Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography

Abstract

The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.

International Consensus on Diverticulosis and Diverticular Disease. Statements from the 3rd International Symposium on Diverticular Disease

“…The first three statements confirm the important predicting value of C-reactive protein (CRP) in define the presence and the severity of acute diverticulitis [47,48], and that fecal calprotectin (FC) may be useful in differentiating between SUDD and IBS [35]. The forth statement confirms that the contrast-enhanced computer tomography is the gold standard to pose the diagnosis of AD and its complications [49]. The statements 3.5-3.8 underscore the increasing role of the intestinal ultrasound (IUS) in diagnosis both SUDD and AD, underscoring also the limit of this technique, namely that it operator-sensitive [50][51][52].…”

What’s New in Diagnosing Diverticular Disease

“…CT is a significant predictor of surgery during the first attack, the presence of extraintestinal gas ≥5 mm being correlated with unfavourable outcome of nonsurgical treatment [34]. Length of involved colon >5 cm and retroperitoneal abscess were associated with diverticulitis recurrence: distant intraperitoneal air is the most important factor predicting surgical treatment [35,36]. CT colonography (CTC) recently has been proposed as a diagnostic test in patients recovering from an episode of AD; CTC should be performed at least 2 or 3 months after the acute episode of diverticulitis.…”

Antibiotics in Uncomplicated Acute Diverticulitis: To Give or Not to Give?

“…Ambrosetti [22] proposed a revised CT classification in 2013 where he defined stage 1 as uncomplicated acute diverticulitis, stage 2 as complicated acute diverticulitis, and stage 3 as complicated chronic diverticulitis with either fistula or stenosis. He further concluded that imaging not only confirms the diagnosis but appropriately stages the severity of disease in order to best guide therapeutic interventions and assess the risk of recurrence [22].…”