Mistakes in ... Booklet 2020 - 7

ueg education

Mistakes in... 2019

Mistakes in acute diverticulitis and how to avoid them
S.J. Rottier, A.A.W. van Geloven, W.H. Schreurs and M.A. Boermeester
Acute diverticulitis is an inflammatory complication of diverticulosis and can either be
uncomplicated or complicated. Making the distinction between uncomplicated and
complicated acute diverticulitis is essential because treatment strategies differ between
the two. Here, we discuss 10 mistakes frequently made when managing patients with
acute diverticulitis. We focus on using the correct terminology, diagnostic preference
and several treatment options, such as omitting or administering antibiotics,
radiological interventions and various aspects of surgery. Acute diverticulitis is an
important topic because its incidence is rising worldwide and it is becoming a
considerable burden on healthcare systems. Most of the discussion included here is
evidence-based, supplemented with many years' combined clinical experience where
evidence is lacking.
Mistake 1 Using incorrect terminology
A variety in terminology is used in the diverticular
literature, which can lead to misinterpretation
and often makes any recommendations
made unsuitable for use in daily practice.
A diverticulum (pl. diverticula) is a small
outpouching from the lumen of the colon that
results from herniation of the colon wall at the
weakest anatomic location, which is where the
terminal branches of the colonic arteries (the
vasa recta) penetrate.1,2 Diverticulosis means
that a patient has one or more diverticula but no
clinical symptoms whatsoever, which equates to

them being described as asymptomatic.
Most people do not know whether they have
diverticula, because they only see a doctor when
they are symptomatic. Another way diverticula
are diagnosed is during an abdominal CT or
colonoscopy, usually being identified as an
additional finding.
Acute diverticulitis occurs when a
diverticulum becomes inflamed, and this
inflammatory complication of diverticulosis
can be uncomplicated or complicated (figure 1).
Uncomplicated diverticulitis describes
peridiverticular inflammation of the colon,
whereas complicated diverticulitis

Transverse
colon

encompasses diverticular abscess formation,
perforation, obstruction or fistula formation.
Nowadays, the modified Hinchey classification,
which includes CT imaging, is used in both
the literature and daily practice to distinguish
between uncomplicated (Hinchey Ia) and
complicated (> Hinchey Ib) diverticulitis
(table 1).3,4
So, patients with diverticulosis are
asymptomatic and patients with acute
diverticulitis are symptomatic. As there is no
clear way to diagnose so-called symptomatic
uncomplicated diverticular disease (SUDD), the
terms SUDD and diverticular disease should
be avoided. When this terminology is used in
literature, it is not clear whether the information
is about diverticulosis or diverticulitis, since this
is often not explained. Moreover, it is doubtful
whether SUDD can be reliably distinguished from
irritable bowel syndrome (IBS) complaints that
overlap with symptomatic diverticulosis.

Mistake 2 Using dietary restrictions to treat
and prevent diverticulitis

Figure 1 | Diverticulosis of the descending and sigmoid part of the colon. Part of the colon has a thicker wall
caused by inflammation and infection known as diverticulitis.

For many years diet has been mentioned as a
possible risk factor for the development of
diverticula and acute diverticulitis.5 Dietary
restrictions-ranging from nil-by-mouth to liquid
diets and low- or high-fibre diets-have often
been part of the treatment of acute diverticulitis
or, when the acute phase has passed, as a
preventive treatment. Two studies have shown
that an unrestricted diet does not lead to an
increase of diverticular complications in patients
with acute diverticulitis.6,7 One, a prospective

© UEG 2019 Rottier, van Geloven, Schreurs and Boermeester.
Cite this article as: Rottier SJ, et al. Mistakes in acute diverticulitis
and how to avoid them. UEG Education 2019; 19: 31-35.
Simone J. Rottier is an MD working in the Department of Surgery at
Amsterdam University Medical Centers, Amsterdam, The
Netherlands. Anna A.W. van Geloven is a gastrointestinal surgeon at

Images courtesy of: S.J. Rottier, A.A.W. van Geloven, W.H. Schreurs
and M.A. Boermeester. Illustrations: J. Shadwell.
Correspondence to: m.a.boermeester@amsterdamumc.nl
Conflicts of interest: The authors declare there are no conflicts
of interest.
Published online: December 20, 2019.

Ascending
colon

Descending
colon

Cecum
Appendix

Sigmoid
colon

the Department of Surgery at Tergooi, Hilversum, The Netherlands.
W. Hermien Schreurs is a lung and gastrointestinal surgeon in the
Department of Surgery, Northwest Clinics, Alkmaar/Den Helder, The
Netherlands. Marja A. Boermeester is a professor of surgery and a
clinical epidemiologist in the Department of Surgery at Amsterdam
University Medical Centers, Amsterdam, The Netherlands.

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