The Gastroenterologist’s View

Abstract

The traditional view that recurrent episodes of diverticulitis lead to progressively complicated disease resulting in a disadvantageous course, more difficult, complicated operations and lethal outcomes did not stand the test of evidence. Only a minority of patients with acute diverticulitis will ever require surgery, and if so, this occurs during or early after the first episode. Complications and recurrence of disease after surgery are enumerable. Strong indicators favoring sigmoid colectomy are major abscess, free air, and fistula, i.e. perforating disease. This occurs predominantly at the initial presentation, frequently in younger or immunosuppressed patients. Important differential diagnoses must be considered both for initial diagnosis of diverticulitis and for recurrent episodes. Conservative management of recurrent diverticulitis is safe and best guided by gastroenterological expertise. Sophisticated ultrasound experience as a part of this competence allows detailed evaluation of the local status and the best evidence in the literature for diagnosing diverticulitis is on US. In practice, however, the question of perforating diverticulitis is adequately answered by subtle CT scan. Medical therapy is usually the treatment of choice for recurrent diverticulitis. Avoidance of drugs bearing the hazard of perforation (e.g. NSAIDs) is emphasized, and smoking is strongly discouraged. A mathematical model based on published data shows that patients with recurrent diverticulitis overall (only) profit from surgery if they are hit by four episodes during the course of disease. This is where theory and reality (should) meet.

Recurrences and Ongoing Complaints of Diverticulitis; Results of a Survey among Gastroenterologists and Surgeons

“…Opted theories are other conditions such as an irritable bowel syndrome, adhesions, stenosis, incomplete sigmoid resection or changed sympathetic innervation [31]. In accordance with these assumptions, the reported re-operation rates are low and range between 0 and 3% [3]. In our study, a minority of responders feared recurrences and complaints after resection.…”

“…This number is considerable and varies in literature from 3 to 60% [1,2,3]. The etiology of this phenomenon after surgery has not been clarified.…”

“…Therefore, they concluded that the risk of sigmoidectomy is low and absolutely no risk of diverticular disease-related death [1]. Others, however, state that the overall morbidity can be as high as 50% with a related mortality of 1-5% [2,3]. …”

“…Our study indicates that there is still much discussion about the optimal treatment of these patients and that there is need for a uniform scientific-based advice. Reviewing the literature on this topic reveals that there is lack of consensus on an international level as well [2,3,10,11,15]. The situation in the Netherlands is therefore a typical sample of the current situation.…”

“…This is surprising considering the extent of this health care problem, since 33% of patients continued to experience complaints after an episode of uncomplicated diverticulitis. Another 33% experienced recurrent episodes of diverticulitis [1,2,3,4,5,6,7,8,9]. …”