Management of Diverticulitis
Sanjay Adusumilli
MBBS MS FRACS
0411 051 281
• Trained by CSSANZ in Oxford (UK) and Perth
• Appointments at BMDH, HSS, Norwest Private and SAN Hospital
• Surgery performed:
• Laparoscopic and open colorectal surgery
• Laparoscopic general surgery (including gall bladders and
hernias)
• Perianal conditions
• Endoscopy
• Patients seen within seven days
• Strictly “no gap”
• Happy to bulk bill (please note on referral)
Diverticular disease
Diverticula form at
weak points in the
bowel wall
Often where vasa
recta vessels
penetrate the
muscle layer
Most common in
left colon (70-90%)
Why does it occur?
Congenital
Acquired
Association with Western diets high
in refined carbohydrates and low in
dietary fibre
Deficiency of vegetable fibre in diet
Disordered motility
Hyperelastosis may lead to
structure change
Collagen abnormalities
Age
Prevalence
< 10% in people under 40 year old
50% to 66% over age 80
10-25% develop symptoms from it
Pathophysiology
Faecolith
Bacterial flora
Micro or macro
perforation
75 to 90 percent have
uncomplicated
diverticulitis
Various presentations
Emergency:
Diverticulitis – uncomplicated
Diverticulitis - complicated
Obstruction
Diverticular bleed
Chronic:
Recurrent diverticulitis attacks
Fistula (colovaginal/colovesical)
Hinchey classification
1. Uncomplicated Diverticulitis
(Hinchey 0 or Ia)
Antibiotic treatment
Severe or complicated diverticulitis is managed with bowel rest, IV fluids
and IV antibiotics.
For empirical therapy, use:
gentamicin IV
PLUS
amoxy/ampicillin 2 g IV, 6-hourly
PLUS
metronidazole 500 mg IV, 12-hourly.
If IV antibiotics are required beyond 72 hours or if gentamicin is
contraindicated:
piperacillin+tazobactam 4+0.5 g IV, 8-hourly
OR
ticarcillin+clavulanate 3+0.1 g IV, 6-hourly.
Are antibiotics really needed?
• Multicentre trial in Sweden involving ten hospitals
• 623 patients randomised into treatment with and without
antibiotics
• Median hospital stay 3 days in both groups
• Recurrent diverticulitis at one year similar in both groups
• Conclusion – “Antibiotics for uncomplicated diverticulitis does
not accelerate recovery”
155 patients
97.4 percent of patients managed successfully as outpatients with
no antibiotics
2.6 percent required later admission and treatment with antibiotics
not requiring surgery
Conclusion – “Outpatient management with acute uncomplicated
diverticulitis is now shown to be feasible”
Is a diet restriction needed?
All patients hospitalised with Hinchey 0, 1a and 1b
diverticulitis between 2010 and 2011
256 patients included
ASCRS guidelines
2. Complicated diverticulitis with abscess
(Hinchey Ib or II)
Very few studies have evaluated antibiotic
treatment alone versus radiological drainage
1996
Success rate of medical therapy 85.9 percent
Less favourable medical therapy in abscesses greater than 5
cm
2005
Retrospective review of 114 patients
66 patients improved with medical therapy
More likely to fail when abscess greater than 6.5cm in size.
But things have changed since
then…
• More accurate CT scanning
• More accessible points in abdomen
• Better experience and equipment
• So surgeons probably likely to use radiological drainage for
smaller abscess
ASCRS guidelines
CAN THESE PATIENTS WITH AN ABSCESS BE
MANAGED MEDICALLY?
• Retrospective review of all patients between 2005 and 2011
• 59 patients with an abscess and 663 patients without
• Median follow up of 28 months
• Review of all patients with a diverticular abscess between 2004 and
2014
• 210 patients
60.5%
58.9%
Key points:
Larger abscess were associated with a higher risk of
recurrence (5.3cm vs 3.2cm)
Overall 59 percent of patients with a recurrence required
surgery
ADVICE TO PATIENTS
• Retrospective review of 954 patients over 7 year period
• Overall recurrence at 5 years of 36 percent
• More likely to recur if:
- Family history of diverticulitis
- Long segment of colon involved
- Retroperitoneal abscess
Diet changes
For many years patients have been advised to avoid nuts and
seeds
Prospective study of 47228 men over 18 years
Inverse association between consumption of nuts and seeds,
and incidence of diverticulitis
Conclusion – “No association between consumption of nuts
and seeds and diverticulitis”
WHO SHOULD BE OFFERED
SURGERY?
ASCRS Guidelines
SURGERY
Surgery – All about blood supply!
CASE
68 year old gentleman presented to GP with left iliac fossa
pain, peritonism and fevers
Previous attacks of diverticulitis 6 months and 2 years ago
Thank you
