THE MEDICAL BULLETIN OF
SISLI ETFAL HOSPITAL
DOI: 10.14744/SEMB.2022.27095
Med Bull Sisli Etfal Hosp 2022;56(4):503–508
Original Research
Management of Acute Uncomplicated Diverticulitis:
Inpatient or Outpatient
Emre Teke,1
Anıl Ergin,1
Huseyin Ciyiltepe,2 Nuriye Esen Bulut,1
Bora Karip,3 Kemal Memisoglu1
Yasin Gunes,1
Mehmet Mahir Fersahoglu,1
1
Department of General Surgery, University of Health Sciences Türkiye, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Türkiye
Department of Gastroenterology Surgery, Antalya Training and Research Hospital, Antalya, Türkiye
3
Department of General Surgery, Istanbul Oncology Hospital, Istanbul, Türkiye
2
Abstract
Objectives: Diverticular disease is a highly frequent condition and affects 50% of the population in the 9th decade in Western
society. Acute diverticulitis is the most prevalent complication. The patients who are clinically stable and tolerate fluid should be
hospitalized if fluid intake tolerance worsens, fever occurs, or pain increases. Bowel rest, intravenous fluid therapy, and empiric
antibiotic therapy are the traditional treatments for patients admitted to the hospital. This retrospective study aimed to determine
the parameters that will affect the outpatient or inpatient treatment of patients diagnosed with uncomplicated acute diverticulitis.
Methods: Patients who presented to the emergency department with abdominal pain between January 2018 and December
2020 and were diagnosed with uncomplicated diverticulitis (modified Hinchey 1a) on computed tomography (CT) taken after
intravenous contrast material shoot up were included in the study. Patient records were recorded retrospectively in the Excel file.
After being seen in the emergency department, a comparison was performed between the inpatient group (Group 1) and the
outpatient follow-up group (Group 2).
Results: The study comprised 172 patients with acute uncomplicated diverticulitis (modified Hinchey 1a). While 110 (64.0%) patients were followed up and treated as inpatients (Group 1), 62 (36.0%) patients were followed up as outpatients (Group 2). There
was no statistically significant difference between the two groups in terms of patients readmitted to the hospital in the first 30 days
after discharge (both for outpatient follow-up in the emergency department and after treatment in the inpatient group).
Conclusion: In this retrospective study, in which we evaluated the hospitalization criteria in uncomplicated Modified Hinchey 1a
patients, it was found that patients can be safely treated as an outpatient if they have poor physical examination findings. Although
there was no difference between the two groups in terms of hospital readmission after discharge and it was thought that follow-up
of patients with Modified Hinchey 1a diverticulitis with outpatient oral antibiotic therapy might be reliable, prospective studies
with larger numbers of patients are needed.
Keywords: Diverticular disease, Diverticulitis, Hinchey 1a, Outpatient management, Uncomplicated diverticulitis
Please cite this article as ”Teke E, Ciyiltepe H, Bulut NE, Gunes Y, Fersahoglu MM, Ergin A, et al. Management of Acute Uncomplicated
Diverticulitis: Inpatient or Outpatient. Med Bull Sisli Etfal Hosp 2022;56(4):503–508”.
C
olonic diverticulum is an outwardly protruding saccular
protrusion of the colon wall. Diverticulitis is defined as
the presence of peridiverticular inflammation and infection.
Diverticulitis is a common disease that brings a huge financial burden on health-care systems worldwide. The annual cost in the United States is estimated to be $2.1 billion.[2]
[1]
Address for correspondence: Emre Teke, MD. Sağlık Bilimleri Üniversitesi Fatih Sultan Mehmet Eğitim ve Araştırma Hastanesi,
Genel Cerrahi Kliniği, İstanbul, Türkiye
Phone: +90 554 627 93 09 E-mail: dr.emreteke@gmail.com
Submitted Date: February 21, 2022 Revised Date: April 17, 2022 Accepted Date: May 15, 2022 Available Online Date: December 19, 2022
Copyright 2022 by The Medical Bulletin of Sisli Etfal Hospital - Available online at www.sislietfaltip.org
OPEN ACCESS This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
©
504
The Medical Bulletin of Sisli Etfal Hospital
The incidence of diverticular disease is 33–66% and is increasing in Western and Asian countries.[3,4] However, 10–
25% of these patients develop acute attacks of diverticulitis.[5] The majority of patients (80%) have uncomplicated
diverticulitis, which is a self-limiting condition.[6,7] The prevalence of diverticular disease increases with age. While it
is <10% in people under the age of 40, it increases up to
50–66% in patients over the age of 80, and the most common location is the sigmoid colon.[8,9]
The clinical symptoms of acute diverticulitis vary widely,
ranging from mild phlegmonous changes to free perforation. The diagnosis is suspected when the triad of the lower
abdominal pain, fever, and leukocytosis with localized or
generalized peritonitis is present. There are many classifications for colonic diverticulitis such as Hansen-Stock
classification,[10] Neff classification,[11] Ambrosetti classification,[12] and Hinchey classification.[13] However, the Hinchey
classification is the most commonly used diverticulitis classification. The Hinchey classification was first published in
1978 to traditionally distinguish the four acute diverticulitis
stages (Table 1). However, with the widespread use of computerized tomography (CT), which is preferred as the most
sensitive tool in diagnosis, the modified Hinchey classification, which includes radiologic findings, is more commonly
used (Table 1).[14-16]
Hospitalization, bowel rest, intravenous fluid and electrolyte therapy, and intravenous broad-spectrum antibiotics
to cover anaerobes and Gram-negative organisms are conventional treatments for patients with uncomplicated diverticulitis. Recent studies, however, suggest that patients
with uncomplicated diverticulitis who are clinically stable
and can tolerate fluids should receive outpatient treatment
with oral antibiotics.[17]
Another study examined the pathophysiology of diverticulitis and emphasized that diverticulitis is an inflammatory process caused by microperforation.[18-21] Before these
studies questioning the utility of antibiotics in uncomplicated diverticulitis, antibiotic therapy was one of the main
treatment components used to treat all stages of this disease. However, it was reported that the use of antibiotics in
treating patients with early-stage diverticulitis (Hinchey 1
or 1a) had no effect on patient survival and complications.
[22]
However, it has a place in the treatment of high-risk patients with significant comorbidities, symptoms of systemic infection, or immunosuppression.[18,19]
This study aimed to determine the demographic characteristics and clinical parameters that would influence the outpatient or inpatient management of patients diagnosed
with uncomplicated acute diverticulitis in the emergency
department.
Methods
For our study, research permission was obtained from the
Local Ethics Committee on November 18, 2021, numbered
E-17073117–50.06.99. This study was conducted in accordance with the Declaration of Helsinki.
The retrospective study included patients who presented
to the emergency department with abdominal pain between January 2018 and December 2020 and were diagnosed with uncomplicated diverticulitis (modified Hinchey
1a) on ab- dominal examination CT with IV contrast (Fig. 1).
Patients diagnosed with complicated diverticulitis, those
whose data could not be obtained at screening, those under 18, and those who refused treatment were excluded
from the study.
Radiologists with at least 5 years of experience evaluated
the CTs. The modified Hinchey classification (Wasvary[16])
was used for the Hinchey classification in CT.
Of the patients evaluated in the emergency department,
those whose pain persisted after IV hydration and analgesics or rebound findings on abdominal examination were
hospitalized. Patients were divided into two groups: Inpatient Group 1 and outpatient Group 2. Treatment with oral
ciprofloxacin (1500 mg/day, 2 doses) and oral metronidazole (1500 mg/day, 3 doses) was given to outpatients for
7 days. At the 48th h after being discharged from the emer-
Table 1. Hinchey classification
Hinchey classification (13)
I
II
Pericolic abscess or phlegmon
Pelvic, intraabdominal or
retroperitoneal abscess
III Generalized purulent peritonitis
IV Generalized fecal peritonitis
Modified Hinchey classification by wasvary (16)
0
Ia
Ib
Mild clinical peritonitis
Confined pericolic inflammation or phlegmon
Pericolic or mesocolic abscess
II
Pelvic, distant intraabdominal, or retroperitoneal
abscess
Generalized purulent peritonitis
Generalized fecal peritonitis
III
IV
Teke et al., Management of Acute Uncomplicated Diverticulitis / doi: 10.14744/SEMB.2022.27095
505
methods (mean, standard deviation, median, and frequency). To compare qualitative data, the Pearson Chi-square test
was used. The level of significance was assessed at p<0.05.
Results
Figure 1. Modified Hinchey 1a diverticulitis in axial tomographic
section.
gency department, outpatients were called for outpatient
control. Here, a physical examination was performed, and
leukocyte CRP levels were noted.
Inpatients were treated with IV fluid administration, IV ciprofloxacin (1500 mg/day), and IV metronidazole (1500 mg/
day). Oral intake continued as regimen 1. Patients whose
pain complaints regressed and whose leukocyte and CRP
levels regressed were discharged with oral ciprofloxacin
and oral metronidazole, completing antibiotic treatment
for 7 days. On the 7th day after discharge, they were invited
to the outpatient clinic. Physical examination findings and
leukocyte and CRP levels were recorded here. If no progression or clinical worsening of laboratory values was observed in the controls, no additional imaging examination
was performed. None of the patients underwent emergency colonoscopy, but elective colonoscopy was scheduled
for all patients at week 6 after the diverticulitis attack.
Patient records were retrospectively reviewed, and age,
gender, presence of additional medical conditions, physical examination findings at the time of admission to the
emergency department (sensitivity, guarding, and rebound), pulse rate, presence of >38° fever, leukocyte and
neutrophil percentage, CRP level, location of diverticulitis
on CT, time of onset of symptoms, whether the patient was
hospitalized, length of hospital stay and readmission in the
first 30 days after discharge were recorded in the Excel file.
Statistical Analysis
To evaluate the findings obtained in the study, IBM SPSS Statistics 22 (IBM SPSS, Turkey) was used for statistical analysis.
The conformity of the parameters with normal distribution
was evaluated using the Shapiro–Wilks test and it was found
that the parameters displayed a normal distribution. In the
analysis of the study data, one-way ANOVA test was used to
compare quantitative data, as well as descriptive statistical
The study comprised 172 patients who presented to emergency department between January 2018 and December
2020 and diagnosed with acute uncomplicated diverticulitis (modified Hinchey 1a). While 110 (64.0%) patients were
admitted and treated as inpatients (Group 1), 62 (36.0%)
patients received treatment as outpatients (Group 2). The
median age of the patients was 56.09 years, and the two
groups were similar. About 55.2% of the patients were female, and there was no statistical difference in regard to
gender between the groups. Diverticulitis was localized
to the sigmoid colon in 61% of patients on CT. Transverse
colon localization or localization in the right colon was observed in 11 patients (6.4%). In terms of diverticulitis location, there was no difference between the groups. The average period of the commencement of complaints was 2.77
days, with no difference between the groups. There was no
significant difference between the two groups in terms of
readmission. Only 1 (0.6%) of all patients had a clinical condition requiring hospitalization within the first 30 days. Table 2 contains information on demographic characteristics.
Patients in the hospitalized group had higher leukocyte
counts and CRP levels at the time of admission (12.9 vs. 11.3,
P: 0.01 and 5.8 vs. 4.3, respectively; P: 0.04). Sensitivity was
determined in 87.2% of patients (94.5% in Group 1, 74.2%
in Group 2), guarding in 12.2% (17.3% in Group 1, 3.2% in
Group 2), and rebound in 21.5% (31.8% in Group 1, 3.2% in
Group 2). In hospitalized patients, physical examination findTable 2. Demographic characteristics and localization of diverticulitis
Age (mean)
Gender (n, %)
Female
Male
Localization of diverticulitis
Descending colon
Sigmoid colon
Both descending and
sigmoid colon
Other
Complaint period (day)
Readmission rate
Group 1
n=110
Group 2
n=62
Total
n=172
p
56.09
56.10
56.09
0.99a
63 (57.3)
47 (42.7)
32 (51.6)
30 (48.4)
9 (8.2)
71 (64.5)
24 (21.8)
9 (14.5) 18 (10.5) 0.46b
34 (54.8) 105 (61.0)
14 (22.6) 38 (22.1)
6 (5.5)
2.75
1 (0.9)
One-way ANOVA; bPearson Chi-square.
a
5 (8.1)
2.81
0 (0)
95 (55.2) 0.28b
77 (44.8)
11 (6.4)
2.77
1 (0.6)
0.92a
0.64b
506
The Medical Bulletin of Sisli Etfal Hospital
ings were significantly more pronounced. Table 3 shows the
patients’ physical examination and laboratory findings at the
time of admission to the emergency department.
One hundred and ten patients in Group 1 were hospitalized and followed up or treated for a median of 2.89 days.
Discussion
This study investigated the characteristics of patients with
uncomplicated diverticulitis (Modified Hinchey 1a) treated
as outpatients or inpatients; it was determined that physical examination findings were more pronounced in the
inpatient group, as well as a higher leukocyte count and
CRP. While there was no readmission among the patients
discharged from the emergency department, one of the
patients discharged after inpatient treatment had to be
hospitalized.
The incidence of diverticular disease increases with age.
<10% u of cases occur under 40 years of age, while 50–66%
of cases occur over 80 years of age. In this regard, the weakening of the intestinal wall caused by age-related changes
in collagen structure is effective.[17] When evaluated by
gender, although the first series found a preponderance of
males, later studies showed that the distribution between
the genders was equal.[2,4] Wheat et al. showed in their
study that there was a marked preponderance of women
in the prevalence of diverticulitis.[23] In our study, 55.2% of
the patients were female, and there was no significant difference between the groups in terms of gender. The rate of
patients under 40 years of age was 3.4%.
There are also studies showing that the localization of the
Table 3. Comparison of the characteristics of Groups 1 and 2
Group 1 Group 2
n=110
n=62
Sensitivity
(+)
104 (94.5)
(–)
6 (5.5)
Guarding
(+)
19 (17.3)
(–)
91 (82.7)
Rebound
(+)
35 (31.8)
(–)
75 (68.2)
6 (5.5)
Fever >38.2oC
Heart rate (mean)/minute
96.2
White blood cell count (mean) 12.9
Neutrophil count (%) (mean)
71.4
CRP (mg/L)
58.2
Pearson Chi-square, bOne-way ANOVA.
a
Total
n=172
p
46 (74.2) 150 (87.2) 0.00a
16 (25.8) 22 (12.8)
2 (3.2) 21 (12.2) 0.00a
60 (96.8) 151 (87.8)
2 (3.2) 37 (21.5) 0.00a
60 (96.8) 135 (78.5)
3 (4.8)
9 (5.2) 0.82a
92.2
94.8
0.10b
11.3
12.3
0.01b
69.7
70.8
0.32b
43.6
53.3
0.04b
diverticulum may be one of the factors that may play a
role in the severity and recurrence of the disease.[24] In our
study, 95% of the patients had diverticulitis located in the
sigmoid colon. In 65% of the patients, the diverticula are
found only in the sigmoid colon and in 24% in other parts
of the colon together with the sigmoid colon. However,
in 10% of patients, they are in a segment more proximal
than the sigmoid colon.[8,9] Similarly, in our study, diverticulitis was localized only to the sigmoid colon in 61% of the
patients. In 83.1% of the patients, the diverticulum was located in the left colon.
Looking at the literature, it is recommended that antibiotic
treatment be completed for 14 days after patients have
been treated with IV antibiotics in the hospital for an average of 3–5 days. Other similar studies found that the average length of hospital stay in patients with acute uncomplicated diverticulitis was 6 days.[23,25] In our study, the average
length of stay for hospitalized patients in Group 1 was 2.89
days and appeared to be lower than the literature data. We
think that this may be related to the clinical improvement
observed in patients with an average of 3 days of IV antibiotic treatment followed by close outpatient follow-up.
Anamnesis and physical examination are critical parameters in the diagnosis of acute diverticulitis. Although diverticulitis is classically characterized by the left lower
quadrant pain, left lower quadrant sensitivity, fever, and
leukocytosis, often, not all symptoms are present in the
same patient. In the study conducted by Toorenvliet et al.,
it was determined that 78.9% of diverticulitis patients experienced left lower quadrant sensitivity, 35.1% had right
lower quadrant sensitivity, 22.8% had suprapubic sensitivity, 8.8% had guarding, and 40.4% had rebound.[26] In our
study, sensitivity was identified in 87.2% of the patients,
guarding in 12.2%, and rebound in 21.5% of the patients,
with the inpatient group having a significantly higher rate
of sensitivity.
CRP was identified as a marker for complicated diverticulitis in many case series. In the retrospective study carried
out by Mäkelä et al. involving 350 patients, CRP level of 150
mg/L was crucial in distinguishing between uncomplicated
diverticulitis and complicated diverticulitis. In addition, this
study reported that a CRP level >150 mg/L and free fluid at
CT significantly increased the risk of mortality.[27] The mean
CRP level in our study was 53 mg/L (58 mg/L in Group 1 and
43 mg/L in Group 2).
Bolkenstein et al., in their study comparing the parameters
in uncomplicated diverticulitis and complicated diverticulitis, found that the mean leukocyte count was 11.9 × 109
in uncomplicated diverticulitis and 14.6 × 109 in complicated diverticulitis, with a significant statistical difference
Teke et al., Management of Acute Uncomplicated Diverticulitis / doi: 10.14744/SEMB.2022.27095
between them.[28] In our study, the median leukocyte count
was 12.3 × 109, which is in agreement with the literature,
and a significant difference was found between the two
groups (Group 1 12.9 × 109 vs. group 2 11.3 × 109; p=0.01).
In the study by P.F. Ridgway, the oral antibiotic and IV antibiotic treatments were compared in uncomplicated diverticulitis patients, when the mean hospital stay, readmission, and
treatment success were compared, no significant difference
was found.[29] Our study also showed no significant difference in treatment success and readmission rate between
Group 1, who were admitted as inpatients and started on IV
antibiotics, and Group 2, who were continued on oral antibiotics as outpatients. There are many studies in the literature
comparing antibiotic treatment and non-antibiotic treatment in the patients with acute uncomplicated diverticulitis. In many analyses, no significant difference was found
between the addition of antibiotics to treatment, treatment
failure, recurrence, complications, hospital readmissions, and
needed surgery compared to treatment without antibiotics.
[30,31]
Although these studies suggest antibiotic-free followup of patients with acute uncomplicated diverticulitis, more
comprehensive studies are needed.
The study’s limitations are that it was designed retrospectively, the number of patients was limited, and the surgeons who made the hospitalization decision had varying
levels of clinical experience. Based on our clinic’s approach
to patients with acute uncomplicated diverticulitis, all patients received antibiotic treatment. Consequently, there
was no antibiotic-free treatment group, and no comparison could be made.
Conclusion
In patients with uncomplicated colon diverticulitis who are
admitted to the emergency department without the use
of clinical or imaging methods, the clinician’s decision to
admit the patient is based on physical examination findings as well as leukocyte and CRP levels. Patients with poor
physical examination findings can be safely treated with
oral antibiotic therapy on an outpatient basis.
Disclosures
Ethics Committee Approval: For our study, research permission
was obtained from the Local Ethics Committee on November 18,
2021, numbered E-17073117–50.06.99. This study was conducted
in accordance with the Declaration of Helsinki.
Peer-review: Externally peer-reviewed.
Conflict of Interest: None declared.
Authorship Contributions: Concept – E.T.; Design – E.T.; Supervision – H.C.; Materials – N.E.B.; Data collection &/or processing –
A.E., Y.G.; Analysis and/or interpretation M.M.F.; Literature search
– B.K.; Writing – E.T.; Critical review – K.M.
507
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