The document summarizes the treatment options for colonic diverticulitis, including conservative, medical, and surgical approaches. Conservative treatment involves antibiotics, bed rest, and fluid diets for uncomplicated cases. Medical management uses antibiotics both as outpatient treatment for mild cases or inpatient IV antibiotics for severe cases. Surgical options include resection of the affected colon either with or without anastomosis, with laparoscopic procedures becoming more common due to lower complication rates. While guidelines favor initially conservative approaches, optimal treatment remains complex and individualized based on each patient's presentation and risk factors.

1. Surgical versus conservative treatment of Colonic
Diverticulitis
Review Paper
5/8/2020
DTMU
Vedica Sethi

2. Table of Contents:
1. Abstract
2. Diverticulitis
(i) Uncomplicated Diverticulitis
(ii) Complicated Diverticulitis
3. Management of Colonic Diverticulitis
(i) Conservative
(ii) Medical
(iii) Surgical
4. Conclusion
5. References

3. 1. Abstract
Colonic diverticulitis is an undeniably common Western disease related with a high mortality
and cost of treatment. Improvement in the comprehension of the medical aspect as well as the
surgical procedures, alongside progression in the conclusion and clinical administration has
prompted ongoing changes in treatment proposals. The common history of diverticulitis is
more severe than recently suspected, and current patterns favor increasingly traditionalist,
less intrusive administration. In spite of current proposals of progressively prohibitive signs for
medical procedure, practice patterns demonstrate an expansion in elective procedures being
performed for the treatment of diverticulitis. Because of variable presentation of the disease
introduction, much of the time, ideal careful treatment of intense diverticulitis stays muddled
as to persistent choice, timing, and specialized methodology in conservative, medical, elective
and urgent settings. This paper reviews the treatment proposals for careful management of
diverticulitis, a comparative study between present management of Diverticulitis.
Key Words: Diverticulitis, conservative, medicine, surgery

4. 2. Diverticulitis
Colonic diverticulitis is the disease of the gastrointestinal system, identified with the
inflammation of the large intestine and is very common disease in Western nations.(1
) Patient
symptoms range from sudden onset of pain in left lower abdominal quadrant which is
indicative of Sigmoid Diverticulitis. Associated symptoms include nausea, vomiting, diarrhea or
constipation, fever and blood in stool indicates severe diverticulitis with or without
complications. (2
)
The causes for diverticulitis are uncertain. Risk factors maybe obesity, absence of activity,
smoking, a family ancestry of the ailment, and utilization of non-steroidal anti-inflammatory
drugs (NSAIDs).The job of a low fiber diet as a risk factor is unclear. Pouch formation in the
large intestine, that are not aggravated is known as diverticulosis. Inflammation happens in
the middle of 10% and 25% sooner or later in time, and is because of a bacterial infection. (3
)
Diagnosis is regularly by CT examination, however blood tests, colonoscopy, or a lower
gastrointestinal series may likewise be supportive. (4
) Our developing comprehension of the
pathophysiology and common history of the illness, just as enhancements in indicative imaging
and nonsurgical administration of the the disease have prompted huge changes in treatment
suggestions.
Preventive measures incorporate adjusting risk factors, for example, weight, no exercise, and
smoking. Less forceful clinical and careful medicines have been proposed. In instances of
uncomplicated diverticulitis, outpatient management includes Mesalazine and rifaximin, also
seem valuable for forestalling assaults in those with diverticulosis and suggested fluid diet
regimen are recommended.(5
) So also, in instances of complicated diverticulitis, nonsurgical
administration is favored at first, including percutaneous seepage of abscesses, given the high
morbidity and mortality of pressing tasks. Complications, for example, ulcer and fistula
formation, and perforation of the colon may require hospital admission, intravenous antibiotic
administration and complete bowel rest or surgery. Intestinal continuity is maintained via the
means of essential anastomosis and the utilization of negligibly intrusive methodologies are
upheld for in elective settings. (6
) Current practice rules are custom fitted to the individual
patient, considering risk factors, severity of the disease, determined manifestations, and
patient inclinations.
1
“Diverticular Disease | NIDDK.”
2
Tursi, “Diverticulosis Today.”
3
“Principles and Practice of Infectious Diseases - John E. Bennett, Raphael Dolin, Martin J. Blaser -
Google Books.”
4
Rafferty et al., “Practice Parameters for Sigmoid Diverticulitis.”
5
Biondo et al., “Outpatient versus Hospitalization Management for Uncomplicated Diverticulitis.”
6
Regenbogen et al., “Surgery for Diverticulitis in the 21st Century.”

5. (7
)
Hinchey Classification for Diverticulitis
7
“Table 1 Hinchey Classification and Modified Hinchey Classification By...”

6. 3. Management of Colonic Diverticulitis
(8
)
8
“Diagnosis and Management of Acute Diverticulitis - American Family Physician.”

7. (i) Conservative Management-
 Diet- Dietary restrictions, from nil-per-mouth to liquids only or low-fiber diet,
have been imposed as part of the routine treatment of acute diverticulitis.
 Bed Rest- Along with dietary restrictions, bed rest has been part of the routine
treatment of acute diverticulitis. However, beneficial effects of bed rest have
never been studied nor proven.
 Antibotics- Routine antibiotic treatment of uncomplicated acute diverticulitis
used to be, and in part still is, a standard practice. The patients are placed on n
empiric borad-spectrum antibiotic therapy to provide 100% effectivity and
coverage to enteric pathoges. Complicated diverticulitis responds well to
carbapenems due to increase in bacterial resistance. Drugs of choice:
Ciprofloxacin plus metronidazole or Trimethoprim-sulfamethoxazole plus
metronidazole or Amoxicillin-clavulanate or Moxifloxacin (use in patients
intolerant of both metronidazole and beta lactam agents) (9)
 Outpatient treatment- Until several years ago, routine intravenous antibiotic
treatment made hospital admission inevitable. As at first oral antibiotic
treatment and later treatment without antibiotics appeared to be safe in
uncomplicated diverticulitis patients, outpatient treatment became feasible.
 Pericolic Extraluminal Air- Along with an increasing usage and quality of
computed tomography (CT) in diagnosing acute diverticulitis, pericolic
extraluminal air is encountered more and more. Although in approximately
15% of all acute diverticulitis patients pericolic extraluminal air is seen, little is
known about the natural course and whether these patients should be treated as
uncomplicated diverticulitis or more aggressively as complicated diverticulitis.
Nowadays, treatment of these patients is mainly based on the opinion and
experiences of the physician, possibly causing over- or under treatment. There
have been published studies regarding the identication of pre colic air and
correspondence to diverticulitis, using a variety of terms like “free air within
5 cm of the inflamed colon segment,” “contained perforation,” “localized
pericolic free air,” or “air within the mesentery. The studies have failed to
identify a proper treatment fro percolic extraluminal air, so the first approach to
the concern is medical management. (10)
(ii) Medical management-
 The treatment approach for diverticulitis can be extensively arranged into
either complicated or uncomplicated, and it considers a couple of other
unique contemplations. Acute uncomplicated diverticulitis is effectively
treated with antibiotics, and computed tomography (CT) examine
discoveries have been assessed. Complicated diverticulitis will in general be
9
“Diverticulitis Treatment & Management: Approach Considerations, Medical Care, Surgical Care.”
10
van Dijk et al., “A Systematic Review of Pericolic Extraluminal Air in Left-Sided Acute Colonic
Diverticulitis.”

8. increasingly severe in old individuals and in patients who are
immunocompromised or who have incapacitating comorbid conditions, for
example, diabetes and renal disappointment.
 Outpatient treatment of diverticulitis- Patients with uncomplicated
diverticulitis, ordinarily with Modified Hinchey stage 0 and Ia, can be begin
an outpatient treatment routine. This comprises of an away from diet and 7-
10 days of an oral (PO) expansive range antimicrobial routine that covers
anaerobic microorganisms, for example, Bacteroides fragilis and
Peptostreptococcus and Clostridium creatures, just as oxygen consuming
microorganisms, for example, Escherichia coli and Klebsiella, Proteus,
Streptococcus, and Enterobacter. (As mmentioned above: ciprofloxacin (or
trimethoprim-sulfamethoxazole) and metronidazole. Monotherapy with
moxifloxacin or amoxicillin/clavulanic acid are fitting for outpatient
treatment of complicated diverticulitis.) Train patients about being on a
reasonable fluid eating regimen just, and that they can gradually propel the
eating regimen as endured after clinical improvement, which generally
happens inside 2-3 days. (11
)
 Inpatient treatment of diverticulitis- Hospitalization is required for severe
diverticulitis, for example, fundamental indications of disease or peritonitis.
Patients who can't endure oral hydration, whose condition is headstrong to
outpatient treatment (ie, tireless or expanding fever, agony, or leukocytosis
following 2-3 days), who are immunocompromised, or who have
comorbidities may likewise require hospitalization. Patients' torment might
be sufficiently extreme to require parenteral opiate analgesic. Start
complete bowel rest and intravenous (IV) liquid hydration. Start wide range
IV anti-biotic inclusion until culture results, whenever acquired, are
accessible. Monotherapy with beta-lactamase-repressing anti-infection
agents or carbapenems gives wide antibacterial inclusion and is fitting for
patients who are respectably sick and require inpatient confirmation. Such
anti-biotic agents incorporate piperacillin/tazobactam,
ampicillin/sulbactam, ticarcillin/clavulanic corrosive, imipenem, or
meropenem. (12
)
 In emergency clinic setting- Use of metronidazole and a third-age
cephalosporin or a fluoroquinolone. Such anti-biotics incorporate
ceftriaxone, cefotaxime, ceftolozane/tazobactam, ciprofloxacin, or
levofloxacin. Already, gentamicin was suggested as a major aspect of a
empiric therapy.
 For immunocompromised patients, imipenem or meropenem might be
favored over ertapenem for better enterococcal and pseudomonal inclusion.
 Pain management- Morphine is drug of choice and is favored over
meperidine inferable from the unfriendly impacts related with meperidine.
11
Rezapour, Ali, and Stollman, “Diverticular Disease.”
12
Janes, Meagher, and Frizelle, “Management of Diverticulitis.”

9. Meperidine can alter the tone of smooth muscle in GI tract and the resting
tone of spinchter of Oddi, so is avoided. Utilization of NSAIDS and
corticosteroids have been related with a more serious danger of colon
perforation and should be avoided. (13
)
 Post 2-3 days of hospitalization, the patient's fever, pain, and leukocytosis
should start to determine when he or she will be able to start a reasonable
fluid eating regimen and advance as endured. On the off chance that the
patient endures oral admission and is clinically steady, they can be released
to finish a 7-10-day course of PO anti-microbial treatment.
 Sequential assessments uncover exacerbating clinical signs or new peritoneal
discoveries, a recurrent CT sweep of the stomach area is fitting to preclude
a stomach ulcer or abscss or phlegomn.
 In the event that a patient has a peri-diverticular ulcer that estimates in
excess of 4 cm in measurement (Hinchey stage II), CT examine guided
percutaneous debriment is used. This normally prompts a brief (< 72 hour)
decrease in pain, fever, and leukocytosis. For ulcerations containing gross
fecal material or within the sight of an aperture, early surgical management
is required.
 Post hospital discharge- Patient symptoms improves after 2-6 day of
admission and can be discharged. Like the above mentioned diet, patient
can also be shifted on food or liquid by mouth.
 Colonoscopy or, sigmoidoscopy should be performed normally 2-6 wk after
flare disease to rule out immenent threat ischemia or infection.
 Other drugs- Drugs like mesalamine; nonabsorbable anti-toxins, for example,
rifaximin; and probiotics alone or in mix in the administration of
diverticulitis. (14
)
(iii) Surgical Management
 Hartmann method (HP) - Alternatives for complete medical procedure
include resection of the affected colon with or without anastomosis. The
two-phase approach, generally called HP, alludes to sigmoid colectomy
with end colostomy and later colostomy inversion. HP is the preferred
procedure for perforated diverticulitis, utilized since 1980, has high
mortality rate.HP is mainly used to maintain intestinal continuity,
through sigmoid colectomy and primary anastomosis (PA), with or
without diverting loop ileostomy (DLI).(15
) The margin of resection
should stretch from coherent intestine, proximally to upper rectum,
distally (where the taeniae coli combine). A satisfactory distal edge is
the most significant factor in deciding repeat after resection Repeat
13
“Patterns of Pain in Diverticular Disease and the Influence of Acute Diverticulitis. - PubMed - NCBI.”
14
Tursi, Brandimarte, and Daffinà, “Long-Term Treatment with Mesalazine and Rifaximin versus
Rifaximin Alone for Patients with Recurrent Attacks of Acute Diverticulitis of Colon.”
15
Wieghard, Geltzeiler, and Tsikitis, “Trends in the Surgical Management of Diverticulitis.”

10. hazard with colocolonic anastomosis is up to multiple times higher than
that of colorectal anastomosis . The requirement for this is resolved
intra-operatively, in light of the patient body-habitus and length of colon
resected.
 Primary Anastmosis- PA is a colonic resection with with primary
anastomosis and defunctioning ileostomy. (16
) The second operation
(stoma reversal) requires an entero-enteral anastomosis and also the
most common procedure performed for the treatment of diverticulitis
 Laparoscopic colon resection: -Elective The laparoscopic approach has
been appeared to have a few points of interest over open medical
procedure, including lower mortality and postoperative complication
rates, shorter emergency clinic stays, and lower generally speaking
expense.(17
)(18
) Generally speaking, the quantity of laparoscopic
colectomies performed for diverticulitis complications has been
expanding, yet remains lower than the open colectomy. Pressing setting:
The job of laparoscopy in the critical setting is not completely assessed.
Post operation complications and shorter length of hospital care is the
credential for use of laproscopic procedures, when contrasted with open
surgery. A laparoscopic HP has been proposed. (19
)
 Laparoscopic lavage- Current accord holds that there is inadequate proof
to prescribe laparoscopic lavage as an option in contrast to resection.
Laparoscopic lavage has been proposed as an elective prospect in
patients with peritonitis so as to control the spread of infection and
move the patients to elective resection with essential anastomosis
sometime in the future. Good outcomes in terms of patients using
Laproscopic Lavage at lower stages of Hinchey classification have been
observed. (20
)
16
“Hartmann’s Versus Primary Anastomosis in Left-Sided Colon Perforation - Full Text View -
ClinicalTrials.Gov.”
17
Lipman and Reynolds, “Laparoscopic Management of Diverticular Disease.”
18
“Diverticular Disease: Laparoscopic Management of Diverticular Disease.”
19
Information et al., Diverticular Disease and Diverticulitis.
20
“Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent
Peritonitis.”

11. (21
)
21
Wieghard, Geltzeiler, and Tsikitis, “Trends in the Surgical Management of Diverticulitis.”

12. 4. Conclusion
Even though the primary management of symptomatic Diverticulitis includes dietary
fiber supplementation has been a preventive rather than therapeutic intervention.
Drugs like NSAIDS have been identified as offending agents, and put the patient on
the risk of perforation. Medical management of diverticulitis is based on
symptomatic treatment of the disease, and thus lets the disease take a benign
course. Even though, complications to diverticulitis are inevitable, proper
management on outpatient and inpatient scenarios are treated well. Surgical
requirement in an elective setting might be unwanted for post complications of
diverticulitis without offering guarantee in preventions of future complications. As
any surgical procedure warrants no safety, similar is the case for Diverticulitis. With
high rates of complications, and increase rate in mortality post surgery is often
unpredictable. But usage of one-stage elective procedures is the current trend.
Despite the evolution of medical and surgical management of Colonic diverticulitis,
patients opinion for the requirement of necessary treatment and decision making
process must be individualized.
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