Research Article
Management of Colonic Diverticulitis Tailored to Location and Severity: Comparison of Right and Left Colon
Byeoung Hoon Chung, Gi Won Ha, Min Ro Lee* and Jong Hun Kim
1Department of Clinical Medicine, Chonbuk National University Medical School, South Korea
*Corresponding author: Min Ro Lee, Department of Clinical Medicine, Research Institute of Clinical Medicine, Chonbuk National University Medical School, San 2-20 Geumamdong, Deokjin-gu, Jeonju, Jeonbuk 561-180, South Korea
Published: 28 Oct, 2016
Cite this article as: Chung BH, Ha GW, Lee MR, Kim JH.
Management of Colonic Diverticulitis
Tailored to Location and Severity:
Comparison of Right and Left Colon.
Clin Surg. 2016; 1: 1164.
Abstract
Aim: To assess optimal management of colonic diverticulitis as a function of location and disease severity, as well as factors associated with complicated diverticulitis.
Methods: This retrospective review analyzed 202 patients diagnosed with colonic diverticulitis by abdominopelvic CT between 2007 and 2014 at Chonbuk National University Hospital, South Korea. Diverticulitis location was determined, and disease severity categorized by modified Hinchey classification.
Results: The 202 patients included 108 males (53.5%) and 94 females (46.5%); of these, 167 patients (82.7%) were diagnosed with right-sided and 35 (17.3%) with left-sided colonic diverticulitis. Of the 167 patients with right-sided colonic diverticulitis, 12 (7.2%) had complicated and 155 (92.8%) had uncomplicated diverticulitis; of these, 157 patients (94.0%) were successfully managed conservatively. Of the 35 patients with left-sided colonic diverticulitis, 23 (65.7%) had complicated and 12 (34.3%) had uncomplicated diverticulitis; of these, 23 patients (65.7%) were managed surgically. Among patients with right-sided diverticulitis, those with complicated disease were significantly older (54.3±12.7 versus 42.5±13.4 years, p=0.004) and more likely to be smokers (66.7% versus 32.9%, p=0.027) than those with uncomplicated disease. However, among patients with leftsided diverticulitis, those with complicated disease had significantly lower body mass index (BMI; 21.9±4.7 versus 25.8±4.3 kg/m2, p=0.021) than those with uncomplicated disease.
Conclusion: Conservative management may be effective in patients with right-sided diverticulitis,
as well as in patients with uncomplicated left-sided colonic diverticulitis. Surgical management
may be required for patients with complicated left-sided diverticulitis. Factors associated with
complicated diverticulitis include older age, smoking and lower BMI.
Keywords: Diverticulitis; Colonic; Computed tomography; Anti-Bacterial Agents/Therapeutic
Use; Treatment outcome; Risk factors
Introduction
The incidence of colonic diverticulitis is increasing, both in Asian and Western countries.
This increase may be due to improvements in diagnostic tools, such as abdominopelvic computed
tomography (CT), which can provide detailed diagnosis of diverticulitis between the different variants
of disease progression [1,2]. Diverticulitis can be classified as uncomplicated or complicated by CT
evaluation. Uncomplicated diverticulitis is characterized by evidence of colonic wall thickening or
pericolic inflammatory changes, whereas complicated diverticular disease is characterized by the
presence of abscesses, fistulas, obstructions, and/or localized or free perforations. The severity of
acute diverticulitis is often graded by the modified Hinchey classification [1-4]. Surgical management
of diverticulitis has been questioned, with conservative management increasingly used in patients
with diverticulitis in both the right and left colon. Moreover, surgery may not always be appropriate
in patients with a complicated form of diverticulitis.
Few studies to date have compared management of patients with diverticulitis in the right and
left colon. This study evaluated the management of diverticulitis as a function of disease location
(right or left colon) and disease severity (complicated or uncomplicated). In addition, factors
associated with complicated diverticulitis were determined.
Materials and Methods
Patients diagnosed with colonic diverticulitis by abdominopelvic CT at Chonbuk National
University Hospital, South Korea, from 2007 to 2014 were retrospectively evaluated. Demographics
and clinical features were obtained from patient records, including
age, sex, results of physical examinations, body mass index (BMI), comorbidities,
changes in bowel habits, length of hospital stay, duration
of antibiotic use, bowel rest, CT findings, type of surgery, and disease
recurrence. Abdominopelvic CT findings were categorized by the
modified Hinchey classification, with patients classified as having
stages Ib, II, III and IV diverticulitis, as well as fistula or obstruction,
defined as having complicated diverticulitis [2]. Patients without CT
scan evidence of diverticulitis were excluded from the study.
Categorical variables were compared by chi-square and Fisher’s
exact tests, whereas continuous variables were compared by Student’s
t-tests. Logistic regression analysis was used for multivariate analysis.
P values < 0.05 were considered statistically significant.
Table 1
Results
During the study period, 202 patients, 108 males (53.5%) and
94 females (46.5%) were diagnosed with diverticulitis, including
167 patients (82.7%) with right-sided and 35 (17.3%) with left-sided
colonic diverticulitis. Patients with right-sided diverticulitis were
significantly younger (43.4±13.7 versus 65.8±15.4 years, p=0.001),
significantly more likely to be male (58.1% versus 31.4%, p=0.004) and
significantly less likely to have comorbidities (31.7% versus 62.9%,
p=0.013) than patients with left-sided diverticulitis. Other variables
in these two groups are shown in (Table 1), and multivariate analysis
of factors significantly associated with the location of diverticulitis is
shown in (Table 2).
Statistical analysis showed that factors significantly associated
with complicated diverticulitis were dependent on disease
location. Compared with patients with uncomplicated right-sided
diverticulitis, those with complicated right-sided diverticulitis were
significantly older (54.3±12.7 versus 42.5±13.4 years, p=0.004) and
were significantly more likely to be smokers (66.7% versus 32.9%,
p=0.027) (Table 3). However, among patients with left-sided
diverticulitis, those with complicated disease had significantly lower
body mass index (BMI; 21.9±4.7 versus 25.8±4.3 kg/m2, p=0.021)
than those with uncomplicated disease (Table 4).
Of the 172 patients with right-sided disease, 12 (7.2%) had
complicated and 155 (92.8%) had uncomplicated diverticulitis. Of
the 12 patients with complicated diverticulitis, seven were managed
surgically and five were managed conservatively. Of the 155 patients
with uncomplicated diverticulitis, 152 were successfully managed
conservatively. The other three patients were initially managed
conservatively, but eventually underwent surgery (Figure 1a).
Of the 35 patients with left-sided disease, 23 (65.7%) had
complicated and 12 (34.3%) had uncomplicated diverticulitis. Of
the 23 patients with complicated diverticulitis, 17 were managed
surgically and six were initially managed conservatively. Three of
the latter six patients, however, failed conservative management and
eventually underwent surgery. Of the 12 patients with uncomplicated
diverticulitis, nine were successfully managed conservatively, with
the remaining three patients requiring surgery (Figure 1b).
Table 2
Table 3
Table 4
Discussion
This retrospective analysis suggests that management of patients
with colonic diverticulitis is dependent on both disease location
and severity. This analysis also identified clinicopathological factors
associated with both disease location and disease severity.
The demographic and clinical characteristics of patients in
the present study were similar to those in previous studies of
diverticulitis. Right-sided colonic diverticulitis has been reported to
occur predominantly in relatively young males, whereas left-sided
diverticular disease is more common in women, with its incidence
increasing with age [5-9]. The present study also found that left-sided
colonic diverticulitis was significantly associated with both older age
and female gender.
Diverticulitis in younger patients (< 50 years) has been described
as more virulent and more likely to be associated with complications
[10,11]. In addition, smoking was found to be a risk factor in
patients with symptomatic disease and to be related to complications
[12,13]. The present study found that older age and smoking were
significantly associated with complicated right-sided diverticulitis,
whereas low BMI was significantly associated with complicated leftsided
diverticulitis. To our knowledge, no previous study has assessed
factors associated with locations of complicated diverticulitis from
the same population. The findings of this study suggest that special
considerations may be required to manage patients with factors
associated with complicated diverticulitis. These patients initially
have uncomplicated diverticulitis, which becomes aggravated and
complicated, resulting in a switch from conservative to surgical
management. Additional large scale studies are required to confirm
these findings, especially in patients with complicated left-sided
diverticulitis.
Conservative management has been shown to be effective in
patients with uncomplicated diverticulitis, both in the right and
left colon [14-19]. However, the optimal treatment of complicated
diverticulitis has not been determined, as improvements in
surgical techniques and medical management have led to changes
in management. Traditionally, most patients with complicated
diverticulitis were managed surgically, by, for example, resection of the
perforated segment of the colon [20-23]. Conservative management
of complicated diverticulitis has been reported successful [24,25].
Medical management in patients with complicated diverticulitis
may have the goal of converting an emergency to an elective surgical
situation [2,26,27].
The results of the present study suggest that conservative
management may be effective in patients with right-sided colonic
diverticulitis. Of the 155 patients with uncomplicated right-sided
diverticulitis, 152 (98%) were treated conservatively, and only 12 (7%)
of the 167 patients with right-sided diverticulitis had complicated
disease. Of these 12 patients, only two required emergency surgery for
acute peritonitis and sepsis. Three patients with uncomplicated and
five with complicated right-sided diverticulitis were initially managed
conservatively, but eventually underwent right hemicolectomy. A
review of medical records and radiologic findings could not identify
any criteria or indications for surgery in these patients, suggesting that
these patients may have undergone unnecessary surgery, performed
at the discretion of a surgeon not specializing in colorectal surgery.
These patients likely could have been managed conservatively.
Because the number of patients with left-sided colonic
diverticulitis was relatively small, we could not determine any effective
treatment modality. Our findings suggest, however, that conservative
management may be effective for patients with uncomplicated
diverticulitis, but that surgical management may be better for patients
with complicated diverticulitis. Of the 23 patients with complicated
left-sided diverticulitis, 20 (87%) underwent surgery, with 15 having
Hinchey stage III or IV disease requiring emergency surgery.
This study had several limitations, including its retrospective
design and its performance at a single tertiary center where almost all
patients were Asian. Moreover, only inpatients were included; there
were no outpatients with mild diverticulitis. Therefore, this study
was limited in assessing the clinical features of all patients diagnosed
with diverticulitis. In addition, the number of patients with left-sided
diverticulitis was much smaller than the number with right colonicsided
diverticulitis. Finally, this study did not evaluate the long-term
effects of conservative management of diverticulitis, specifically
recurrence rate.
In conclusion, conservative management may be effective in
patients with right-sided colonic diverticulitis, whether complicated
or uncomplicated, and in patients with uncomplicated left-sided
diverticulitis. Patients with complicated left-sided diverticulitis
may, however, require surgical management. In addition, special
attention should be paid in managing patients with factors associated
with complications, such as older age and smoking in patients with
right-sided and low BMI in patients with left-sided complicated
diverticulitis.
References
- 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.
- Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005; 100: 910-917.
- Hachigian MP, Honickman S, Eisenstat TE, Rubin RJ, Salvati EP. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum. 1992; 35: 1123-1129.
- Rao PM, Rhea JT, Novelline RA, Dobbins JM, Lawrason JN, Sacknoff R, et al. Helical CT with only colonic contrast material for diagnosing diverticulitis: prospective evaluation of 150 patients. AJR Am J Roentgenol. 1998; 170: 1445-1449.
- Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg. 1996; 171: 244-246.
- Lee IK, Jung SE, Gorden DL, Lee YS, Jung DY, Oh ST, et al. The diagnostic criteria for right colonic diverticulitis: prospective evaluation of 100 patients. Int J Colorectal Dis. 2008; 23: 1151-1157.
- Lee IK, Lee YS, Kim SJ, Gorden DL, Won DY, Kim HJ, et al. Laparoscopic and open surgery for right colonic diverticulitis. Am Surg. 2010; 76: 486- 491.
- Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol. 1975; 4: 53-69.
- Commane DM, Arasaradnam RP, Mills S, Mathers JC, Bradburn M. Diet, ageing and genetic factors in the pathogenesis of diverticular disease. World J Gastroenterol. 2009; 15: 2479-2488.
- Cortesini C, Pantalone D. Usefulness of colonic motility study in identifying patients at risk for complicated diverticular disease. Dis Colon Rectum. 1991; 34: 339-342.
- Cranston D, McWhinnie D, Collin J. Dietary fibre and gastrointestinal disease. Br J Surg. 1988; 75: 508-512.
- Aldoori WH, Giovannucci EL, Rimm EB, Ascherio A, Stampfer MJ, Colditz GA, et al. Prospective study of physical activity and the risk of symptomatic diverticular disease in men. Gut. 1995; 36: 276-282.
- Papagrigoriadis S, Macey L, Bourantas N, Rennie JA. Smoking may be associated with complications in diverticular disease. Br J Surg. 1999; 86: 923-926.
- Alonso S, Pera M, Parés D, Pascual M, Gil MJ, Courtier R, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2010; 12: 278-282.
- Etzioni DA, Chiu VY, Cannom RR, Burchette RJ, Haigh PI, Abbas MA. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum. 2010; 53: 861-865.
- Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014; 5: 284-294.
- Park HC, Chang MY, Lee BH. Nonoperative management of right colonic diverticulitis using radiologic evaluation. Colorectal Dis. 2010; 12: 105- 108.
- Tan KK, Wong J, Sim R. Non-operative treatment of right-sided colonic diverticulitis has good long-term outcome: a review of 226 patients. Int J Colorectal Dis. 2013; 28: 849-854.
- Ha GW, Lee MR, Kim JH. Efficacy of conservative management in patients with right colonic diverticulitis. Anz J Surg. 2015.
- Blair NP, Germann E. Surgical management of acute sigmoid diverticulitis. Am J Surg. 2002; 183: 525-528.
- Mastrorilli M, Mastrorilli G, Martini A, Santo C, Maresca M. Surgical management of acute sigmoid diverticulitis. Ann Ital Chir. 2008; 79: 311- 320.
- Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg. 2003; 185: 135-140.
- Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson JE Jr. Surgical approach to cecal diverticulitis. J Am Coll Surg. 1999; 188: 629-634.
- Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, Mutch MG. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011; 54: 663-671.
- Nelson RS, Ewing BM, Wengert TJ, Thorson AG. Clinical outcomes of complicated diverticulitis managed nonoperatively. Am J Surg. 2008; 196: 969-972.
- 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.
- 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.