What is considered complicated diverticulitis (diverticular disease)?

From the Guidelines

Complicated diverticulitis is defined as diverticular inflammation that has progressed beyond simple inflammation to include serious complications, such as perforation of the colon with abscess formation, peritonitis, fistula development, bowel obstruction, or bleeding, as stated in the 2022 guidelines from the American College of Physicians 1. The diagnosis of complicated diverticulitis is typically made using abdominal CT imaging, which has high sensitivity and specificity for detecting complications such as abscesses, perforation, and bowel obstruction 1. Some key points to consider in the diagnosis and management of complicated diverticulitis include:

• The use of abdominal CT imaging to diagnose and stage the disease 1
• The importance of early recognition and treatment of complications such as abscesses, perforation, and bowel obstruction 1
• The role of antibiotic therapy in the management of complicated diverticulitis, including the use of broad-spectrum antibiotics such as piperacillin-tazobactam, ceftriaxone plus metronidazole, or meropenem 1
• The potential need for surgical intervention, including percutaneous drainage of abscesses, Hartmann's procedure, or primary resection with anastomosis, depending on the severity of the disease and the presence of complications 1 According to the most recent guidelines, the management of complicated acute left colon diverticulitis stage 1 or 2a involves adequate source control, which consists of antibiotic therapy alone in patients with small diverticular abscesses (< 4–5 cm) and percutaneous drainage combined with antibiotic therapy for 3–5 days in larger diverticular abscesses 1. It is essential to consider the patient's overall clinical condition, including the presence of comorbidities, signs of sepsis, and the severity of the disease, when making decisions about diagnosis and management. In terms of specific treatments, antibiotic therapy should be tailored to the individual patient's needs, taking into account the severity of the disease, the presence of complications, and the patient's underlying health status 1. Additionally, surgical intervention should be considered in patients with severe complications, such as perforation, bowel obstruction, or abscesses that are not responsive to antibiotic therapy or percutaneous drainage 1. Overall, the management of complicated diverticulitis requires a multidisciplinary approach, involving close collaboration between clinicians, radiologists, and surgeons to ensure optimal patient outcomes.

From the Research

Definition of Complicated Diverticulitis

Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis 2. It encompasses a variety of clinical scenarios, including acute presentations such as abscesses and free perforations with peritonitis, to more chronic sequelae such as fistulas and strictures 3.

Classification and Treatment

The classification of complicated diverticulitis is based on clinical and computed tomography (CT) findings, and treatment is tailored accordingly 2. The management of complicated diverticulitis can be conservative or surgical, depending on the severity of the condition.

• Diverticulitis with a localized abscess is generally resolved with conservative treatment, but if the abscess is larger or conservative treatment fails, percutaneous drainage or surgery should be considered 2.
• Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis 2, 4.
• In cases of perforated diverticulitis with generalized peritonitis, surgery is indicated in case of diffuse peritonitis or failure of conservative management, and the decision to operate is not based on the presence of extraluminal air 4.

Surgical Options

Surgical options for complicated diverticulitis include:

• Resection and anastomosis
• Hartmann's procedure
• Laparoscopic lavage 4
• Non-restorative resection and/or damage control surgery, depending on the severity of hemodynamic instability 4

Medical Management

Multidisciplinary medical management is essential in the treatment of complicated diverticulitis, with the main aims of controlling infection, relieving postoperative pain, and preventing and/or treating postoperative ileus 4. Antibiotic regimens, such as ceftriaxone and metronidazole, have been shown to be non-inferior to piperacillin/tazobactam in the treatment of complicated diverticulitis 5.