Long-Term Evolution of Acute Colonic Diverticulitis After Successful Medical Treatment Long-Term Follow-up After an Initial Episode of Diverticulitis: What Are the Predictors of Recurrence? Danish national guidelines for treatment of diverticular disease. Diverticula and Diverticulitis: Time for a Reappraisal. One year intermittent rifaximin plus fibre supplementation vs. fibre supplementation alone to prevent diverticulitis recurrence: a proof-of-concept study. Prediction and management of recurrent right colon diverticulitis Conservative treatment of acute colonic diverticulitis: Are antibiotics always mandatory? Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence. Colonic diverticulitis: impact of imaging on surgical management – a prospective study of 542 patients Sigmoid Diverticulitis in Young Patients—A More Aggressive Disease than in Older Patients? Balsalazide and/or high-potency probiotic mixture (VSL#3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials. Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe One-stage Sigmoid Colon Resection for Perforated Sigmoid Diverticulitis (Hinchey Stages III and IV) Long-Term Outcome of Mesocolic and Pelvic Diverticular Abscesses of the Left Colon: A Prospective Study of 73 Cases Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis: A Prospective, Multicenter Randomized Clinical Trial (DIVER Trial) A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial) Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence: a randomised multicentre pilot double-blind placebo-controlled study of 24-month duration Short-term Intravenous Antibiotic Treatment in Uncomplicated Diverticulitis Does Not Increase the Risk of Recurrence Compared to Long-term Treatment The out‐patient management of patients with acute mild‐to‐moderate colonic diverticulitis Association of steroid use with complicated sigmoid diverticulitis: potential role of activated CD68+/CD163+ macrophages Assessment of recurrence and complications following uncomplicated diverticulitis Primaryvs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV)
Background The evidence is sparse concerning the natural history of acute diverticulitis after successful conservative management . This observational study aim ed to evaluate the rate , severity , and need of surgery for recurrence after a first episode of acute diverticulitis successfully managed conservatively . Methods All patients admitted for acute diverticulitis between 1994 and 2011 were considered for inclusion in the study . Severity of the first episode , demographic data , comorbidities , management , recurrence , and elective or emergency surgery during the follow-up period were prospect ively recorded . Results The study included 560 patients . The mean follow-up period was of 67.2 ± 44.4 months . Severe diverticulitis was diagnosed in 22.3 % of the cases . Recurrence was observed in 14.8 % of the patients , and the rate of severe recurrence was 3.4 % . Most of the recurrences occurred during the first year of follow-up evaluation . Chronic corticoid therapy ( P = 0.043 ) and the presence of more than one abscess ( P < 0.001 ) were significantly related to recurrence . In the event of a mild recurrence , the first episode was either mild or severe ( P = 0.172 ) . In the case of severe recurrence , most patients presented with a previous severe diverticulitis ( P < 0.001 ) . During the follow-up period , 6.8 % of the patients needed an elective operation , and 1.4 % of them underwent emergency surgery . Conclusion The rate of severe recurrence after successful nonoperative management of acute diverticulitis was low , and emergency surgery was rare . Prophylactic surgery , even in cases of recovered severe diverticulitis , should be considered on a case-by-case basis . Strict follow-up assessment during the first year is advised PURPOSE : The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively . METHODS : We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008 . Patients were identified with International Classification of Diseases , 9th Revision/Current Procedural Terminology codes . Patients were excluded if they had subsequent colectomy based on the first attack ( n = 81 ) , or if the attack they had between 2002 and 2008 was not their first attack ( n = 201 ) . We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists . These radiologists review ed the available published literature for CT imaging characteristics thought to predict diverticulitis severity . CT variables ( n = 20 ) were determined by prospect i ve reevaluation of scans by blinded study radiologists . Clinical variables ( n = 43 ) were coded based on a retrospective chart review . Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates . Multivariate analysis was performed using Cox proportional hazards modeling . Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm . RESULTS : The study population included 672 patients ; mean age , 61 ± 15 years ; mean follow-up , 42.8 ± 24 months . The index presentation of diverticulitis was most commonly located in the sigmoid colon ( 72 % ) , followed by descending colon ( 33 % ) , right colon ( 5 % ) , and transverse colon ( 3 % ) . Overall recurrence at 5 years was 36 % by ( 95 % CI 31.4%–40.6 % ) Kaplan-Meier estimate . Complicated recurrence ( fistula , abscess , free perforation ) occurred in 3.9 % ( 95 % CI 2.2%–5.6 % ) of patients at 5 years by Kaplan-Meier estimate . Family history of diverticulitis ( HR 2.2 , 95 % CI 1.4–3.2 ) , length of involved colon > 5 cm ( HR 1.7 , 95 % CI 1.3–2.3 ) , and retroperitoneal abscess ( HR 4.5 , 95 % CI 1.1–18.4 ) were associated with diverticulitis recurrence . Right colon disease ( HR 0.27 , 95 % CI 0.09–0.86 ) was associated with freedom from recurrence . CONCLUSION : Although diverticulitis recurrence is common following an initial attack that has been managed medically , complicated recurrence is uncommon . Patients who present with a family history of diverticulitis , long segment of involved colon , and /or retroperitoneal abscess are at higher risk for recurrent disease . Patients who present with right-sided diverticulitis are at low risk for recurrent disease . These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy In order to elaborate evidence -based , national Danish guidelines for the treatment of diverticular disease the literature was review ed concerning the epidemiology , staging , diagnosis and treatment of diverticular disease in all its aspects . The presence of colonic diverticula , which is considered to be a mucosal herniation through the intestinal muscle wall , is inversely correlated to the intake of dietary fibre . Other factors in the genesis of diverticular disease may be physical inactivity , obesity , and use of NSAIDs or acetaminophen . Diverticulosis is most common in Western countries with a prevalence of 5 % in the population aged 30 - 39 years and 60 % in the part of the population > 80 years . The incidence of hospitalization for acute diverticulitis is 71/100,000 and the incidence of complicated diverticulitis is 3.5 - 4/100,000 . Acute diverticulitis is conveniently divided into uncomplicated and complicated diverticulitis . Complicated diverticulitis is staged by the Hinchey classification 1 - 4 ( 1 : mesocolic/pericolic abscess , 2 : pelvic abscess , 3 : purulent peritonitis , 4 : faecal peritonitis ) . Diverticulitis is suspected in case of lower left quadrant abdominal pain and tenderness associated with fever and raised WBC and /or CRP ; but the clinical diagnosis is not sufficiently precise . Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey . The distinction between Hinchey 3 and 4 is done by laparoscopy or , when not possible , by laparotomy . Uncomplicated diverticulitis is treated by conservative means . There is no evidence of any beneficial effect of antibiotics in uncomplicated diverticulitis , but antibiotics may be used in selected cases depending on the overall condition of the patients and the severity of the infection . Abscess formation is best treated by US- or CT-guided drainage in combination with antibiotics . When the abscess is < 3 cm in diameter , drainage may be unnecessary , and only antibiotics should be instituted . The surgical treatment of acute perforated diverticulitis has interchanged between resection and non-resection strategies : The three-stage procedure dominating in the beginning of the 20th century was later replaced by the Hartmann procedure or , alternatively , resection of the sigmoid with primary anastomosis . Lately a non-resection strategy consisting of laparoscopy with peritoneal lavage and drainage has been introduced in the treatment of Hinchey stage 3 disease . Evidence so far for the lavage regime is promising , comparing favourably with resection strategies , but lacking in solid proof by r and omized , controlled investigations . In recent years , morbidity has declined in complicated diverticulitis due to improved diagnostics and new treatment modalities . Recurrent diverticulitis is relatively rare and furthermore often uncomplicated than previously assumed . Elective surgery in diverticular disease should probably be limited to symptomatic cases not amenable to conservative measures , since prophylactic resection of the sigmoid , evaluated from present evidence , confers unnecessary risks in terms of morbidity and mortality to the individual as well as unnecessary costs to society . Any recommendation for routine resection following multiple cases of diverticulitis should await results of r and omized studies . Laparoscopic resection is preferred in case of need for elective surgery . When malignancy is ruled out preoperatively , a sigmoid resection with preservation of the inferior mesenteric artery , oral division of colon in soft compliant tissue and anastomosis to upper rectum is recommended . Fistulae to bladder or vagina , or stenosis of the colon may be dealt with according to symptoms and comorbidity . Resection of the diseased segment of colon is preferred when possible and safe ; alternatively , a diverting stoma can be the best solution Colonic diverticula are very common and may be associated with symptoms or complicated by diverticulitis and its associated problems . Many of the traditional concepts relating to the pathophysiology , prevention , and management of these entities have been question ed recently based on findings from high- quality prospect i ve studies . Although dietary fiber may protect against symptoms and complications , its impact on the formation of diverticula may be limited . It is now evident that the risk for an episode of diverticulitis in an individual with diverticula is lower than previously thought . Furthermore , the necessity for antibiotic use in uncomplicated diverticulitis has been question ed and serious doubt cast upon the belief that surgery should be performed when a second attack occurs . Although data are far from conclusive , there is some evidence to suggest that diverticulosis may be associated with chronic abdominal symptoms , with or without underlying chronic inflammatory changes in the involved segment of the colon . In addition , colonoscopy is not routinely required after an attack of acute uncomplicated diverticulitis , as the risk of cancer in this population is not much higher than in the general population BACKGROUND Evidence supporting appropriate medical therapy to prevent recurrence of colonic diverticulitis is limited . Our goal was to evaluate the potential of rifaximin given periodically in addition to fibre for the prophylaxis of recurrences . METHODS We conducted a multicentre , r and omized , open controlled study in patients with a recent episode of colonic diverticulitis , currently in remission . Patients received 3.5 g of high-fibre supplementation b.d . with or without one week per month of the non-absorbable antibiotic rifaximin ( 400 mg b.d . ) for 12months . Primary endpoint was recurrence of diverticulitis , encompassing acute symptomatic flare with or without complications , analyzed by multivariable logistic regression analysis and by Cox proportional hazard method . RESULTS After r and omizing 165 patients , the study was interrupted since the recruitment rate was largely below the minimum anticipated , and the trial was switched from evidence -gathering to proof-of-concept . Recurrences occurred in 10.4 % of patients given rifaximin plus fibres vs. 19.3 % of patients receiving fibres alone . The logistic analysis adjusted for sex , age , illness duration , time from last episode , disease localization and centre recruitment rate , yielded a significant treatment effect ( odds ratio 3.20 ; 95 % confidence interval : 1.16 - 8.82 ; P=0.025 ) . Patients with diverticulitis diagnosed since ≥1 year receiving rifaximin  also had a lower incidence of recurrences ( 10 % ; 95 % confidence interval : 2 - 47 % vs. 67 % ; 95 % confidence interval : 37 - 100 % ) . Both treatments were safe . CONCLUSIONS This study represents a proof-of concept of the efficacy of cyclic rifaximin treatment , added to fibre supplements , to reduce the risk of recurrences of diverticulitis in patients in remission Purpose While the incidence of right colonic diverticulitis ( RCD ) is rare in Western countries , the right colon is the most common site of diverticulitis in Asian countries . However , its recurrent pattern and management were rarely studied . This study was design ed to eluci date the pattern of recurrence in RCD . Methods Of the 154 patients admitted as right colonic diverticulitis between February 2004 and March 2012 , 104 patients were enrolled , prospect ively . The recurrence rate , size , multiplicity , location , diagnostic criteria score , and predisposing factors were evaluated based on Hinchey ’s classification of diverticulitis . Results There were 104 patients with right colonic diverticulitis in this study , and 20 patients ( 19.2 % ) recurred after medical treatment . When the diverticula were not located in the right colon , the recurrence rate was significantly higher than the diverticula located only in the right colon ( p = 0.004 ) . The recurrence rate of diverticulitis for a single diverticulum was significantly lower than that for multiple diverticula ( p = 0.02 ) . Of the 20 patients with recurrence , 1 ( 5 % ) patient underwent laparoscopic diverticulectomy due to a misdiagnosis of diverticulitis as appendicitis . The remaining 19 patients ( 95 % ) received nonoperative management and recovered without any sequelae . Conclusions The recurrence rate was 19.2 % , and the predisposing factors were the location of diverticula and the multiplicity of primary diverticula . The re-recurrence rate of recurred patients was 26.3 % . The recurred lesions were controlled simply by nonoperative management . Elective surgery was also a treatment option Objective . Most patients admitted for acute colonic diverticulitis ( AD ) are managed conservatively and receive antibiotics , although it is uncertain whether all patients with AD benefit from this treatment . The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD . Material and methods . A retrospective audit of 311 patients ( 64 % F , mean age 60 years ) hospitalized for AD was carried out . All patients were initially treated conservatively with observation and restriction of oral intake . Patients receiving antibiotics ( n=118 ) were compared with patients treated with observation and restriction of oral intake only ( n=193 ) . Mean follow-up time ( FU ) was 30 months . Results . Inflammation in patients treated with antibiotics was more pronounced ( laboratory parameters ( C-reactive protein , white blood cell count ) were higher ( p<0.01 ) , fever was more common ( p<0.01 ) and CT grading of inflammation was classified as severe in a higher proportion ( p<0.01 ) ) compared with patients treated without antibiotics . When initially treated with antibiotics , 3 patients ( 3 % ) failed to respond to treatment and had to undergo surgery . There were 7 ( 4 % ) failures in patients initially treated without antibiotics , and antibiotics were then added . During FU , 29 % of patients treated with antibiotics had further events ( recurrent AD and /or subsequent surgery ) compared with 28 % ( NS ) among those treated without antibiotics . In a multivariate analysis , the risk of a further event was not influenced by antibiotic treatment ( OR 1.03 , CI 95 % 0.61–1.74 ) . Conclusions . Our results indicate that antibiotics are not m and atory in mild AD . Treatment without antibiotics appears to be safe and seems not to change the rate of further events . These results warrant further r and omized prospect i ve studies BACKGROUND Colonic diverticulitis shows a high recurrence rate . AIMS To assess the efficacy of three different therapeutic strategies in preventing diverticulitis recurrence . MATERIAL S AND METHODS One hundred thirty patients suffering from Acute Uncomplicated Diverticulitis ( AUD ) ( 81 males , 49 females , mean age 64.71 years , range 40 - 85 ) were prospect ively assessed . After obtaining remission , considered present when both endoscopic and histological damage were absent , the patients were treated with mesalazine 1.6 g/day ( 59 patients , group A ) , or rifaximin 800 mg/day for 7 days every month ( 52 patients , group B ) . Clinical , endoscopic and histological follow-up was performed after 6 , 12 and thereafter every 12 months after diagnosis of AUD . RESULTS Seven patients were excluded from final evaluation because they were lost to follow-up . Fifty-five group A patients and 49 group B patients patients were available for the final assessment at the end of a 24-month follow-up . Sustained remission was significantly higher in group A with respect to group B. CONCLUSIONS Patients taking mesalazine have lower risk of diverticulitis recurrence than patients taking rifaximin because of the lower prevalence of persisting endoscopic and histological inflammation Abstract . The aim of this study was to compare the performance of the CT and the water-soluble contrast enema ( CE ) in the diagnosis and the severity of acute left-colonic diverticulitis , and to recognize the impact of CT during the acute phase and after a first acute episode successfully treated medically . From 1986 to 1997 , all patients admitted in our emergency center with clinical ly suspected left-colonic diverticulitis had a CE and a CT  within 72 h of their admission , unless clinical findings required immediate laparotomy . They were prospect ively included in the study if one or both radiological exams showed signs of acute diverticulitis and /or diverticulitis was surgically removed and histologically proven . Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall ( 5 mm or more ) and inflammation of pericolic fat and CE showed segmental lumen narrowing and tethered mucosa ; it was considered severe when abscess and /or extraluminal air and /or contrast were observed on CT and when one or both of the latter signs were seen on CE . Five hundred forty-two patients entered the study ; 465 patients ( 86 % ) had a CT exam , 439 ( 81 % ) had a CE , and 420 ( 77 % ) had both exams . The performance of CT is significantly superior to CE in terms of sensitivity ( 98 vs 92 % , p<0.01 ) , and in the evaluation of the severity of the inflammation ( 26 vs 9 % , p<0.02 ) . Moreover , of 69 patients who had an associated abscess seen on CT , only 20 ( 29 % ) had indirect signs of this complication on CE . During the acute phase the chances of medical treatment failure are statistically greater when diverticulitis is considered severe on CT than when it is considered moderate ( 26 % for the severe diverticulitis vs 4 % for the moderate ones , p<0.0001 ) . After successful medical treatment of the acute episode , patients with severe diverticulitis on the CT had statistically greater incidence of secondary bad outcome than patients with moderate diverticulitis ( 36 vs 17 % , p<0.0001 ) . Computed tomography should be preferred to CE as the initial radiological exam of diverticulitis because of its statistically significant superiority in sensitivity and for its statistically much higher performance in the detection of severe infection , especially when an abscess is associated with the disease . The severity of diverticulitis on CT is statistically predictive of the risk of medical treatment failure during the acute phase and of the chances of bad secondary outcome after a successful medical treatment of the first episode Introduction There is controversy over whether sigmoid diverticulitis ( SD ) is more aggressive with a higher risk of perforation in younger than in older patients . The aim of this study was to assess the clinical presentation and outcome of patients ≤40 and > 40 years old with acute diverticulitis . Patients and Methods Consecutive admissions of all patients with acute SD were prospect ively recruited from January 1998 to June 2010 . Results A total of 1,019 patients were included : 513 ( 69 ≤40 years and 444 > 40 years ) presented with their first episode , while 506 ( 20 ≤40 years , 486 > 40 years ) had a prior history of SD . The percentage of patients with severe SD did not differ between the two age groups either for the first ( covered perforation , 30.4 % vs. 29.5 % , p = 0.875 ; free perforation , 26.1 % vs. 23.9 % , p = 0.69 ) or for the recurrent episode ( covered perforation , 15 % vs. 8.2 % , p = 0.287 ; free perforation , 5 % vs. 4.1 % , p = 0.846 ) . Furthermore , the rate of emergency surgery did not differ between both age groups either for the first ( 26.1 % vs. 23.9 % , p = 0.690 ) or the recurrent episode ( 5 % vs. 4.1 % , p = 0.846 ) . No differences in the rate of Hartmann ’s procedure ( 52.6 % vs. 68.3 % , p = 0.180 ) and failure of conservative treatment ( 3.4 % vs. 4.9 % , p = 0.607 ) were observed between younger and older patients . Conclusion Acute SD in younger patients is not more aggressive and has no higher risk of perforation or need for emergency surgery compared to older patients Background and aims The role of probiotics in the treatment of diverticulitis is still not known . The aim of our study was to investigate whether balsalazide and /or VSL#3 is effective in preventing diverticulitis recurrence . Material s and methods In this pilot study , 30 consecutive patients ( 19 males , 11 females , mean age 60.1 years , range 47–75 years ) affected by uncomplicated diverticulitis of the colon were monitored . After obtaining remission , the patients were r and omly assigned to one of the following groups as follows : group A , balsalazide 2.25 g daily for 10 days every month plus VSL#3 450 billions/day for 15 days every month and group B , VSL#3 alone 450 billions/day for 15 days every month . Primary end-point was considered the maintaining of remission throughout a 12-month follow-up . Secondary end-points considered were ( 1 ) the assessment of the overall scores at the end of the follow-up and ( 2 ) the effects of the two different treatments with regards to every symptom assessed . Results / findings One group A patient was withdrawn from the study at the 6th month and one group B patient was lost at the 6th month of follow-up . One group A patient ( 6.66 % ) showed relapse of symptoms at the 10th month of follow-up . At the end of follow-up , 11 patients were completely symptom-free ( 73.33 % ) , whilst 2 patients complained of only mild , recurrent symptoms ( 13 % ) . Two group B patients ( 13.33 % ) showed relapse of the disease at the 5th and 8th month of follow-up , respectively . At the end of follow-up , 8 patients were completely symptom-free ( 60 % ) , 2 patients complained of mild , recurrent symptoms ( 13.33 % ) , 1 patient ( 6.66 % ) complained of mild but continuous symptoms . No side effects were recorded throughout the follow-up in both groups . Interpretation/ conclusions Combination probiotic/anti-inflammatory drug was found better than probiotic treatment in preventing relapse of uncomplicated diverticulitis of the colon , even if without statistical significance BACKGROUND & AIMS No therapy has been proven to prevent the recurrence of diverticulitis . Mesalamine has shown efficacy in preventing relapse in inflammatory bowel disease , and there is preliminary evidence that it might be effective for diverticular disease . We investigated the efficacy of mesalamine in preventing recurrence of diverticulitis in 2 identical but separate phase 3 , r and omized , double-blind , placebo-controlled , multicenter trials ( identical confirmatory trials were conducted for regulatory reasons ) . METHODS We evaluated the efficacy and safety of multimatrix mesalamine vs placebo in the prevention of recurrent diverticulitis in 590 ( PREVENT1 ) and 592 ( PREVENT2 ) adult patients with ≥1 episodes of acute diverticulitis in the previous 24 months that resolved without surgery . Patients received mesalamine ( 1.2 g , 2.4 g , or 4.8 g ) or placebo once daily for 104 weeks . The primary end point was the proportion of recurrence-free patients at week 104 . Diverticulitis recurrence was defined as surgical intervention at any time for diverticular disease or presence of computed tomography scan results demonstrating bowel wall thickening ( > 5 mm ) and /or fat str and ing consistent with diverticulitis . For a portion of the study , recurrence also required the presence of abdominal pain and an increase in white blood cells . RESULTS Mesalamine did not reduce the rate of diverticulitis recurrence at week 104 . Among patients in PREVENT1 , 53%-63 % did not have disease recurrence , compared with 65 % of those given placebo . Among patients in PREVENT2 , 59%-69 % of patients did not have disease recurrence , compared with 68 % of those given placebo . Mesalamine did not reduce time to recurrence , and the proportions of patients requiring surgery were comparable among treatment groups . No new adverse events were identified with mesalamine administration . CONCLUSIONS Mesalamine was not superior to placebo in preventing recurrent diverticulitis . Mesalamine is not recommended for this indication . Clinical Trials.gov ID : NCT00545740 and NCT00545103 BACKGROUND : Initial nonoperative management of diverticular abscess has become the st and ard of care ; however , the need for elective resection after this index episode is unclear . OBJECTIVE : The purpose of this study was to assess the long-term outcomes of expectant management after initial nonoperative treatment of diverticular abscess . DESIGN : This was a retrospective chart review with prospect i ve telephone follow-up of patients . SETTING S : The study was conducted at a large tertiary academic colorectal surgery practice in Canada . PATIENTS : Adult patients with CT-documented acute sigmoid diverticulitis complicated by abscess managed nonoperatively from 2000 to 2013 were included . INTERVENTIONS : Long-term definitive nonoperative management of diverticular abscess . MAIN OUTCOME MEASURES : The primary outcome was  emergency sigmoidectomy or death from recurrent diverticulitis . Secondary outcomes were recurrent diverticulitis and elective sigmoidectomy for diverticulitis . RESULTS : Of 135 patients with acute diverticulitis complicated by abscess , a total of 73 patients were managed with nonoperative intent and long-term expectant management . The median follow-up was 62 ( Q1 to Q3 : 28–98 ) months . After resolution of the index episode , 22 patients [ 30.1 % ( 95 % CI , 19.6%–40.6 % ) ] experienced a recurrent episode of diverticulitis at a median of 23 ( range , 9–40 ) months . Two patients [ 2.7 % ( 95 % CI , –1.0 % to 6.4 % ) ] had a recurrent episode with peritonitis that required sigmoidectomy with stoma at 6 and 64 months . Both patients underwent reversal after 4 and 8 months . Seven [ 9.6 % ( 95 % CI , 2.8%–16.4 % ) ] patients experienced a complicated recurrence and underwent an  elective sigmoidectomy  [ median time to colectomy , 33 ( range , 16–56 ) months ] . Thirteen patients [ 17.8 % ( 95 % CI , 9.0%–26.6 % ) ] experienced an uncomplicated recurrence , all of whom were managed with continued nonoperative intent [ median follow-up , 81 ( range , 34–115 ) months ] . No mortality occurred . On multivariate logistic regression , female gender ( p = 0.048 ) and a previous episode of uncomplicated diverticulitis before the index diverticular abscess ( p = 0.020 ) were associated with a recurrent episode . LIMITATIONS : This study was limited by its retrospective design and modest sample size . CONCLUSIONS : After initial successful nonoperative management of diverticulitis with abscess , expectant management with nonoperative intent is a safe long-term option with low rates of surgery , especially in the emergency setting . See Video , Supplemental Digital Content 1 , on the nonoperative management of diverticular abscess at http://links.lww.com/DCR/A234 Introduction Guidelines for the treatment of complicated sigmoid diverticulitis recommend Hartmann ’s procedure or anastomosis with protective colostomy for Hinchey stage III diverticulitis and Hartmann ’s procedure only for Hinchey stage IV diverticulitis . We evaluated the outcome of patients with perforated sigmoid diverticulitis Hinchey III/IV undergoing one-stage colon resection and primary anastomosis without protective colostomy .  Methods After implementation of a protocol to treat Hinchey III/IV diverticulitis with primary anastomosis without protective ileocolostomy , the patients ’ data were recorded prospect ively between August 2001 and August 2003 and analyzed retrospectively from a computer-related data base . Results Of 41 patients , 34 ( 81%% ) underwent one-stage sigmoid resection and primary anastomosis , 3 of 41 patients ( 7%% ) underwent primary anatomosis with protective ileostomy , and 5 of 41 patients ( 12%% ) had a Hartmann ’s procedure . The mortality was 11%% in patients undergoing primary anastomosis and 60%% in patients with Hartmann ’s procedure . The relative risk of co-morbidity factors for lethal outcome after sigmoid resection was 6.94 for preceding operations , 3.75 for renal failure or renal transplantation , and 3.25 for immunosuppression . Conclusions One-stage sigmoid resection and primary anastomosis can be performed safely in nearly 90%% of all patients with perforated sigmoid diverticulitis ( Hinchey III/IV ) by surgeons of different training levels . Patients with immunosuppression , chronic renal failure , liver cirrhosis , or previous organ transplantation or complex cardiovascular reconstructive procedures have a significantly increased risk of dying after sigmoid resection for perforated diverticulitis PURPOSE The aim of of this study was to evaluate prospect ively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon . METHODS Between October 1986 and October 1997 , a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan .  Of 76 patients ( 17 percent ) who had an associated mesocolic or pelvic abscess , 3 were lost to follow-up . The remaining 73 patients ( 45 with a mesocolic abscess and 28 with a pelvic abscess ) were followed for a median of 43 months . RESULTS of the 45 patients with a mesocolic abscess , 7 ( 15 percent ) required surgery during their first hospitalization versus 11 ( 39 percent ) of the 28 patients with a pelvic abscess ( P = 0.04 ) . At the end of follow-up , 22 ( 58 percent ) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 ( 47 percent ) of the 17 who had a pelvic abscess . Altogether , 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess ( P = 0.09 ) . CONCLUSIONS Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis , percutaneous drainage followed by secondary colectomy seems justified . Mesocolic abscess by itself is not an absolute indication for colectomy Objective : We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs . Background : The most frequent st and ard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States . Methods : This multicenter , r and omized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis . All the patients underwent abdominal computed tomography .  There were 2 strategies of management : hospitalization ( group 1 ) and outpatient ( group 2 ) . The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged . The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission . The secondary end points included quality -of-life assessment and evaluation of costs . Results : A total of 132 patients were r and omized : 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups ( P = 0.619 ) . The overall health care cost per episode was 3 times lower in group 2 , with savings of & OV0556;1124.70 per patient . No differences were observed between the groups in terms of quality of life . Conclusions : Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis . Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis . Trial registration ID : EudraCT number 2008 - 008452 - 17 Background Conservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy . It is , however , uncertain whether patients with acute diverticulitis indeed benefit from antibiotics . In most guidelines issued by professional organizations antibiotics are considered m and atory in the treatment of mild diverticulitis . This advice lacks evidence and is merely based on experts ' opinion . Adverse effects of the use of antibiotics are well known , including allergic reactions , development of bacterial resistance to antibiotics and other side-effects . Methods A r and omized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis . I ) A conservative strategy with antibiotics : hospital admission , supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral , if tolerated ( for a total duration of antibiotic treatment of 10 days ) . II ) A liberal strategy without antibiotics : admission only if needed on clinical grounds , supportive measures only . Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging . Only patients with stages 1a and 1b according to Hinchey 's classification or " mild " diverticulitis according to the Ambrosetti criteria are included . The primary endpoint is time-to-full recovery within a 6-month follow-up period . Full recovery is defined as being discharged from the hospital , with a return to pre-illness activities , and VAS score below 4 without the use of daily pain medication . Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention , morbidity , costs , health-related quality of life , readmission rate and acute diverticulitis recurrence rate . In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85 % and a confidence level of 95 % . With an estimated one percent of patients lost to follow up , a total of 533 patients will be included . Conclusion A clinical ly relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected . The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach . Trial registration Trial registration number : Background and aim Recurrence of diverticulitis is frequent within 5 years from the uncomplicated first attack , and its prophylaxis is still unclear . We have undertaken a multicentre , r and omised , double-blind , placebo-controlled pilot study in order to evaluate the role of mesalazine in preventing diverticulitis recurrence as well as its effects on symptoms associated to diverticular disease . Methods Ninety-six patients with the recent first episode of uncomplicated diverticulitis were r and omised to receive mesalazine 800 mg twice daily for 10 days every month or placebo for 24 months . The primary efficacy end point was the diverticulitis recurrence at intention to treat analysis . Clinical evaluations were performed using the Therapy Impact Question naire ( TIQ ) for physical condition and quality of life at admission and at 3-month intervals . Treatment tolerability and routine biochemistry parameters as well as the use of additional drugs were also evaluated . Results Ninety-two patients ( mean age , 61.5 ) completed the study , 45 of whom received mesalazine , and 47 , placebo .  Diverticulitis relapse incidence in mesalazine-treated group was 5/45 ( 11 % ) at the 12th month and 6/45 ( 13 % ) at the 24th month ; in the placebo-treated group , the correspondent rates were 13 % ( 6/47 ) and 28 % ( 13/47 ) , respectively . Mean values of TIQ at 24 months were significantly better in mesalazine-treated group than in placebo-treated group ( p = 0.02 ) ; in addition , average additional drug consumption was significantly lower ( −20.4 % , p < 0.03 ) in mesalazine than in placebo . Conclusions Diverticulitis recurrence occurred in as many as 28 % of patients under placebo within 24 months from the initial episode . Intermittent prophylaxis with mesalazine did not significantly reduce the risk of relapse but induced a significant improvement of patients ' physical conditions and significantly lowered the additional consumption of other gastrointestinal drugs Purpose This study included all patients treated at the University Hospital of Geneva for a first episode of uncomplicated diverticulitis . Risks of recurrence and treatment failure were evaluated by comparing the results between short-course and long-course intravenous ( IV ) antibiotic therapy groups . Methods The records of all patients hospitalized at our facility from January 2007 to February 2012 for a first episode of uncomplicated diverticulitis ( Hinchey Ia ) , as confirmed by computed tomography , were prospect ively collected . We published an auxiliary analysis from this registered study at Clinical trials.gov ( identifier number : NCT01015378 ) . Two groups of patients were considered : one received a short-course IV antibiotic arm ( ceftriaxone and metronidazole ) for up to 5 days ( followed by 5 days of oral antibiotics ) ; the other received a long-course IV arm between days 5 and 10 . The primary outcome was the recurrence-free survival time . Results Follow-up was completed for 256 patients -50 % men and 50 % women , with a median age of 56 years ( range , 24 - 85 years ) . The average follow-up was 50 months ( range , 19 - 89 months ) . Of the 256 patients included in the study , 46 patients received a short-course IV antibiotic treatment and 210 received a long-course treatment .  The recurrence-free survivals were very similar between the two groups , which was supported by a log rank test ( P = 0.772 ) . Four treatment failures , all in the long-course IV antibiotic treatment group , occurred . Conclusion Treatment of diverticulitis with a short IV antibiotic treatment is possible and does not modify the recurrence rate in patients with uncomplicated diverticulitis Background : There are no management criteria for optimum out‐patient care in mild‐to‐moderate acute colonic diverticulitis . Background Immunosupression and , especially , intake of steroids have previously been identified as risk factors for complicated types of sigmoid diverticulitis . However , little is known about the underlying molecular and cellular mechanisms . We aim ed to eluci date the potential role of activated macrophages in this respect . Methods A consecutive series of n = 101 patients having undergone surgical resection for sigmoid diverticulitis at our institution was analyzed regarding the inflammatory infiltrate and prevalence of comorbid diseases as well as risk factors , including steroid use . Fifty-seven patients had complicated types of diverticulitis with severe inflammation ( group A ) . Forty-four patients had moderate inflammation , most of whom had been operated for chronically recurrent diverticulitis ( group B ) . R and omly selected 50 patients ( n = 20/group A/n = 30 group B ) underwent immunolabelling against CD68 and CD163 . Results Using immunofluorescence double labeling experiments we found a strong positive correlation of CD68 expression with CD163 expression ( т = 0.934 ) . High CD68 expression ( x ≥ 23 % ) and high CD163 expression ( x ≥ 22 % ) within stromal cells of the lamina propria was significantly associated with steroid use ( CD68 , p = 0.012 and CD163 , p = 0.004 , respectively ) and complicated sigmoid diverticulitis with severe inflammation ( CD68 , p = 0.0001 and CD163 , p = 0.001 , respectively ) . Conclusions Inflammation , especially mediated by activated ( CD68+/CD163 + ) macrophages in histopathological specimen might resemble the cellular link between steroid use and complicated types of sigmoid diverticulitis . Macrophages might be a suitable target for future supportive/preventive therapies . However , as long as we are lacking such strategies , we must bear in mind that steroid intake is a risk factor for complicated diverticulitis , especially when indicating surgical resection The natural history of sigmoid diverticulitis has been inferred from population ‐based or retrospective studies . This study assessed the risk of a recurrent attack following the first episode of uncomplicated diverticulitis PURPOSE : Our hypothesis was that in patients with perforated sigmoid colon diverticulitis and peritonitis ( Hinchey Stage III and IV ) a one-stage sigmoid colon resection is safe and cost effective when performed by an experienced colorectal surgeon . We evaluated outcome and cost of one-stagevs . two-stage sigmoid colon resection after diverticulitis perforation and peritonitis . METHODS : Patients undergoing emergency resection for perforated sigmoid colon diverticulitis and peritonitis ( Hinchey Stage III and IV ) . Outcome , costs , and insurers reimbursement were compared between 13 patients undergoing sigmoid colon resection and primary anastomosis ( Group A ) and 42 patients undergoing sigmoid colon resection with Hartmann 's procedure and secondary descendorectostomy ( Group B ) . RESULTS : Group A patients were comparable to Group B patients in age , gender , preoperative risk and severity of peritonitis ( Mannheim Peritonitis Index and C-reactive protein ) . Operating room time for sigmoid colon resection with primary anastomosis ( 3.3±1.2 hours ) was identical to the time for sigmoid colon resection with colostomy ( 3.3±1 hour ) , and morbidity and mortality , intensive care unit , and in-hospital stay were not significantly different between the two groups . In Group B patients ' intestinal continuity was restored 169±74 days after the primary resection in 32 of 42 patients only ( 78 percent ) . The second procedure took on average 1.4 hours longer than the first procedure . Patients in Group B received more antibiotics ( 2.2vs . 2 ) albeit for a shorter period of time ( 4.5vs . 5.7 days , P = not significant ) . Overall expenses for restoration of intestinal continuity were between 74 and 229 percent higher for Group B patients than for Group A patients . Reimbursement was 18,191±16,761 SFr ( Group A ) and 41,321±26,983 SFr ( Group B ) respectively . CONCLUSION : With meticulous surgical technique and extensive intraoperative lavage , perforated sigmoid colon diverticulitis with peritonitis can be treated by a one-stage sigmoid colon resection and anastomosis with a low mortality and morbidity . A one-stage procedure is considerably cheaper and patients are rehabilitated faster and to a higher percentage
Primary diverticulitis with abscess formation and young age increased the risk of recurrence .
Readmission risk was higher within the first year after remission .
Conclusions The best treatment strategy for recurrent diverticulitis is undetermined .
Purpose Several factors may influence the risk of recurrence after an episode of acute colonic diverticulitis .
Until now , a comprehensive systematic overview and evaluation of relevant risk factors have not been presented .
This review aim ed at assembling and evaluating current evidence on risk factors for recurrence after conservatively treated acute colonic diverticulitis .