Long-Term Evolution of Acute Colonic Diverticulitis After Successful Medical Treatment Long-Term Follow-up After an Initial Episode of Diverticulitis: What Are the Predictors of Recurrence? Danish national guidelines for treatment of diverticular disease. Diverticula and Diverticulitis: Time for a Reappraisal. One year intermittent rifaximin plus fibre supplementation vs. fibre supplementation alone to prevent diverticulitis recurrence: a proof-of-concept study. Prediction and management of recurrent right colon diverticulitis Conservative treatment of acute colonic diverticulitis: Are antibiotics always mandatory? Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence. Colonic diverticulitis: impact of imaging on surgical management – a prospective study of 542 patients
Background The evidence is sparse concerning the natural history of acute diverticulitis after successful conservative management . This observational study aim ed to evaluate the rate , severity , and need of surgery for recurrence after a first episode of acute diverticulitis successfully managed conservatively . Methods All patients admitted for acute diverticulitis between 1994 and 2011 were considered for inclusion in the study . Severity of the first episode , demographic data , comorbidities , management , recurrence , and elective or emergency surgery during the follow-up period were prospect ively recorded . Results The study included 560 patients . The mean follow-up period was of 67.2 ± 44.4 months . Severe diverticulitis was diagnosed in 22.3 % of the cases . Recurrence was observed in 14.8 % of the patients , and the rate of severe recurrence was 3.4 % . Most of the recurrences occurred during the first year of follow-up evaluation . Chronic corticoid therapy ( P = 0.043 ) and the presence of more than one abscess ( P < 0.001 ) were significantly related to recurrence . In the event of a mild recurrence , the first episode was either mild or severe ( P = 0.172 ) . In the case of severe recurrence , most patients presented with a previous severe diverticulitis ( P < 0.001 ) . During the follow-up period , 6.8 % of the patients needed an elective operation , and 1.4 % of them underwent emergency surgery . Conclusion The rate of severe recurrence after successful nonoperative management of acute diverticulitis was low , and emergency surgery was rare . Prophylactic surgery , even in cases of recovered severe diverticulitis , should be considered on a case-by-case basis . Strict follow-up assessment during the first year is advised PURPOSE : The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively . METHODS : We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008 . Patients were identified with International Classification of Diseases , 9th Revision/Current Procedural Terminology codes . Patients were excluded if they had subsequent colectomy based on the first attack ( n = 81 ) , or if the attack they had between 2002 and 2008 was not their first attack ( n = 201 ) . We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists . These radiologists review ed the available published literature for CT imaging characteristics thought to predict diverticulitis severity . CT variables ( n = 20 ) were determined by prospect i ve reevaluation of scans by blinded study radiologists . Clinical variables ( n = 43 ) were coded based on a retrospective chart review . Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates . Multivariate analysis was performed using Cox proportional hazards modeling . Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm . RESULTS : The study population included 672 patients ; mean age , 61 ± 15 years ; mean follow-up , 42.8 ± 24 months . The index presentation of diverticulitis was most commonly located in the sigmoid colon ( 72 % ) , followed by descending colon ( 33 % ) , right colon ( 5 % ) , and transverse colon ( 3 % ) . Overall recurrence at 5 years was 36 % by ( 95 % CI 31.4%–40.6 % ) Kaplan-Meier estimate . Complicated recurrence ( fistula , abscess , free perforation ) occurred in 3.9 % ( 95 % CI 2.2%–5.6 % ) of patients at 5 years by Kaplan-Meier estimate . Family history of diverticulitis ( HR 2.2 , 95 % CI 1.4–3.2 ) , length of involved colon > 5 cm ( HR 1.7 , 95 % CI 1.3–2.3 ) , and retroperitoneal abscess ( HR 4.5 , 95 % CI 1.1–18.4 ) were associated with diverticulitis recurrence . Right colon disease ( HR 0.27 , 95 % CI 0.09–0.86 ) was associated with freedom from recurrence . CONCLUSION : Although diverticulitis recurrence is common following an initial attack that has been managed medically , complicated recurrence is uncommon . Patients who present with a family history of diverticulitis , long segment of involved colon , and /or retroperitoneal abscess are at higher risk for recurrent disease . Patients who present with right-sided diverticulitis are at low risk for recurrent disease . These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy In order to elaborate evidence -based , national Danish guidelines for the treatment of diverticular disease the literature was review ed concerning the epidemiology , staging , diagnosis and treatment of diverticular disease in all its aspects . The presence of colonic diverticula , which is considered to be a mucosal herniation through the intestinal muscle wall , is inversely correlated to the intake of dietary fibre . Other factors in the genesis of diverticular disease may be physical inactivity , obesity , and use of NSAIDs or acetaminophen . Diverticulosis is most common in Western countries with a prevalence of 5 % in the population aged 30 - 39 years and 60 % in the part of the population > 80 years . The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5 - 4/100,000 . Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis . Complicated diverticulitis is staged by the Hinchey classification 1 - 4 ( 1 : mesocolic/pericolic abscess , 2 : pelvic abscess , 3 : purulent peritonitis , 4 : faecal peritonitis ) . Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and /or CRP ; but the clinical diagnosis is not sufficiently precise . Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey . The distinction between Hinchey 3 and 4 is done by laparoscopy or , when not possible , by laparotomy . Uncomplicated diverticulitis is treated by conservative means . There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis , but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection . Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics . When the abscess is < 3 cm in diameter , drainage may be unnecessary , and only antibiotics should be instituted . The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies : The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or , alternatively , resection of the sigmoid with primary anastomosis . Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease . Evidence so far for the lavage regime is promising , comparing favourably with resection strategies , but lacking in solid proof by r and omized , controlled investigations . In recent years , morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities . Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed . Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures , since prophylactic resection of the sigmoid , evaluated from present evidence , confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society . Any recommendation for routine resection following multiple cases of diverticulitis should await results of r and omized studies . Laparoscopic resection is preferred in case of need for elective surgery . When malignancy is ruled out preoperatively , a sigmoid resection with preservation of the inferior mesenteric artery , oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended . Fistulae to bladder or vagina , or stenosis of the colon may be dealt with according to symptoms and comorbidity . Resection of the diseased segment of colon is preferred when possible and safe ; alternatively , a diverting stoma can be the best solution Colonic diverticula are very common and may be associated with symptoms or complicated by diverticulitis and its associated problems . Many of the traditional concepts relating to the pathophysiology , prevention , and management of these entities have been question ed recently based on findings from high- quality prospect i ve studies . Although dietary fiber may protect against symptoms and complications , its impact on the formation of diverticula may be limited . It is now evident that the risk for an episode of diverticulitis in an individual with diverticula is lower than previously thought . Furthermore , the necessity for antibiotic use in uncomplicated diverticulitis has been question ed and serious doubt cast upon the belief that surgery should be performed when a second attack occurs . Although data are far from conclusive , there is some evidence to suggest that diverticulosis may be associated with chronic abdominal symptoms , with or without underlying chronic inflammatory changes in the involved segment of the colon . In addition , colonoscopy is not routinely required after an attack of acute uncomplicated diverticulitis , as the risk of cancer in this population is not much higher than in the general population BACKGROUND Evidence supporting appropriate medical therapy to prevent recurrence of colonic diverticulitis is limited . Our goal was to evaluate the potential of rifaximin given periodically in addition to fibre for the prophylaxis of recurrences . METHODS We conducted a multicentre , r and omized , open controlled study in patients with a recent episode of colonic diverticulitis , currently in remission . Patients received 3.5 g of high-fibre supplementation b.d . with or without one week per month of the non-absorbable antibiotic rifaximin ( 400 mg b.d . ) for 12months . Primary endpoint was recurrence of diverticulitis , encompassing acute symptomatic flare with or without complications , analyzed by multivariable logistic regression analysis and by Cox proportional hazard method . RESULTS After r and omizing 165 patients , the study was interrupted since the recruitment rate was largely below the minimum anticipated , and the trial was switched from evidence -gathering to proof-of-concept . Recurrences occurred in 10.4 % of patients given rifaximin plus fibres vs. 19.3 % of patients receiving fibres alone . The logistic analysis adjusted for sex , age , illness duration , time from last episode , disease localization and centre recruitment rate , yielded a significant treatment effect ( odds ratio 3.20 ; 95 % confidence interval : 1.16 - 8.82 ; P=0.025 ) . Patients with diverticulitis diagnosed since ≥1 year receiving rifaximin  also had a lower incidence of recurrences ( 10 % ; 95 % confidence interval : 2 - 47 % vs. 67 % ; 95 % confidence interval : 37 - 100 % ) . Both treatments were safe . CONCLUSIONS This study represents a proof-of concept of the efficacy of cyclic rifaximin treatment , added to fibre supplements , to reduce the risk of recurrences of diverticulitis in patients in remission Purpose While the incidence of right colonic diverticulitis ( RCD ) is rare in Western countries , the right colon is the most common site of diverticulitis in Asian countries . However , its recurrent pattern and management were rarely studied . This study was design ed to eluci date the pattern of recurrence in RCD . Methods Of the 154 patients admitted as right colonic diverticulitis between February 2004 and March 2012 , 104 patients were enrolled , prospect ively . The recurrence rate , size , multiplicity , location , diagnostic criteria score , and predisposing factors were evaluated based on Hinchey ’s classification of diverticulitis . Results There were 104 patients with right colonic diverticulitis in this study , and 20 patients ( 19.2 % ) recurred after medical treatment . When the diverticula were not located in the right colon , the recurrence rate was significantly higher than the diverticula located only in the right colon ( p = 0.004 ) . The recurrence rate of diverticulitis for a single diverticulum was significantly lower than that for multiple diverticula ( p = 0.02 ) . Of the 20 patients with recurrence , 1 ( 5 % ) patient underwent laparoscopic diverticulectomy due to a misdiagnosis of diverticulitis as appendicitis . The remaining 19 patients ( 95 % ) received nonoperative management and recovered without any sequelae . Conclusions The recurrence rate was 19.2 % , and the predisposing factors were the location of diverticula and the multiplicity of primary diverticula . The re-recurrence rate of recurred patients was 26.3 % . The recurred lesions were controlled simply by nonoperative management . Elective surgery was also a treatment option Objective . Most patients admitted for acute colonic diverticulitis ( AD ) are managed conservatively and receive antibiotics , although it is uncertain whether all patients with AD benefit from this treatment . The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD . Material and methods . A retrospective audit of 311 patients ( 64 % F , mean age 60 years ) hospitalized for AD was carried out . All patients were initially treated conservatively with observation and restriction of oral intake . Patients receiving antibiotics ( n=118 ) were compared with patients treated with observation and restriction of oral intake only ( n=193 ) . Mean follow-up time ( FU ) was 30 months . Results . Inflammation in patients treated with antibiotics was more pronounced ( laboratory parameters ( C-reactive protein , white blood cell count ) were higher ( p<0.01 ) , fever was more common ( p<0.01 ) and CT grading of inflammation was classified as severe in a higher proportion ( p<0.01 ) ) compared with patients treated without antibiotics . When initially treated with antibiotics , 3 patients ( 3 % ) failed to respond to treatment and had to undergo surgery . There were 7 ( 4 % ) failures in patients initially treated without antibiotics , and antibiotics were then added . During FU , 29 % of patients treated with antibiotics had further events ( recurrent AD and /or subsequent surgery ) compared with 28 % ( NS ) among those treated without antibiotics . In a multivariate analysis , the risk of a further event was not influenced by antibiotic treatment ( OR 1.03 , CI 95 % 0.61–1.74 ) . Conclusions . Our results indicate that antibiotics are not m and atory in mild AD . Treatment without antibiotics appears to be safe and seems not to change the rate of further events . These results warrant further r and omized prospect i ve studies BACKGROUND Colonic diverticulitis shows a high recurrence rate . AIMS To assess the efficacy of three different therapeutic strategies in preventing diverticulitis recurrence . MATERIAL S AND METHODS One hundred thirty patients suffering from Acute Uncomplicated Diverticulitis ( AUD ) ( 81 males , 49 females , mean age 64.71 years , range 40 - 85 ) were prospect ively assessed . After obtaining remission , considered present when both endoscopic and histological damage were absent , the patients were treated with mesalazine 1.6 g/day ( 59 patients , group A ) , or rifaximin 800 mg/day for 7 days every month ( 52 patients , group B ) . Clinical , endoscopic and histological follow-up was performed after 6 , 12 and thereafter every 12 months after diagnosis of AUD . RESULTS Seven patients were excluded from final evaluation because they were lost to follow-up . Fifty-five group A patients and 49 group B patients patients were available for the final assessment at the end of a 24-month follow-up . Sustained remission was significantly higher in group A with respect to group B. CONCLUSIONS Patients taking mesalazine have lower risk of diverticulitis recurrence than patients taking rifaximin because of the lower prevalence of persisting endoscopic and histological inflammation Abstract . The aim of this study was to compare the performance of the CT and the water-soluble contrast enema ( CE ) in the diagnosis and the severity of acute left-colonic diverticulitis , and to recognize the impact of CT during the acute phase and after a first acute episode successfully treated medically . From 1986 to 1997 , all patients admitted in our emergency center with clinical ly suspected left-colonic diverticulitis had a CE and a CT  within 72 h of their admission , unless clinical findings required immediate laparotomy . They were prospect ively included in the study if one or both radiological exams showed signs of acute diverticulitis and /or diverticulitis was surgically removed and histologically proven . Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall ( 5 mm or more ) and inflammation of pericolic fat and CE showed segmental lumen narrowing and tethered mucosa ; it was considered severe when abscess and /or extraluminal air and /or contrast were observed on CT and when one or both of the latter signs were seen on CE . Five hundred forty-two patients entered the study ; 465 patients ( 86 % ) had a CT exam , 439 ( 81 % ) had a CE , and 420 ( 77 % ) had both exams . The performance of CT is significantly superior to CE in terms of sensitivity ( 98 vs 92 % , p<0.01 ) , and in the evaluation of the severity of the inflammation ( 26 vs 9 % , p<0.02 ) . Moreover , of 69 patients who had an associated abscess seen on CT , only 20 ( 29 % ) had indirect signs of this complication on CE . During the acute phase the chances of medical treatment failure are statistically greater when diverticulitis is considered severe on CT than when it is considered moderate ( 26 % for the severe diverticulitis vs 4 % for the moderate ones , p<0.0001 ) . After successful medical treatment of the acute episode , patients with severe diverticulitis on the CT had statistically greater incidence of secondary bad outcome than patients with moderate diverticulitis ( 36 vs 17 % , p<0.0001 ) . Computed tomography should be preferred to CE as the initial radiological exam of diverticulitis because of its statistically significant superiority in sensitivity and for its statistically much higher performance in the detection of severe infection , especially when an abscess is associated with the disease . The severity of diverticulitis on CT is statistically predictive of the risk of medical treatment failure during the acute phase and of the chances of bad secondary outcome after a successful medical treatment of the first episode
Primary diverticulitis with abscess formation and young age increased the risk of recurrence .
Readmission risk was higher within the first year after remission .
Conclusions The best treatment strategy for recurrent diverticulitis is undetermined .
Purpose Several factors may influence the risk of recurrence after an episode of acute colonic diverticulitis .
Until now , a comprehensive systematic overview and evaluation of relevant risk factors have not been presented .
This review aim ed at assembling and evaluating current evidence on risk factors for recurrence after conservatively treated acute colonic diverticulitis .