The classifications of acute uncomplicated diverticulitis and complicated diverticulitis have served us well for many years. However, in recent years, we have noted the prevalence of variations of uncomplicated diverticulitis, which have not precisely fit under the classification of ‘acute resolving uncomplicated diverticulitis’, which manifests itself with the typical left lower quadrant pain, fever, diarrhea, elevated white blood count, and CT findings, such as stranding, and which resolves fairly promptly and completely on oral antibiotic therapy. For these other variations, we would suggest we use the term chronic diverticulitis, as a subset of uncomplicated diverticulitis, meaning there is no abscess, stricture, or fistula, but the episode does not respond to the usual antibiotic treatment, and there is a rebound symptomatology once the treatment has stopped, or there is continuing subliminal inflammation that continues, typically, for several weeks after the initial episode without complete resolution. This variation could also be termed ‘smoldering’ diverticulitis. A second variation of uncomplicated diverticulitis should be termed atypical diverticulitis, since this variant does not manifest all of the usual components of acute diverticulitis, particularly an absence of fever, and even white blood count elevation, and there may be a lack of diagnostic evidence of acute diverticulitis. This diagnosis must be compared with diarrhea-predominant irritable bowel syndrome, and it is sometimes very difficult to distinguish between these two entities. The character of the pain in irritable bowel syndrome is typically cramping intermittently, compared with the more constant pain in smoldering diverticulitis. In our study by Horgan, McConnell, Wolff and coworkers, 5% of 930 patients who underwent sigmoid resection fit into this category of atypical uncomplicated diverticulitis. These 47 patients all had diverticulosis, and 76% that had surgery had evidence of acute and chronic inflammation, and 15% had an unsuspected pericolonic abscess. There was no mortality and a low complication mortality rate (4.2%). Complete resolution of symptoms was achieved in 76.5 with 80% being pain free. Therefore, this is mostly a diagnosis of exclusion, and clinicians must be careful to perform a thorough workup and evaluation before proceeding to surgery with this as a diagnosis. Ischemic colitis is also in the differential diagnosis, and many patients who have diverticulitis, have irritable bowel syndrome as well, so caution must be used in predicting positive outcomes after surgery in these patients.

Keywords:
Prophylactic resection, Uncomplicated diverticulitis, Recurrent diverticulitis
1.
Etzioni DA, Mack TM, et al: Diverticulitis in the United States: 1998–2005: changing patterns of disease and treatment. Ann Surg 2009;249:210–217.
2.
Parra-Blanco A: Colonic diverticular disease: pathophysiology and clinical picture. Digestion 2006;73(suppl 1):47–57.
3.
Stollman N, Raskin J: Diverticular disease of the colon. Lancet 2004;363:631–639.
4.
Spiller R: How inflammation changes neuromuscular function and its relevance to symptoms in diverticular disease. J Clin Gastroenterol 2006;40(suppl 3):S117–S120.
5.
Costedio MM, Coates MD, et al: Serotonin signaling in diverticular disease. J Gastrointest Surg 2008;12:1439–1445.
6.
Tursi A: Mesalazine for diverticular disease of the colon – a new role for an old drug. Expert Opin Pharmacother 2005;6:69–74.
7.
Tursi A, Brandimarte G, et al: Assessment and grading of mucosal inflammation in colonic diverticular disease. J Clin Gastroenterol 2008;42:699–703.
8.
Hinchey EJ, Schaal PG, et al: Treatment of perforated diverticular disease of the colon. Adv Surg 1978;12:85–109.
9.
Parks TG: Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J 1969;4:639–642.
10.
Chapman J, Davies M, et al: Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005;242:576–583.
11.
Mueller MH, Glatzle J, et al: Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol 2005;17:649–654.
12.
Chapman JR, Dozois EJ, et al: Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg 2006;243:297–304.
13.
Richards RJ, Hammitt J: Timing of prophylactic surgery in prevention of diverticulitis recurrence: a cost-effectiveness analysis. Dig Dis Sci 2002;47:1903–1908.
14.
Salem L, Veenstra DL, et al: The timing of elective colectomy in diverticulitis: a decision analysis. J Amn Coll Surg 2004;199:904–912.
15.
Rafferty J, Shellito P, et al: Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939–944.
16.
Ambrosetti P, Grossholz M, et al: Computed tomography in acute left colonic diverticulitis. Br J Surg 1997;84:532–534.
17.
Guzzo J, Hyman N: Diverticulitis in young patients: is resection after a single attack always warranted? Dis Colon Rectum 2004;47:1187–1190.
18.
Wong WD, Wexner SD, et al: 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.
19.
Horgan AF, McConnell EJ, et al: Atypical diverticular disease: surgical results. Dis Colon Rectum 2001;44:1315–1318.
20.
Boostrom SY, Wolff BG, et al: A New classification of uncomplicated diverticular disease. 2011;in preparation.
21.
Moreaux J, Vons C: Elective resection for diverticular disease of the sigmoid colon. Br J Surg 1990;77:1036–1038.
© 2012 S. Karger AG, Basel
2012
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.