Background: The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed. Methods: A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities. Results: The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy. Conclusion: Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.

Keywords:
Practice guideline, Treatment, Colonic diverticulitis

Left-sided diverticulosis of the colon is a common condition in Western society. The prevalence of diverticulosis coli depends on age and increases from about 5% around 40 years of age to 65% at the age of 85 years or older [1,2]. It is estimated that approximately 25% of the patients with diverticulosis will develop an episode of acute left-sided colonic diverticulitis (ACD) [3]. Patients with acute abdominal pain due to ACD impose an impressive burden to healthcare [4]. In the past years, a dramatic rise in the number of hospitalizations for ACD has been noted in the Netherlands. In 2009, 18,355 patients were hospitalized with ACD as compared to 13,655 patients in 2006. Meanwhile, expenditures for these hospital admissions in the Netherlands exceed EUR 80 million per year [5,6]. This rise in hospital admissions is also notable in other countries. A recent study from the United States showed an increase in hospital admissions during the period 1998-2005 of 26%, with the greatest rise in patients between 18 and 44 years of age [4]. In the Netherlands, women make up 60% of hospital admissions for ACD [6]. This difference in incidence of ACD between men and women has been noticed in other countries as well. Patients younger than 50 years of age with ACD are predominantly men, whereas in the age group of 50-70 years there seems to be a preference for women [7,8,9,10,11]. Patients with mild (recurrent) diverticulitis are usually treated by a general practitioner or on an outpatient basis, which makes it difficult to accurately determine the true incidence and recurrence rates of diverticulitis.

Although ACD is a very common disease, the clinical diagnosis remains a challenge for clinicians and health care researchers. Diagnostics and treatment of diverticulitis are mostly characterized by doctors' personal preferences rather than standardized evidence-based protocols. This is mainly due to the fact that there is a large amount of conflicting and low-quality evidence in publications regarding diverticulitis. To provide doctors and other health care providers support in clinical decision-making, practice guidelines can be developed. Guidelines are applicable nationwide, but if based on international literature can be applicable to developed countries. Therefore, a multidisciplinary working group developed national guidelines including the epidemiology, classification, diagnostics and treatment of ACD in all its aspects based on an evidence-based review of the international literature.

The guideline was written under the auspices of the Netherlands Society of Surgery, in collaboration with the Netherlands Societies of Internal Medicine, Gastroenterologists, Radiology, Health Technology Assessment and Dieticians. The working group consisted of four surgeons, a gastroenterologist, a radiologist, an internist specialized in infectious diseases, a dietician and an epidemiologist and statistician. Participation of a patients' representative in the working group was not possible because a patient association for patients with ACD does not exist in the Netherlands. The working group defined the following sections of relevance: terminology and classification, epidemiology, special patient groups with ACD, prevention of recurrent ACD, clinical diagnosis and radiological imaging, colonoscopy, treatment of uncomplicated and complicated ACD, and elective surgery and medical treatment in patients with ACD.

Search Strategy

Systematic searches of the Medline and Embase databases were performed using the keywords relevant to each section. Terms relevant to each section of the guideline were mapped to Medline Subjects Headings (MeSH) terms, as well as searched for as text items. Relevant keywords and search strategies can be found in Appendix 1. Articles describing randomized controlled trials and systematic reviews were searched for using the methodological filters of the Scottish Intercollegiate Guidelines Network (https://www.sign.ac.uk/methodology/filters.html). Different date censoring and limitations were applied according to the relevance of each keyword. Only publications in English, French, German and Dutch were retrieved and read in full. The bibliographies of included articles were subsequently hand-searched for other relevant references, and experts in the field were asked if they found any relevant reports missing.

Critical Appraisal

Articles selected to support recommendations were assessed using the national classification system for evidence-based guideline development (http://www.cbo.nl), which is equivalent to the levels of evidence as published by the Centre for Evidence-Based Medicine of the University of Oxford (www.cebm.net; table 1). Articles were classified according to the type of article and individually assessed for methodological quality using the GRADE method as proposed by the GRADE working group. That working group has developed a common, sensible and transparent approach to grading the quality of evidence and strength of recommendations (http://www.gradeworkinggroup.org).

Table 1

Classification of evidence

Classification of evidence
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Classification of evidence
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The main literature on which the conclusion for each relevant topic is based is stated with the conclusion, accompanied by the level of evidence (table 2). The final recommendations are based on the available evidence from the literature, also taking into account ‘soft' factors such as patient preferences, costs and availability of facilities. Recommendations can be strong (‘we can be confident about the recommendation', level I) to weak (‘we cannot be confident', level IV). A concept guideline was sent to all involved societies for comment and approval after which internal consensus was reached between the members of the working group. Amendments were made based upon these comments, leading to the final version of the guideline ‘Diagnostics and Treatment of Acute Colonic Diverticulitis', as approved by all societies.

Table 2

Grading of the conclusions according to the level of evidence

Grading of the conclusions according to the level of evidence
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Grading of the conclusions according to the level of evidence
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Terminology and Classification

The term ‘diverticular disease' used in Anglo-Saxon literature is made up of a spectrum of conditions all related to diverticulosis of the colon. Some use the term ‘diverticular disease' for patients with symptoms associated with diverticulosis and distinguish diverticulitis as a different entity, whereas others include diverticulitis and diverticular bleeding in the term ‘diverticular disease'. The lack of uniformity in terminology results in difficulties interpreting and comparing findings between studies. It seems best to use the term ‘diverticulosis coli' and to distinguish between uncomplicated (asymptomatic) and complicated (symptomatic) diverticulosis. Patients with uncomplicated diverticulosis have no symptoms, and therefore the term asymptomatic diverticulosis is also used. Complicated diverticulosis coli, or symptomatic diverticulosis coli, is the complete spectrum of symptoms that can arise in patients with diverticulosis coli. This includes patients with (chronic) persistent abdominal pain, acute colonic diverticulitis and diverticular bleeding. ACD refers to inflammation of diverticula. Uncomplicated ACD is referred to when inflammation of one or more diverticula leads to an inflammatory process without perforation or abscess formation. Complicated diverticulitis is associated with abscess formation, perforation or fistula formation. Recurrent episodes of ACD may result in stenosis and obstruction or fistula to nearby organs (mostly bladder) or the skin; these late complications are also referred to as complicated diverticulitis.

To classify acute diverticulitis, Hinchey et al. [12] proposed a classification system, which is currently used in clinical practice in a modified version [13] (table 3). The Hinchey classification has traditionally been used to distinguish four stages of complicated diverticulitis. Wasvary et al. [13] introduced stage 0, clinically mild diverticulitis, and differentiation in stage I between limited pericolic inflammation (stage Ia) and abscess formation smaller than 5 cm in the proximity of the primary inflammatory process (stage Ib). This broadened the original Hinchey classification by not only addressing perforated disease, but also by including mild clinical disease [13,14]. After the introduction of computed tomography (CT) for diagnosing acute diverticulitis, several radiologic classification systems were proposed additionally [15,16]. CT findings were correlated with the modified Hinchey scores to come to uniform reporting of CT findings (table 3).

Table 3

CT findings according to Kaiser et al. [15] (2005)

CT findings according to Kaiser et al. [15] (2005)
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CT findings according to Kaiser et al. [15] (2005)
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Conclusion and Recommendations

Uniform terminology is needed in patients with diverticulosis coli. A distinction is made between uncomplicated (asymptomatic) diverticulosis and complicated (symptomatic) diverticulosis. The latter term is used for the complete spectrum of symptoms that can arise in patients with diverticulosis coli (level 4).

Researching the natural history of ACD is hampered by a number of factors. There is no registry of patients regarding the natural course of the disease. Most patients with recurrent episodes of ACD have had elective surgery after two episodes of ACD, which makes it difficult to determine true recurrence rates in patients with ACD [17]. Recurrence rates of ACD, in which a recurrence is based on the clinical diagnosis without imaging, varies between 9 and 29% (level C [9,18,19,20,21,22,23]). The accuracy of the diagnosis in these studies is questionable because of the lack of a good reference test. There are two studies with adequate reference testing that give information on the natural disease history, and they report an estimated chance of recurrence of 9% (level C [24]) and 23% (level C [25]). The highest risk of recurrence seems to be in the first year (10%) and drops to approximately 3% in the years thereafter (level C [21]). The real risk of recurrence is underestimated in these studies; recurrence rates apply invariably to a selected group of patients, namely patients with symptoms severe enough for hospital admittance. The majority of recurrences tend to be mild recurrences that can be managed by conservative treatment (level C [9,18,19,21,22,23,24,25]). Based on recent studies, most perforations do not occur after recurrences, but after the first attack of ACD (level C [26,27,28,29,30,31,32,33]). Multiple recurrences were not associated with a higher chance of mortality, nor did they lead to a higher chance of complicated disease (level C [26,27,28,29,30,31,32,33]).

Conclusions and Recommendations

The natural history of diverticulitis is usually mild and most patients are treated successfully by conservative means (level 3). Multiple recurrences do not lead to a higher risk of complicated diverticulitis (level 3). Patients should be informed of an approximately 25% risk of recurrence after an initial episode of ACD (level 3).

Young Patients

The definition of young age in patients with ACD is either below 40 or 50 years. Of all patients hospitalized for ACD, 18-34% are younger than 50 years [34,35]. Some authors have reported that young patients have an increased risk of complications and recommend early resection [8,36,37,38]. This assumption is based on outdated studies in which 48-88% of the patients who had surgery for suspected diverticulitis appeared to have another diagnosis at surgery. Recent studies, using CT to diagnose ACD, did not find a higher risk of complications in young patients (level C [7,18,19,20,25,34,35,39,40]). In young patients, the reported high risk of recurrent disease is caused by a higher accumulated risk due to higher life expectancy rather than absolute risk (level C [18,19,20,40]). There is no evidence that younger patients should be treated differently than older patients (level C [20,25,34,35,39,40]).

Immunocompromised Patients

In patients with a compromised immune system, an increased incidence of ACD has been reported compared to healthy individuals, especially in patients with kidney failure, organ transplant patients and patients using corticosteroids (level C [41,42]). These patients were significantly more often diagnosed with complicated diverticulitis (level C [28,42,43,44,45]). Screening and prophylactic sigmoid resection is not routine for patients waiting for organ transplantation (level C [42,46]). Patients with immune deficiency caused by HIV infection, diabetes, malignancy or chemotherapy do not have an increased risk of complicated diverticulitis (level C [47,48]). Some reports indicate an increased risk of ACD in obese patients, but evidence is inconsistent (level B [49] and level C [50,51]).

Conclusions and Recommendations

Young patients do not have a more aggressive course of ACD than older patients (level 3). Young patients have a higher risk of recurrent disease, but the absolute risk difference is relatively small (level 3). Screening for diverticulosis in immunocompromised patients or patients awaiting organ transplantation in order to perform a prophylactic colonic resection is not effective (level 3).

There are indications that people with a healthy lifestyle, characterized by physical exercise, a fiber-rich diet, limited intake of red meat, low alcohol consumption and nonsmoking, have a decreased risk of diverticulitis (level B [52] and level C [53]).

Conclusions and Recommendations

Counseling patients on risk factors for developing diverticulosis should be included in treatment protocols (level 3).

Clinical Diagnosis

The clinical diagnosis of ACD, based on reported complaints, physical examination and laboratory results, is correct in 43-68% of patients (level B [54,55] and level C [56,57]). To improve diagnostic reliability, a clinical decision rule and a clinical scoring system for diagnosing ACD using logistic regression have been published [54,55]. Reliable independent individual risk factors for ACD in both studies were pain only in the left lower abdominal quadrant, the absence of vomiting and a C-reactive protein level >50 mg/l. If all three criteria were met, 97% of the patients had ACD (level B [54,55]).

Radiological Imaging

Radiological imaging techniques that are used for the diagnosis of ACD are soluble contrast enemas, ultrasound (US), CT and magnetic resonance imaging (MRI). Soluble contrast enemas are obsolete for diagnosing ACD due to low accuracy and the inability to determine the extent and complications of the disease (level A2 [58] and level B [59]). The most used US technique to examine patients with suspected ACD is the graded compression procedure. With this technique, interposing fat and bowel can be displaced or compressed by means of gradual compression to show underlying structures [60]. US is a real-time dynamic examination with wide availability and easy accessibility. The use of CT in evaluation of patients with ACD has increased to a large extent. CT has the advantage of delineating the extent of the extraluminal disease process, has an unlimited view and may also direct therapeutic intervention in case of complicated disease, e.g. US-guided percutaneous drainage of intra-abdominal abscesses. CT criteria are also used as a prognostic tool to determine the risk of complications during conservative treatment [16,61]. The most used diagnostic criteria to diagnose ACD with US and CT are increased thickness of the colonic wall, pericolic fat stranding and presence of inflamed diverticula. To optimally depict diverticulitis, the use of intravenous, oral and/or rectal contrast agents are advised [62]. Studies report high diagnostic sensitivity and specificity for both US (92 and 90%, respectively) and CT after negative or inconclusive US (94 and 99%, respectively; level A1 [63,64]). More recently, in a large prospective series of unselected patients with acute abdominal pain at the emergency department, for which imaging was indicated by the treating physician, a much lower sensitivity of 61% (52-70%) was found for US, whereas the sensitivity of CT for the diagnosis of ACD was 81% (74-88%). Sensitivity can be increased up to 94% by performing US first, and CT only in case of a negative or inconclusive US. This step-up approach lowered the exposure to ionizing radiation for the study population (level A2 [65,66]). Besides the known differences between the techniques (availability, costs, reproducibility and interobserver differences), exposure to radiation during CT and contrast-induced nephropathy are a concern [60]. MRI has the advantage that no ionizing radiation and intravenous contrast medium are needed to reach a higher soft tissue contrast than CT. MRI is increasingly used in the acute setting for patients with acute abdominal pain, but accuracy data are still limited. Based on studies with small numbers of patients, sensitivity and specificity of MRI for diagnosing ACD vary between 86 and 100% and 88 and 100% (level B [67,68] and level C [69,70]).

Conclusions and Recommendations

In general, the clinical diagnosis of ACD is not sufficiently accurate and therefore radiological imaging is indicated in these patients (level 2). Patients with mild symptoms and no signs of complicated ACD, and the combination of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l may be withheld from initial imaging for diagnosing ACD (level 2). If imaging is indicated, a conditional CT after negative or inconclusive US is the most appropriate approach in diagnosing ACD (level 2).

Colonoscopy is not recommended in the acute phase to diagnose ACD (level B [71] and level C [72]). Although proven feasible in one prospective study, it is rarely needed in the acute phase (level C). Possible difficulties of colonoscopy in the acute phase are incomplete examination due to pain, stenosis and incomplete bowel preparation. Discouragements to perform colonoscopy in the acute phase are based on the hypothesis that insufflation of air is associated with the risk of converting a sealed perforation to a free perforation [73,74,75].

Colonoscopy is usually done 6 weeks after an episode of ACD, so as to exclude a colonic malignancy. The lifetime risk of developing colonic cancer is approximately 5%. After an episode of ACD, it is unlikely that patients have an increased risk of developing colonic cancer (level B [76,77] and level C [78]). Although safe, routine performance of a colonoscopy in asymptomatic patients after an episode of ACD to exclude other diagnoses was not found to be helpful (level B [71,79,80]).

Conclusions and Recommendations

Colonoscopy in the acute phase of diverticulitis is not recommended for diagnostic purposes (level 3). There is no place for routine endoscopic examination after an episode of ACD (level 2).

Most patients with uncomplicated diverticulitis (Hinchey 0 or Ia) can be treated conservatively with a success rate of 93-100% (level C [15,81,82,83,84,85,86]). Conservative treatment includes antibiotics, starvation and bed rest in almost all studies. There is no evidence that bed rest, dietary restrictions or laxatives positively influence the treatment outcome of ACD. In patients who do not tolerate oral feeding, it is recommended to start parenteral feeding when oral feeding is not to be expected within 3 days (level D [87]). Almost all international guidelines advise the use of antibiotics for the treatment of diverticulitis [17,88,89,90,91]. However, there is no evidence that routine administration of antibiotics influences the course of uncomplicated diverticulitis (level A2 [92] and level B [79]). Oral administration of antibiotics seems equally effective to intravenous administration (level B [93]). Intravenous administration over 4 days is equally effective as 7 days (level B [84]). A recent prospective randomized clinical trial did not find a reduction of abscess formation, perforation and recurrence rates with the use of antibiotics [92]. The use of antibiotics seems appropriate in patients presenting with signs of generalized infection (temperature >38.5°C), affected general condition or signs of bacteremia or septicemia and in immunocompromised patients.

Analgesia is part of the treatment of patients with ACD. There is no evidence that acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) or morphinomimetics have a negative effect on the course of an episode of ACD. Multiple studies found that patients on home NSAID medication present more often with complicated diverticulitis, i.e. perforation (level C [48,94,95,96,97]). The (adverse) effect of NSAIDs started as an analgesic in patients with uncomplicated ACD has not been studied. Morphinomimetics can be safely administered to patients with acute abdominal pain without negatively affecting the diagnostic accuracy of clinical evaluation (level A2 [98,99]).

Conclusions and Recommendations

There is no evidence that bed rest, dietary restrictions or laxatives influence the treatment of ACD (no evidence). There is no evidence that antibiotics should be routinely administered to patients with uncomplicated diverticulitis (level 2). Antibiotic treatment is recommended when signs of generalized infection (temperature >38.5°C) and affected general condition or signs of bacteremia or septicemia are present (level 4). Antibiotic treatment is recommended in immunocompromised patients (level 4).

Hinchey Ib and II

There are no high-quality reports on the management of patients with ACD and abscess formation (Hinchey Ib and II); therefore, no consensus has been reached about the most optimal treatment strategy. Since the introduction of broad-spectrum antibiotics and improvement in US- and CT-guided percutaneous drainage techniques, alternatives to surgery have become available. Conservative treatment with antibiotics is successful in up to 73% (95% CI: 66.3-78.9) of patients presenting with an abscess of less than 4-5 cm in diameter (level C [16,18,100,101,102,103,104]). When conservative treatment fails, percutaneous drainage should be performed, which is successful in up to 81% (95% CI: 73.7-89.1) of patients (level C [15,16,100,101,102,103,104]). The risk of failure of conservative treatment is higher in patients with abscesses larger than 4-5 cm than in patients with smaller abscesses (level C [15,16,100,101,102,103,104]).

Hinchey III and IV

Peritonitis is the most life-threatening complication of ACD, with a mortality of 14% [105,106]. Perforation of the colon to the intra-abdominal cavity results in a purulent or fecal peritonitis. Perforation is a relatively rare complication with an incidence of 3.5 per 100,000 individuals per year [107]. In a large population-based study from the United States, only 1.5% of patients with ACD were found to have a perforation, and 9.6% were found to have an abscess [108]. Peritonitis is a progressive disease leading to general signs of illness expressed in organ dysfunction or organ failure caused by bacteremia and septicemia. Prevention of these events by early intervention, i.e. aggressive resuscitation preventing inadequate tissue perfusion and oxygenation, the administration of broad spectrum antibiotics, and elimination of the source of infection, is the keystone of sepsis treatment [109]. Early treatment in patients with peritonitis significantly improves outcome [109,110,111]. No evidence-based advice can be provided for the indications for surgery in patients with perforated diverticulitis, but the indication seems self-evident.

Operative Therapy

There are different surgical options for patients with Hinchey III and IV peritonitis: diverting colostomy, Hartmann's procedure or primary resection with anastomosis, and laparoscopic lavage with drainage of the abdominal cavity. Hartmann's procedure is the most performed, which is a two-stage procedure involving resection of the diseased colon, closure of the distal rectal stump and construction of an end colostomy. In the second stage the colostomy is reversed; however, restoration of the bowel continuity is not performed in up to 55% of patients due to operative risks [112]. Alternatively, resection with primary anastomosis, with or without a protective ileostomy or colostomy, can be performed. A diverting ileostomy or colostomy combined with intraoperative irrigation of the afferent colon can be performed to reduce the rate of symptomatic complications in case of anastomotic leakage (level B [113,114]). Studies comparing mortality, morbidity, wound complications, operation time and antibiotic treatment of Hartmann's procedure and primary anastomosis did not show any significant differences. However, most studies were prone to selection bias: patients were not randomized for Hartmann's procedure or primary anastomosis and patient groups were not comparable on patient characteristics and disease severity. It is likely that the choice of operation is influenced by patient conditions and perioperative findings. Nevertheless, there are indications that Hartmann's procedure and primary anastomosis have comparable outcomes (level B [113,115,116]). However, in critically ill patients, hemodynamic instability is a relative contraindication for a primary anastomosis. Due to administration of inotropes to maintain sufficient blood pressure, splanchnic perfusion can be reduced, leading to increased risk of anastomotic leakage. This hypothesis has been confirmed (mainly in animal experiments) in studies on anastomotic healing in general surgery, although not after resection for diverticulitis. Fecal contamination of the abdominal cavity is not thought to be a contraindication for construction of a primary anastomosis [117]. Another treatment option in patients with purulent peritonitis is laparoscopic lavage and drainage of the abdominal cavity in which the colon is not resected. In nonrandomized series, hampered by patient selection, laparoscopic treatment accompanied by intravenous antibiotics seems to be an effective and safe treatment in Hinchey III patients (level C [57,118]). However, the results of the first randomized trial need to be reviewed for a definite conclusion [119].

Conclusions and Recommendations

Smaller abscesses (<4-5 cm) can be treated with antibiotics alone, whereas larger abscesses can best be treated with percutaneous drainage combined with antibiotic treatment (level 3). Operative treatment is considered standard therapy for patients with Hinchey III and IV diverticulitis (no evidence). In hemodynamically stable patients with acute diverticulitis and an indication for operative treatment, primary anastomosis with or without a diverting ileostomy or colostomy is preferred over Hartmann's procedure (level 2). In patients with Hinchey III diverticulitis, the safety and efficacy of treatment with laparoscopic peritoneal lavage is uncertain and will remain so until the results of the first randomized trial on the subject become available (level 3).

The American Society of Colon and Rectal Surgeons (ASCRS) state in their most recent guideline that elective sigmoid resection after recovery from ACD should be made on a case-by-case basis [90]. This advice differs significantly from the previous advice, given 6 years earlier, in which a plea for elective surgery after two episodes of diverticulitis was proposed [120]. Recent data on the natural history of diverticulitis has shown that recurrent episodes of diverticulitis mostly run a benign course and only 5.5% of the patients with recurrent hospitalizations for diverticulitis are subjected to emergency surgery [20]. Moreover, most patients who present with complicated diverticulitis do so at the time of their first attack (level C [26,121,122]). Recurrent diverticulitis even seems to reduce the risk of perforation, possibly due to adhesion formation caused by inflammation. Therefore, a policy of elective sigmoid resection after recovery from uncomplicated ACD does not decrease the likelihood of later emergency surgery, and the number of previous episodes itself is no longer an indication for elective sigmoid resection (level C [18,26,33,113,121,122,123]). Persistent colonic symptoms, particularly abdominal pain, have been reported in patients after episodes of diverticulitis. It has been suggested that this pain represents increased visceral sensitivity [124]. These patients might benefit from early colonic resection.

After elective sigmoid resection, there is a risk of anastomotic leakage, stoma formation, morbidity and mortality. Despite resection, even recurrent diverticulitis and continuing complaints have been described. Patients with immune deficiencies might benefit from early resection since they have a greater risk of perforations and a complicated course of recurrent episodes of diverticulitis (level C [18,33,121,122]).

Elective sigmoid resection for complicated diverticulosis can be performed either with an open or laparoscopic approach. Two randomized trials favored laparoscopic surgery over open surgery. In the ‘Sigma trial', significantly more complications, higher pain scores and longer hospital stay were found among patients with open surgery. Operating time was significantly longer in the laparoscopic group, with a conversion rate of 19%. Quality of life was significantly better after 6 weeks, but did not differ after 6 months (level A2 [125]). The study by Gervaz et al. [126] also had equal long-term results, except for the cosmetic outcome, which was better in the laparoscopic group. No difference was found considering ventral hernia, patient satisfaction, quality of life or total costs (level A2). Laparoscopic surgery provides a faster functional recovery than open sigmoid resection and possibly less chance of complications, but the long-term advantages of laparoscopic sigmoid resection are not yet evident (level A2 [125,126] and level B [127,128,129,130,131]). Both the Sigma trial and the Gervaz study did not use the Enhanced Recovery after Surgery (ERAS) principles, which are now widely adopted in the perioperative care of patients with abdominal surgery. The ERAS program reduced the risk of complications and hospital stay of open surgery to a large extent [130]. In addition, laparoscopic surgery is often done by dedicated surgeons, while open surgery is usually performed by a much larger group of surgeons, possibly influencing the results.

To reduce the risk of recurrent diverticulitis, the sigmoid should be resected up to the proximal rectum (level C [131,132]). There is no evidence for the optimal proximal resection margin; however, a resection as limited as possible in soft compliant bowel is recommended [90].

Conclusions and Recommendations

Patient-related factors, not so much the number of previous episodes of diverticulitis, should play the most important role in selecting patients who might benefit from elective sigmoid resection (level 3). If appropriate laparoscopic expertise is present, laparoscopic surgery for recurrent episodes of diverticulitis might be favored over open sigmoid resection in terms of short-term outcome, but no long-term benefits have been reported (level 1). During elective sigmoid resection, the part of the colon resected proximally to the inflammatory process should be as limited as possible with the proximal rectum as the distal margin (level 3).

Traditionally, fiber-enriched diets in patients with diverticulitis have been considered to prevent recurrent episodes of ACD. However, randomized clinical trials on fiber-enriched diets in patients with ACD have had inconsistent results [133]. A recently published systematic review of high-fiber dietary therapy could not include any studies concerning prevention of diverticulitis with a high-fiber diet [134]. Despite the lack of evidence, high daily fiber intake is recommended as treatment in various guidelines [17,88,91,135]. Since obesity and smoking are associated with an increased risk of complications of diverticulitis, weight reduction and cessation of smoking can have a favorable influence on prevention of recurrent diverticulitis (level B [51,136]). Although evidence on lifestyle advice to prevent recurrent episodes of ACD is missing, it is likely that the same measures to prevent ACD also apply to patients after an episode of ACD. Hence, a healthy lifestyle, characterized by physical exercise, a fiber-rich diet, little intake of red meat, low alcohol consumption and nonsmoking are advised in patients after an episode of ACD (level B [52] and level C [53]).

Recently, new theories about similarities between ACD and inflammatory bowel disease have been proposed, leading to new treatment possibilities, such as probiotics, antibiotics and anti-inflammatory agents [137]. Regarding drug treatment, intermittent administration of a nonabsorbable antibiotic (rifaximin) after an episode of acute diverticulitis decreased the chance of readmission by 50% and of recurrent diverticulitis by 73% (level B [138]). Prevention of recurrent disease is more effective when 5-aminosalicylic acid (mesalazine) is combined with rifaximin, compared to rifaximin alone (level A2 [139] and level B [140]). Furthermore, a combination of probiotics and anti-inflammatory medication is preferred over treatment with probiotics alone (level A2 [141]).

Residual complaints after an episode of diverticulitis occur often and medical treatment can reduce symptoms. In these patients a trial period of intermittent administration of a nonabsorbable antibiotic with mesalazine or probiotics should be considered. This is especially so since there is little risk from treatment by nonresorbable antibiotics or mesalazine combined with probiotics, while mortality and morbidity of operative treatment are substantial.

Conclusions and Recommendations

The working group advises to give lifestyle advice to patients following an attack of diverticulitis, focusing on increasing daily fiber intake, weight reduction, cessation of smoking and increasing physical activity (level 4). Nonabsorbable antibiotics seem to reduce the risk of recurrent episodes of diverticulitis (level 3). The combination of 5-aminosalicylic acid and rifaximin is more effective than rifaximin alone in the prevention of recurrent episodes of diverticulitis (level 2). The working group opinion is that in patients with recurrent diverticulitis or patients with residual complaints following an episode of diverticulitis, in which other pathologies have been excluded, a trial period of intermittent mesalazine, with or without a combination of an oral nonresorbable antibiotic or probiotic, should be considered (level 4).

This review of guidelines for diverticulitis summarizes the extensive literature available on epidemiology, prevention, diagnosing and treatment of patients with acute diverticulitis in all its aspects. The guideline was developed in order to standardize the treatment of patients with acute diverticulitis and to provide clinicians who deal with patients with diverticulitis on a daily basis, with an evidence-based medical approach in treating and counseling patients. Despite a large amount of literature, not all topics were equally well addressed. Nevertheless, this review is the best evidence-based approach currently available. The results of well-designed randomized studies will become available in the near future and give more insight into the optimal treatment of patients with acute diverticulitis of the colon.

Search Strategies for the Relevant Key Words

Last search update: February 2012

Subject: natural course of ACD

Date censoring: none

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Natural history” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Natural history” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “uncomplicated”

Subject: natural course in young and immunocompromised patients

Date censoring: from 1960

Restrictions: none

“Diverticulitis” [MesH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Young” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Recurrence” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “diabetes mellitus” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “transplantation” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “immunosuppression” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “AIDS or HIV” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “neoplasms” [MeSH]

Subject: colonoscopy

Date censoring: from 1970

Restrictions: none

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “colonoscopy” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] (“Diverticulitis” OR “Diverticular disease”) AND (“Colon carcinoma” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields]) AND “colon cancer” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “IBD”

Subject: clinical diagnosis

Date censoring: from 1980

Restrictions: none

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “clinical parameters” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “sensitivity” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] AND “diagnosis”

Subject: radiological imaging

Date censoring: from 1980

Restrictions: none

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “contrast enema” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Ultrasonography” [MeSH] OR “ultrasonography” [subheading] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Tomography, Spiral Computed” [MeSH] OR “Tomography, X-Ray Computed” [MeSH] OR “Tomography Scanners, X-Ray Computed” [MeSH] OR “Computed Tomographic” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Magnetic Resonance Imaging” [MeSH] OR “Colonography”

Subject: uncomplicated diverticulitis

Date censoring: from 1975

Restrictions: none

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “uncomplicated diverticulitis” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Anti-Bacterial Agents” [MeSH] OR “Anti-Bacterial Agents” [Pharmacological Action] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis”

((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND (“intestines” [MeSH Terms] OR “intestines” [All Fields] OR “bowel” [All Fields]) AND (“rest” [MeSH Terms] OR “rest” [All Fields])) OR ((“diverticulitis” [MeSH] OR “diverticulitis” [All Fields]) AND (“bed rest” [MeSH] OR (“bed” [All Fields] AND “rest” [All Fields]) OR “bed rest” [All Fields] OR “bedrest” [All Fields])) OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND ((“diverticulitis” [MeSH] OR “diverticulitis” [All Fields]) AND (“overweight” [MeSH] OR “overweight” [All Fields])) OR ((“diverticulitis” [MeSH] OR “diverticulitis” [All Fields]) AND “BMI” [All Fields]) OR ((“diverticulitis” [MeSH] OR “diverticulitis” [All Fields]) AND “adipositas” [All Fields]) OR ((“diverticulum” [MeSH] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND “adipositas” [All Fields]) OR ((“diverticulum” [MeSH] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND “BMI” [All Fields]) OR ((“diverticulum” [MeSH] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND (“overweight” [MeSH] OR “overweight” [All Fields]))

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND [Diet Therapy] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Vegetables” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Fruit” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Starvation” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Laxatives”

Subject: complicated diverticulitis

Date censoring: from 1990

Restrictions: Adults 19+, series >50 patients

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Abscess” [MeSH:NoExp] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Hinchey III” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Hinchey IV” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Diverticulitis, Colonic/mortality” [MeSH] OR “Diverticulitis, Colonic” [MeSH] AND “Intestinal Perforation” [MeSH] OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “laparoscopy”

(“diverticulitis”/exp OR “diverticulitis”:ab,ti OR “diverticular disease”:ab,ti) AND (“laparoscopy”/exp OR “laparoscopic surgery”/exp OR “laparoscope”/exp OR “minimally invasive surgery”/exp OR laparoscop*:ab,ti OR laparascop*:ab,ti OR (minimal*:ab,ti AND adj:ab,ti AND invasive:ab,ti)) AND (“acute disease”/exp OR “emergency”/exp OR acute:ab,ti OR emergenc*:ab,ti OR “colon perforation”/exp OR (perforat*:ab,ti AND [1970-2011]/py)) “Diverticulitis, Colonic” [MeSH] AND “Recurrence” [MeSH] AND “Therapeutics” [MeSH] database

Subject: prevention of recurrence and antibiotics

Date censoring: from 1966

Restrictions: none

(“Diverticulitis” AND “Recurrence” AND “Therapy”) OR (“Diverticulum, Colon” [MeSH]) AND ((“Diet Therapy” [MeSH]) OR (“Dietary Fiber” [MeSH]))

((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND (“overweight” [MeSH Terms] OR “overweight” [All Fields])) OR ((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND “BMI” [All Fields]) OR ((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND “adipositas” [All Fields]) OR ((“diverticulum” [MeSH Terms] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND “adipositas” [All Fields]) OR ((“diverticulum” [MeSH Terms] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND “BMI” [All Fields]) OR ((“diverticulum” [MeSH Terms] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND (“overweight” [MeSH Terms] OR “overweight” [All Fields])) ((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND (“smoking” [MeSH Terms] OR “smoking” [All Fields])) (“diverticular disease” [MeSH Terms] OR “diverticular disease” [All Fields]) AND (“smoking” [MeSH Terms] OR “smoking” [All Fields]) ((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND (“exercise” [MeSH Terms] OR “exercise” [All Fields] OR (“physical” [All Fields] AND “exercise” [All Fields]) OR “physical exercise” [All Fields])) OR ((“diverticulum” [MeSH Terms] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND (“exercise” [MeSH Terms] OR “exercise” [All Fields] OR (“physical” [All Fields] AND “exercise” [All Fields]) OR “physical exercise” [All Fields])) OR ((“diverticulitis” [MeSH Terms] OR “diverticulitis” [All Fields]) AND (“physical therapy modalities” [MeSH Terms] OR (“physical” [All Fields] AND “therapy” [All Fields] AND “modalities” [All Fields]) OR “physical therapy modalities” [All Fields] OR “physiotherapy” [All Fields])) OR ((“diverticulum” [MeSH Terms] OR “diverticulum” [All Fields] OR (“diverticular” [All Fields] AND “disease” [All Fields]) OR “diverticular disease” [All Fields]) AND (“physical therapy modalities” [MeSH Terms] OR (“physical” [All Fields] AND “therapy” [All Fields] AND “modalities” [All Fields]) OR “physical therapy modalities” [All Fields] OR “physiotherapy” [All Fields]))

Subject: Elective surgery

Date censoring: 1970

Restrictions: none

“Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Elective sigmoid resection” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “Elective colectomy” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] OR “Surgery” AND “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “laparoscopic colectomy” OR “Diverticulitis” [MeSH] OR “Diverticulitis, Colonic” [MeSH] OR “diverticulitis” [All Fields] AND “laparosc*”.

1.
Painter NS, Burkitt DP: Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol 1975;4:3-21.
2.
Parks TG: Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4:53-69.
3.
Schoetz DJ: Diverticular disease of the colon: a century-old problem. Dis Colon Rectum 1999;42:703-709.
4.
Etzioni DA, Mack TM, Beart RW, Kaiser AM: Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment. Ann Surg 2009;249:210-217.
5.
Draaisma WA, van de Wall BJ, Vermeulen J, Unlu C, de Korte N, Swank HA: Treatment for diverticulitis not thoroughly researched (in Dutch). Ned Tijdschr Geneeskd 2009;153:A648.
6.
Kiwa Prismant. www.kiwaprismant.nl.
7.
Ambrosetti P, Robert JH, Witzig JA, Mirescu D, Mathey P, Borst F, Rohner A: Acute left colonic diverticulitis in young patients. J Am Coll Surg 1994;179:156-160.
8.
Schauer PR, Ramos R, Ghiatas AA, Sirinek KR: Virulent diverticular disease in young obese men. Am J Surg 1992;164:443-446, discussion 446-448.
9.
Lahat A, Menachem Y, Avidan B, Yanai H, Sakhnini E, Bardan E, Bar-Meir S: Diverticulitis in the young patient - is it different? World J Gastroenterol 2006;12:2932-2935.
10.
Acosta JA, Grebenc ML, Doberneck RC, McCarthy JD, Fry DE: Colonic diverticular disease in patients 40 years old or younger. Am Surg 1992;58:605-607.
11.
Rodkey GV, Welch CE: Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984;200:466-478.
12.
Hinchey EJ, Schaal PG, Richards GK: Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85-109.
13.
Wasvary H, Turfah F, Kadro O, Beauregard W: Same hospitalization resection for acute diverticulitis. Am Surg 1999;65:632-635, discussion 636.
14.
Klarenbeek BR, de Korte N, van der Peet DL, Cuesta MA: Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 2012;27:207-214.
15.
Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, Essani R, Beart RW: The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100:910-917.
16.
Ambrosetti P, Becker C, Terrier F: Colonic diverticulitis: impact of imaging on surgical management - a prospective study of 542 patients. Eur Radiol 2002;12:1145-1149.
17.
Stollman NH, Raskin JB: Diagnosis and management of diverticular disease of the colon in adults. Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94:3110-3121.
18.
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI: Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005;140:576-581, discussion 581-583.
19.
Mäkelä J, Vuolio S, Kiviniemi H, Laitinen S: Natural history of diverticular disease: when to operate? Dis Colon Rectum 1998;41:1523-1528.
20.
Anaya DA, Flum DR: Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005;140:681-685.
21.
Haglund U, Hellberg R, Johnsén C, Hultén L: Complicated diverticular disease of the sigmoid colon. An analysis of short and long term outcome in 392 patients. Ann Chir Gynaecol 1979;68:41-46.
22.
Larson DM, Masters SS, Spiro HM: Medical and surgical therapy in diverticular disease: a comparative study. Gastroenterology 1976;71:734-737.
23.
Parks TG: Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J 1969;4:639-642.
24.
Ambrosetti P, Grossholz M, Becker C, Terrier F, Morel P: Computed tomography in acute left colonic diverticulitis. Br J Surg 1997;84:532-534.
25.
Biondo S, Parés D, Martí Ragué J, Kreisler E, Fraccalvieri D, Jaurrieta E: Acute colonic diverticulitis in patients under 50 years of age. Br J Surg 2002;89:1137-1141.
26.
Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR: Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg 2006;243:876-880, discussion 880-883.
27.
Nylamo E: Diverticulitis of the colon: role of surgery in preventing complications. Ann Chir Gynaecol 1990;79:139-142.
28.
Lorimer JW: Is prophylactic resection valid as an indication for elective surgery in diverticular disease? Can J Surg 1997;40:445-448.
29.
Somasekar K, Foster ME, Haray PN: The natural history diverticular disease: is there a role for elective colectomy? J R Coll Surg Edinb 2002;47:481-482, 484.
30.
Andeweg C, Peters J, Bleichrodt R, van Goor H: Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease. World J Surg 2008;32:1501-1506.
31.
Hart AR, Kennedy HJ, Stebbings WS, Day NE: How frequently do large bowel diverticula perforate? An incidence and cross-sectional study. Eur J Gastroenterol Hepatol 2000;12:661-665.
32.
Pittet O, Kotzampassakis N, Schmidt S, Denys A, Demartines N, Calmes JM: Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis? World J Surg 2009;33:547-552.
33.
Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA: Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010;251:670-674.
34.
Schweitzer J, Casillas RA, Collins JC: Acute diverticulitis in the young adult is not ‘virulent'. Am Surg 2002;68:1044-1047.
35.
Guzzo J, Hyman N: Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum 2004;47:1187-1190, discussion 1190-1191.
36.
Ouriel K, Schwartz SI: Diverticular disease in the young patient. Surg Gynecol Obstet 1983;156:1-5.
37.
Freischlag J, Bennion RS, Thompson JE: Complications of diverticular disease of the colon in young people. Dis Colon Rectum 1986;29:639-643.
38.
Rothenberger DA, Wiltz O: Surgery for complicated diverticulitis. Surg Clin North Am 1993;73:975-992.
39.
Nelson RS, Velasco A, Mukesh BN: Management of diverticulitis in younger patients. Dis Colon Rectum 2006;49:1341-1345.
40.
Janes S, Meagher A, Faragher IG, Shedda S, Frizelle FA: The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature. Dis Colon Rectum 2009;52:1008-1016.
41.
Helderman JH, Goral S: Gastrointestinal complications of transplant immunosuppression. J Am Soc Nephrol 2002;13:277-287.
42.
Hwang SS, Cannom RR, Abbas MA, Etzioni D: Diverticulitis in transplant patients and patients on chronic corticosteroid therapy: a systematic review. Dis Colon Rectum 2010;53:1699-1707.
43.
Dalla Valle R, Capocasale E, Mazzoni MP, Busi N, Benozzi L, Sivelli R, Sianesi M: Acute diverticulitis with colon perforation in renal transplantation. Transplant Proc 2005;37:2507-2510.
44.
Qasabian RA, Meagher AP, Lee R, Dore GJ, Keogh A: Severe diverticulitis after heart, lung, and heart-lung transplantation. J Heart Lung Transplant 2004;23:845-849.
45.
Lederman ED, Conti DJ, Lempert N, Singh TP, Lee EC: Complicated diverticulitis following renal transplantation. Dis Colon Rectum 1998;41:613-618.
46.
McCune TR, Nylander WA, Van Buren DH, Richie RE, MacDonell RC, Johnson HK, Shull H, Cate CK, Helderman JH: Colonic screening prior to renal transplantation and its impact on post-transplant colonic complications. Clin Transplant 1992;6:91-96.
47.
Sachar DB, NDSG: Diverticulitis in immunosuppressed patients. J Clin Gastroenterol 2008;42:1154-1155.
48.
Lorimer JW, Doumit G: Comorbidity is a major determinant of severity in acute diverticulitis. Am J Surg 2007;193:681-685.
49.
Sorser SA, Hazan TB, Piper M, Maas LC: Obesity and complicated diverticular disease: is there an association? South Med J 2009;102:350-353.
50.
Zaidi E, Daly B: CT and clinical features of acute diverticulitis in an urban US population: rising frequency in young, obese adults. AJR Am J Roentgenol 2006;187:689-694.
51.
Dobbins C, Defontgalland D, Duthie G, Wattchow DA: The relationship of obesity to the complications of diverticular disease. Colorectal Dis 2006;8:37-40.
52.
Aldoori W, Ryan-Harshman M: Preventing diverticular disease. Review of recent evidence on high-fibre diets. Can Fam Physician 2002;48:1632-1637.
53.
Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC: A prospective study of diet and the risk of symptomatic diverticular disease in men. Am J Clin Nutr 1994;60:757-764.
54.
Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H: How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. Ann Surg 2011;253:940-946.
55.
Laméris W, van Randen A, van Gulik TM, Busch OR, Winkelhagen J, Bossuyt PM, Stoker J, Boermeester MA: A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum 2010;53:896-904.
56.
Laurell H, Hansson LE, Gunnarsson U: Acute diverticulitis - clinical presentation and differential diagnostics. Colorectal Dis 2007;9:496-501, discussion 501-502.
57.
Toorenvliet BR, Bakker RF, Breslau PJ, Merkus JW, Hamming JF: Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Colorectal Dis 2010;12:179-186.
58.
Cho KC, Morehouse HT, Alterman DD, Thornhill BA: Sigmoid diverticulitis: diagnostic role of CT - comparison with barium enema studies. Radiology 1990;176:111-115.
59.
Ambrosetti P, Jenny A, Becker C, Terrier TF, Morel P: Acute left colonic diverticulitis - compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Dis Colon Rectum 2000;43:1363-1367.
60.
Stoker J, van Randen A, Laméris W, Boermeester MA: Imaging patients with acute abdominal pain. Radiology 2009;253:31-46.
61.
Ambrosetti P: Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg 2008;12:1318-1320.
62.
Balfe DM, Levine MS, Ralls PW, Bree RL, DiSantis DJ, Glick SN, Megibow AJ, Saini S, Shuman WP, Greene FL, Laine LA, Lillemoe K: Evaluation of left lower quadrant pain. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215:167-171.
63.
Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J: Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol 2008;18:2498-2511.
64.
Liljegren G, Chabok A, Wickbom M, Smedh K, Nilsson K: Acute colonic diverticulitis: a systematic review of diagnostic accuracy. Colorectal Dis 2007;9:480-488.
65.
Laméris W, van Randen A, van Es HW, van Heesewijk JP, van Ramshorst B, Bouma WH, ten Hove W, van Leeuwen MS, van Keulen EM, Dijkgraaf MG, Bossuyt PM, Boermeester MA, Stoker J, OPTIMA study group: Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009;338:b2431.
66.
van Randen A, Laméris W, van Es HW, van Heesewijk HP, van Ramshorst B, Ten Hove W, Bouma WH, van Leeuwen MS, van Keulen EM, Bossuyt PM, Stoker J, Boermeester MA, OPTIMA study group: A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 2011;21:1535-1545.
67.
Heverhagen JT, Sitter H, Zielke A, Klose KJ: Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum 2008;51:1810-1815.
68.
Halpenny DF, McNeil G, Snow A, Geoghegan T, Torreggiani WC: Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum 2009;52:1030-1031, author reply 1031.
69.
Ajaj W, Ruehm SG, Lauenstein T, Goehde S, Kuehle C, Herborn CU, Langhorst J, Zoepf T, Gerken G, Goyen M: Dark-lumen magnetic resonance colonography in patients with suspected sigmoid diverticulitis: a feasibility study. Eur Radiol 2005;15:2316-2322.
70.
Schreyer AG, Fürst A, Agha A, Kikinis R, Scheibl K, Schölmerich J, Feuerbach S, Herfarth H, Seitz J: Magnetic resonance imaging based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis 2004;19:474-480.
71.
Lahat A, Yanai H, Menachem Y, Avidan B, Bar-Meir S: The feasibility and risk of early colonoscopy in acute diverticulitis: a prospective controlled study. Endoscopy 2007;39:521-524.
72.
Sakhnini E, Lahat A, Melzer E, Apter S, Simon C, Natour M, Bardan E, Bar-Meir S: Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36:504-507.
73.
Hale WB, NDSG: Colonoscopy in the diagnosis and management of diverticular disease. J Clin Gastroenterol 2008;42:1142-1144.
74.
Crispin A, Birkner B, Munte A, Nusko G, Mansmann U: Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy 2009;41:1018-1025.
75.
Brayko CM, Kozarek RA, Sanowski RA, Howells T: Diverticular rupture during colonoscopy. Fact or fancy? Dig Dis Sci 1984;29:427-431.
76.
Krones CJ, Klinge U, Butz N, Junge K, Stumpf M, Rosch R, Hermanns B, Heussen N, Schumpelick V: The rare epidemiologic coincidence of diverticular disease and advanced colonic neoplasia. Int J Colorectal Dis 2006;21:18-24.
77.
Stefánsson T, Ekbom A, Sparèn P, Påhlman L: Association between sigmoid diverticulitis and left-sided colon cancer: a nested, population-based, case control study. Scand J Gastroenterol 2004;39:743-747.
78.
Meurs-Szojda MM, Terhaar sive Droste JS, Kuik DJ, Mulder CJ, Felt-Bersma RJ: Diverticulosis and diverticulitis form no risk for polyps and colorectal neoplasia in 4,241 colonoscopies. Int J Colorectal Dis 2008;23:979-984.
79.
Hjern F, Josephson T, Altman D, Holmström B, Mellgren A, Pollack J, Johansson C: Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory? Scand J Gastroenterol 2007;42:41-47.
80.
Lahat A, Yanai H, Sakhnini E, Menachem Y, Bar-Meir S: Role of colonoscopy in patients with persistent acute diverticulitis. World J Gastroenterol 2008;14:2763-2766.
81.
Alonso S, Pera M, Parés D, Pascual M, Gil MJ, Courtier R, Grande L: Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis 2010;12:e278-e282.
82.
Al-Sahaf O, Al-Azawi D, Fauzi MZ, El-Masry S, Gillen P: Early discharge policy of patients with acute colonic diverticulitis following initial CT scan. Int J Colorectal Dis 2008;23:817-820.
83.
Tursi A, Brandimarte G, Elisei W, Giorgetti GM, Inchingolo CD, Danese S, Aiello F: Assessment and grading of mucosal inflammation in colonic diverticular disease. J Clin Gastroenterol 2008;42:699-703.
84.
Schug-Pass C, Geers P, Hügel O, Lippert H, Köckerling F: Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis 2010;25:751-759.
85.
Ribas Y, Bombardó J, Aguilar F, Jovell E, Alcantara-Moral M, Campillo F, Lleonart X, Serra-Aracil X: Prospective randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicillin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Colorectal Dis 2010;25:1363-1370.
86.
Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA: Patterns of recurrence in patients with acute diverticulitis. Br J Surg 2010;97:952-957.
87.
Basisset kwaliteits indicatoren publieke gezondheidszorg. http://www.igz.nl.
88.
Köhler L, Sauerland S, Neugebauer E: Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999;13:430-436.
89.
Surgical treatment of diverticulitis. Patient Care Committee of the Society for Surgery of the Alimentary Tract (SSAT). J Gastrointest Surg 1999;3:212-213.
90.
Rafferty J, Shellito P, Hyman NH, Buie WD: Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939-944.
92.
Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K, AVOD Study Group: Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012;99:532-539.
93.
Ridgway PF, Latif A, Shabbir J, Ofriokuma F, Hurley MJ, Evoy D, O'Mahony JB, Mealy K: Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis 2009;11:941-946.
94.
Wilson RG, Smith AN, Macintyre IM: Complications of diverticular disease and non-steroidal anti-inflammatory drugs: a prospective study. Br J Surg 1990;77:1103-1104.
95.
Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR: Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease. Br J Surg 2003;90:1267-1272.
96.
Goh H, Bourne R: Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Ann R Coll Surg Engl 2002;84:93-96.
97.
Corder A: Steroids, non-steroidal anti-inflammatory drugs, and serious septic complications of diverticular disease. Br Med J (Clin Res Ed) 1987;295:1238.
98.
Ranji SR, Goldman LE, Simel DL, Shojania KG: Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA 2006;296:1764-1774.
99.
Manterola C, Vial M, Moraga J, Astudillo P: Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev 2011;1:CD005660.
100.
Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F: Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005;48:787-791.
101.
Hamy A, Paineau J: Société de chirurgie viscérale de l'ouest (SCVO). Percutaneous drainage of perisigmoid abscesses of diverticular origin (in French). Ann Chir 2001;126:133-137.
102.
Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA: Percutaneous CT scan-guided drainage versus antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum 2006;49:1533-1538.
103.
Siewert B, Tye G, Kruskal J, Sosna J, Opelka F, Raptopoulos V, Goldberg SN: Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol 2006;186:680-686.
104.
Singh B, May K, Coltart I, Moore NR, Cunningham C: The long-term results of percutaneous drainage of diverticular abscess. Ann R Coll Surg Engl 2008;90:297-301.
105.
Antolovic D, Reissfelder C, Koch M, Mertens B, Schmidt J, Büchler MW, Weitz J: Surgical treatment of sigmoid diverticulitis - analysis of predictive risk factors for postoperative infections, surgical complications, and mortality. Int J Colorectal Dis 2009;24:577-584.
106.
Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E, Coene PP, Weidema WF, Lange JF: Outcome after emergency surgery for acute perforated diverticulitis in 200 cases. Dig Surg 2007;24:361-366.
107.
Morris CR, Harvey IM, Stebbings WS, Hart AR: Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008;95:876-881.
108.
Ricciardi R, Baxter NN, Read TE, Marcello PW, Hall J, Roberts PL: Is the decline in the surgical treatment for diverticulitis associated with an increase in complicated diverticulitis? Dis Colon Rectum 2009;52:1558-1563.
109.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, Surviving Sepsis Campaign Guidelines including the Pediatric Subgroup: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41:580-637.
110.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
111.
Lin SM, Huang CD, Lin HC, Liu CY, Wang CH, Kuo HP: A modified goal-directed protocol improves clinical outcomes in intensive care unit patients with septic shock: a randomized controlled trial. Shock 2006;26:551-557.
112.
Vermeulen J, Coene PP, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GH, Weidema WF, Lange JF: Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009;11:619-624.
113.
Salem L, Veenstra DL, Sullivan SD, Flum DR: The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 2004;199:904-912.
114.
Kam MH, Tang CL, Chan E, Lim JF, Eu KW: Systematic review of intraoperative colonic irrigation versus manual decompression in obstructed left-sided colorectal emergencies. Int J Colorectal Dis 2009;24:1031-1037.
115.
Abbas S: Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007;22:351-357.
116.
Constantinides VA, Heriot A, Remzi F, Darzi A, Senapati A, Fazio VW, Tekkis PP: Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures. Ann Surg 2007;245:94-103.
117.
Vermeulen J, Lange JF: Treatment of perforated diverticulitis with generalized peritonitis: past, present, and future. World J Surg 2010;34:587-593.
118.
Alamili M, Gögenur I, Rosenberg J: Acute complicated diverticulitis managed by laparoscopic lavage. Dis Colon Rectum 2009;52:1345-1349.
119.
Swank H, Vermeulen J, Lange JF, et al: The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann's procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis. BMC Surg 2010;10:29.
120.
Wong WD, Wexner SD, Lowry A, Vernava A, Burnstein M, Denstman F, Fazio V, Kerner B, Moore R, Oliver G, Peters W, Ross T, Senatore P, Simmang C: Practice parameters for the treatment of sigmoid diverticulitis - supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000;43:290-297.
121.
Janes S, Meagher A, Frizelle FA: Elective surgery after acute diverticulitis. Br J Surg 2005;92:133-142.
122.
Collins D, Winter DC: Elective resection for diverticular disease: an evidence-based review. World J Surg 2008;32:2429-2433.
123.
Richards RJ, Hammitt JK: Timing of prophylactic surgery in prevention of diverticulitis recurrence: a cost-effectiveness analysis. Dig Dis Sci 2002;47:1903-1908.
124.
Simpson J, Neal KR, Scholefield JH, Spiller RC: Patterns of pain in diverticular disease and the influence of acute diverticulitis. Eur J Gastroenterol Hepatol 2003;15:1005-1010.
125.
Klarenbeek BR, Veenhof AA, Bergamaschi R, van der Peet DL, van den Broek WT, de Lange ES, Bemelman WA, Heres P, Lacy AM, Engel AF, Cuesta MA: Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial: Ann Surg 2009;249:39-44.
126.
Gervaz P, Inan I, Perneger T, Schiffer E, Morel P: A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 2010;252:3-8.
127.
Siddiqui MR, Sajid MS, Qureshi S, Cheek E, Baig MK: Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis. Am J Surg 2010;200:144-161.
128.
Purkayastha S, Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Tilney H, Darzi AW, Heriot AG: Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum 2006;49:446-463.
129.
Siddiqui MR, Sajid MS, Khatri K, Cheek E, Baig MK: Elective open versus laparoscopic sigmoid colectomy for diverticular disease: a meta-analysis with the Sigma trial. World J Surg 2010;34:2883-2901.
130.
Nygren J, Soop M, Thorell A, Hausel J, Ljungqvist O, ERAS Group: An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 consecutive patients. Dis Colon Rectum 2009;52:978-985.
131.
Thaler K, Weiss EG, Nogueras JJ, Arnaud JP, Wexner SD, Bergamaschi R: Recurrence rates at minimum 5-year follow-up: laparoscopic versus open sigmoid resection for uncomplicated diverticulitis. Surg Laparosc Endosc Percutan Tech 2003;13:325-327.
132.
Benn PL, Wolff BG, Ilstrup DM: Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986;151:269-271.
133.
Brodribb AJ: Treatment of symptomatic diverticular disease with a high-fibre diet. Lancet 1977;1:664-666.
134.
Ünlü C, Daniels L, Vrouenraets BC, Boermeester MA: A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis 2012;27:419-427.
135.
Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons: Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939-944.
136.
Turunen P, Wikström H, Carpelan-Holmström M, Kairaluoma P, Kruuna O, Scheinin T: Smoking increases the incidence of complicated diverticular disease of the sigmoid colon. Scand J Surg 2010;99:14-17.
137.
Floch CL: Diagnosis and management of acute diverticulitis. J Clin Gastroenterol 2006;40(suppl 3):S136-S144.
138.
Porta E, Germano A, Ferrieri A, Koch M: The natural history of diverticular disease of the colon: a role for antibiotics in preventing complications? A retrospective study. Riv Eur Sci Med Farmacol 1994;16:33-39.
139.
Tursi A, Brandimarte G, Daffinà R: Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon. Dig Liver Dis 2002;34:510-515.
140.
Tursi A: New physiopathological and therapeutic approaches to diverticular disease of the colon. Expert Opin Pharmacother 2007;8:299-307.
141.
Dughera L, Serra AM, Battaglia E, Tibaudi D, Navino M, Emanuelli G: Acute recurrent diverticulitis is prevented by oral administration of a polybacterial lysate suspension. Minerva Gastroenterol Dietol 2004;50:149-153.
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