubMed  Google Scholar 

  97. Hall, J. F. et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis. Colon Rectum 54, 283–288 (2011).

    Article  PubMed  Google Scholar 

  98. Farmakis, N., Tudor, R. G. & Keighley, M. R. The 5-year natural history of complicated diverticular disease. Br. J. Surg. 81, 733–735 (1994).

    Article  CAS  PubMed  Google Scholar 

  99. Lamb, M. N. & Kaiser, A. M. Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Dis. Colon Rectum 57, 1430–1440 (2014).

    Article  PubMed  Google Scholar 

  100. Reissfelder, C., Buhr, H. J. & Ritz, J. P. What is the optimal time of surgical intervention after an acute attack of sigmoid diverticulitis: early or late elective laparoscopic resection? Dis. Colon Rectum 49, 1842–1848 (2006).

    Article  PubMed  Google Scholar 

  101. Constantinides, V. A. et al. Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis. Colon Rectum 49, 966–981 (2006).

    Article  PubMed  Google Scholar 

  102. Oberkofler, C. E. et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann. Surg. 256, 819–826; discussion 826–827 (2012).

    Article  PubMed  Google Scholar 

  103. Constantinides, V. A., Tekkis, P. P., Senapati, A. & Association of Coloproctology of Great Britain and Ireland. Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br. J. Surg. 93, 1503–1513 (2006).

    Article  CAS  PubMed  Google Scholar 

  104. O'Sullivan, G. C., Murphy, D., O'Brien, M. G. & Ireland, A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am. J. Surg. 171, 432–434 (1996).

    Article  CAS  PubMed  Google Scholar 

  105. Afshar, S. & Kurer, M. A. Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis. Colorectal Dis. 14, 135–142 (2012).

    Article  CAS  PubMed  Google Scholar 

  106. Alamili, M., Gogenur, I. & Rosenberg, J. Acute complicated diverticulitis managed by laparoscopic lavage. Dis. Colon Rectum 52, 1345–1349 (2009).

    Article  PubMed  Google Scholar 

  107. Toorenvliet, B. R., Swank, H., Schoones, J. W., Hamming, J. F. & Bemelman, W. A. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis. 12, 862–867 (2010).

    Article  CAS  PubMed  Google Scholar 

  108. Swank, H. A. et al. The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg. 10, 29 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  109. Thornell, A. et al. Treatment of acute diverticulitis laparoscopic lavage vs. resection (DILALA): study protocol for a randomised controlled trial. Trials 12, 186 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  110. Mutch, M. G. Complicated diverticulitis: are there indications for laparoscopic lavage and drainage? Dis. Colon Rectum 53, 1465–1466 (2010).

    Article  PubMed  Google Scholar 

  111. Sauerland, S. et al. Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery. Surg. Endosc. 20, 14–29 (2006).

    Article  CAS  PubMed  Google Scholar 

  112. Simpson, J., Neal, K. R., Scholefield, J. H. & Spiller, R. C. Patterns of pain in diverticular disease and the influence of acute diverticulitis. Eur. J. Gastroenterol. Hepatol. 15, 1005–1010 (2003).

    Article  PubMed  Google Scholar 

  113. Jones, R., Latinovic, R., Charlton, J. & Gulliford, M. Physical and psychological co-morbidity in irritable bowel syndrome: a matched cohort study using the General Practice Research Database. Aliment. Pharmacol. Ther. 24, 879–886 (2006).

    Article  CAS  PubMed  Google Scholar 

  114. Jung, H. K. et al. Diarrhea-predominant irritable bowel syndrome is associated with diverticular disease: a population-based study. Am. J. Gastroenterol. 105, 652–661 (2010).

    Article  PubMed  Google Scholar 

  115. Simpson, J. et al. Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms. Neurogastroenterol. Motil. 21, 847–e58 (2009).

    Article  CAS  PubMed  Google Scholar 

  116. Clemens, C. H., Samsom, M., Roelofs, J., van Berge Henegouwen, G. P. & Smout, A. J. Colorectal visceral perception in diverticular disease. Gut 53, 717–722 (2004).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  117. Humes, D. J. et al. Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation. Neurogastroenterol. Motil. 24, 318–e163 (2012).

    Article  CAS  PubMed  Google Scholar 

  118. Kruis, W. et al. Randomised clinical trial: mesalazine (Salofalk granules) for uncomplicated diverticular disease of the colon—a placebo-controlled study. Aliment. Pharmacol. Ther. 37, 680–690 (2013).

    Article  CAS  PubMed  Google Scholar 

  119. Tursi, A. et al. Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease—a double-blind, randomised, placebo-controlled study. Aliment. Pharmacol. Ther. 38, 741–751 (2013).

    Article  CAS  PubMed  Google Scholar 

  120. Comparato, G. et al. Prevention of complications and symptomatic recurrences in diverticular disease with mesalazine: a 12-month follow-up. Dig. Dis. Sci. 52, 2934–2941 (2007).

    Article  CAS  PubMed  Google Scholar 

  121. Di Mario, F. et al. Efficacy of mesalazine in the treatment of symptomatic diverticular disease. Dig. Dis. Sci. 50, 581–586 (2005).

    Article  CAS  PubMed  Google Scholar 

  122. Tursi, A. et al. Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence. Eur. Rev. Med. Pharmacol. Sci. 17, 342–348 (2013).

    CAS  PubMed  Google Scholar 

  123. Latella, G. & Scarpignato, C. Rifaximin in the management of colonic diverticular disease. Expert Rev. Gastroenterol. Hepatol. 3, 585–598 (2009).

    Article  CAS  PubMed  Google Scholar 

  124. Raskin, J. B. et al. Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials. Gastroenterology 147, 793–802 (2014).

    Article  CAS  PubMed  Google Scholar 

  125. Chapman, J. R., Dozois, E. J., Wolff, B. G., Gullerud, R. E. & Larson, D. R. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann. Surg. 243, 876–830 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  126. Ritz, J. P. et al. Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 149, 606–613 (2011).

    Article  PubMed  Google Scholar 

  127. Benn, P. L., Wolff, B. G. & Ilstrup, D. M. Level of anastomosis and recurrent colonic diverticulitis. Am. J. Surg. 151, 269–271 (1986).

    Article  CAS  PubMed  Google Scholar 

  128. Breen, R. E., Corman, M. L., Robertson, W. G. & Prager, E. D. Are we really operating on diverticulitis? Dis. Colon Rectum 29, 174–176 (1986).

    Article  CAS  PubMed  Google Scholar 

  129. Egger, B., Peter, M. K. & Candinas, D. Persistent symptoms after elective sigmoid resection for diverticulitis. Dis. Colon Rectum 51, 1044–1048 (2008).

    Article  PubMed  Google Scholar 

  130. Leigh, J. E., Judd, E. S. & Waugh, J. M. Diverticulitis of the colon. Recurrence after apparently adequate segmental resection. Am. J. Surg. 103, 51–54 (1962).

    Article  CAS  PubMed  Google Scholar 

  131. Mueller, M. H. et al. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur. J. Gastroenterol. Hepatol. 17, 649–654 (2005).

    Article  CAS  PubMed  Google Scholar 

  132. Munson, K. D., Hensien, M. A., Jacob, L. N., Robinson, A. M. & Liston, W. A. Diverticulitis. A comprehensive follow-up. Dis. Colon Rectum 39, 318–322 (1996).

    Article  CAS  PubMed  Google Scholar 

  133. Parks, T. G. & Connell, A. M. The outcome in 455 patients admitted for treatment of diverticular disease of the colon. Br. J. Surg. 57, 775–778 (1970).

    Article  CAS  PubMed  Google Scholar 

  134. Peppas, G., Bliziotis, I. A., Oikonomaki, D. & Falagas, M. E. Outcomes after medical and surgical treatment of diverticulitis: a systematic review of the available evidence. J. Gastroenterol. Hepatol. 22, 1360–1368 (2007).

    Article  PubMed  Google Scholar 

  135. Binda, G. A. et al. Multicentre observational study of the natural history of left-sided acute diverticulitis. Br. J. Surg. 99, 276–285 (2012).

    Article  CAS  PubMed  Google Scholar 

  136. Broderick-Villa, G., Burchette, R. J., Collins, J. C., Abbas, M. A. & Haigh, P. I. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch. Surg. 140, 576–581 (2005).

    Article  PubMed  Google Scholar 

  137. Garcea, G., Majid, I., Sutton, C. D., Pattenden, C. J. & Thomas, W. M. Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases. Colorectal Dis. 8, 347–352 (2006).

    Article  CAS  PubMed  Google Scholar 

  138. Hjern, F., Goldberg, S. M., Johansson, C., Parker, S. C. & Mellgren, A. Management of diverticular fistulae to the female genital tract. Colorectal Dis. 9, 438–442 (2007).

    Article  CAS  PubMed  Google Scholar 

  139. Menenakos, E. et al. Laparoscopic surgery for fistulas that complicate diverticular disease. Langenbecks Arch. Surg. 388, 189–193 (2003).

    Article  PubMed  Google Scholar 

  140. Klarenbeek, B. R. et al. Indications for elective sigmoid resection in diverticular disease. Ann. Surg. 251, 670–674 (2010).

    Article  PubMed  Google Scholar 

  141. Lemberg, B. & Vargo, J. J. Balloon dilation of colonic strictures. Am. J. Gastroenterol. 102, 2123–2125 (2007).

    Article  PubMed  Google Scholar 

  142. Small, A. J., Young-Fadok, T. M. & Baron, T. H. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg. Endosc. 22, 454–462 (2008).

    Article  CAS  PubMed  Google Scholar 

  143. Carson, J. L. et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann. Intern. Med. 157, 49–58 (2012).

    Article  PubMed  Google Scholar 

  144. Davila, R. E. et al. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest. Endosc. 62, 656–660 (2005).

    Article  PubMed  Google Scholar 

  145. Jensen, D. M., Machicado, G. A., Jutabha, R. & Kovacs, T. O. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N. Engl. J. Med. 342, 78–82 (2000).

    Article  CAS  PubMed  Google Scholar 

  146. Kaltenbach, T. et al. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin. Gastroenterol. Hepatol. 10, 131–137 (2012).

    Article  PubMed  Google Scholar 

  147. Green, B. T. et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am. J. Gastroenterol. 100, 2395–2402 (2005).

    Article  PubMed  Google Scholar 

  148. Poncet, G., Heluwaert, F., Voirin, D., Bonaz, B. & Faucheron, J. L. Natural history of acute colonic diverticular bleeding: a prospective study in 133 consecutive patients. Aliment. Pharmacol. Ther. 32, 466–471 (2010).

    Article  CAS  PubMed  Google Scholar 

  149. McGuire, H. H. Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann. Surg. 220, 653–656 (1994).

    Article  PubMed  PubMed Central  Google Scholar 

  150. Plummer, J. M., Gibson, T. N., Mitchell, D. I., Herbert, J. & Henry, T. Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over-utilised or under-estimated? Int. J. Clin. Pract. 63, 865–868 (2009).

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Klinikum Döbeln, Academic Teaching Hospital of Leipzig University, Sörmitzer Strasse 10, Döbeln, 04720, Germany

    Roland H. Pfützer

  2. Department of Internal Medicine, Evangelisches Krankenhaus Kalk, University of Cologne, Buchforststrasse 2, Cologne, 51103, Germany

    Wolfgang Kruis

Authors
  1. Roland H. Pfützer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wolfgang Kruis
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Both authors contributed equally to all aspects of this manuscript.

Corresponding author

Correspondence to Wolfgang Kruis.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pfützer, R., Kruis, W. Management of diverticular disease. Nat Rev Gastroenterol Hepatol 12, 629–638 (2015). https://doi.org/10.1038/nrgastro.2015.115

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2015.115

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing