Diverticulitis Treatment & Management: Medical Care, Surgical Care,... http://emedicine.medscape.

com/article/173388-treatment

Diverticulitis Treatment & Management

Author: Kamyar Shahedi, MD; Chief Editor: BS Anand, MD more...

Updated: Jan 14, 2015

Medical Care
The approach to the treatment of diverticulitis can be broadly classified into either uncomplicated disease or
complicated disease, with a few other special considerations to take into account. Acute uncomplicated diverticulitis
is successfully treated in 70-100% of patients with conservative management.[9, 10]

Acute diverticulitis tends to be more severe in very elderly people and in patients who are
immunocompromised or who have debilitating comorbid conditions, such as diabetes and renal failure.
Patients with mild diverticulitis, typically with Hinchey stage I disease, can be started on an outpatient
treatment regimen. This consists of a clear liquid diet and 7-10 days of oral broad-spectrum antimicrobial
therapy, which covers anaerobic microorganisms, such as Bacteroides fragilis and Peptostreptococcus and
Clostridium organisms , as well as aerobic microorganisms, such as Escherichia coli and Klebsiella, Proteus,
Streptococcus, and Enterobacter organisms. Single and multiple antibiotic regimens are equally effective as
long as both groups of organisms are covered. According to the World Gastroenterology Organisation (WGO)
2007 practice guidelines for diverticular disease, such a regimen should result in improvement within 48-72
hours. [1]
One typical oral antibiotic regimen is a combination of ciprofloxacin (or trimethoprim-sulfamethoxazole)
and metronidazole. Moxifloxacin is appropriate monotherapy for outpatient treatment of uncomplicated
diverticulitis. Amoxicillin/clavulanic acid monotherapy is acceptable as well.
Patients should be instructed to be on a clear liquid diet only and can advance the diet slowly as
tolerated after clinical improvement, which usually occurs within 2-3 days.
Hospitalization is required with evidence of severe diverticulitis, such as systemic signs of infection or
peritonitis. Patients who are unable to tolerate oral hydration, who fail outpatient therapy (ie, persistent or
increasing fever, pain, or leukocytosis after 2-3 d), who are immunocompromised, or who have comorbidities
may also require hospitalization. Pain may be severe enough to require parenteral narcotic analgesia.
Initiate bowel rest and intravenous fluid hydration. Start broad-spectrum intravenous antibiotic
coverage until culture results, if obtained, are available.
Monotherapy with beta-lactamase inhibiting antibiotics or carbapenems provides broad antibacterial
coverage and is appropriate for patients who are moderately ill and require admission. Such antibiotics
include the following: piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid,
imipenem, or meropenem.
Multiple drug regimens are also appropriate options in the hospital setting and may consist of
metronidazole and a third-generation cephalosporin or a fluoroquinolone. Such antibiotics include the
following: ceftriaxone, cefotaxime, ceftolozane/tazobactam, ciprofloxacin, or levofloxacin. Previously,
gentamicin was recommended as part of a multiple drug regimen. Although it is still a reasonable
choice, substitution with a third-generation cephalosporin or a fluoroquinolone has been advocated to
avoid the risk of aminoglycoside nephrotoxicity.
When severe penicillin allergy is a concern, tigecycline is a good choice for monotherapy.
For patients who are immunocompromised, imipenem or meropenem may be preferred over
ertapenem for better enterococcal and pseudomonal coverage.
Pain management is important. Morphine is acceptable for pain control and is preferable over
meperidine given the adverse effects associated with meperidine. Although early recommendations for
pain management favored meperidine based on a theoretical risk of affecting bowel tone and
sphincters, randomized prospective studies comparing the narcotic options are not available. Use of
nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a greater risk of
colon perforation and should be avoided whenever possible.
Within 2-3 days of hospitalization, the patient's fever, pain, and leukocytosis should begin to resolve.
The patient can then be started on a clear liquid diet and advanced as tolerated. If tolerating oral
intake and clinically stable, the patient can be discharged to complete a 7- to 10-day course of oral
antibiotic therapy.
If fever and leukocytosis do not resolve after 2-3 days of treatment or if serial examinations reveal
worsening signs or new peritoneal findings, a repeat CT scan of the abdomen is advisable to rule out
an abdominal abscess or other complications. The WGO 2007 guidelines state that a lack of
improvement should prompt clinical suspicion and an investigation for a phlegmon or an abscess.[1]
If a patient is found to have a peridiverticular abscess that measures more than 4 cm in diameter
(Hinchey stage II disease), a CTguided percutaneous drainage is indicated. This usually leads to a
prompt (< 72 h) reduction in pain, fever, and leukocytosis. Percutaneous drainage is also beneficial in
that it may allow for elective surgery rather than emergency surgery and increase the likelihood of a
successful 1-stage procedure.
For abscess cavities containing gross fecal material or when there is perforation, early surgical
intervention is required.
Once the acute episode has resolved, the patient may advance diet as tolerated and then maintain a lifelong
high-fiber diet. Colonoscopy or, alternatively, barium enema with flexible sigmoidoscopy should be done after
resolution of an initial episode (typically 2-6 wk after recovery) to exclude other diagnoses, such as cancer,
ischemia, and inflammatory bowel disease.

An increasing number of studies have reported the efficacy of different regimens of anti-inflammatory agents,
including mesalamine, nonabsorbable antibiotics such as rifaximin, and probiotics alone or in combination in the
management of diverticulitis.[11, 12]

In the first US double-blind, placebo-controlled trial of the anti-inflammatory agent mesalamine for diverticulitis, 117
patients were randomly assigned within 7 days of documented acute diverticulitis to a once-daily regimen of either
2.4 g delayed-release mesalamine or placebo over 12 weeks, followed by a 9-month treatment-free period. Global
symptoms scores for 10 gastrointestinal symptoms on a 0-6 Likert scale were persistently lower in patients receiving
mesalamine compared with the placebo group. The rate of complete response was significantly higher with
mesalamine than placebo at 6 weeks and 52 weeks, while probiotics in combination with mesalamine did not provide
additional efficacy.[12]

1 din 6 06.12.2015 16:54

Diverticulitis Treatment & Management: Medical Care, Surgical Care,... http://emedicine.medscape.com/article/173388-treatment

Surgical Care
About 15-25% of patients presenting with a first episode of acute diverticulitis have complicated disease that requires
surgery. According to the WGO 2007 guidelines, 15-30% of patients admitted for management of diverticulitis will
need surgery during their admission, with an 18% surgical mortality rate.[1]

The classic surgical indications include some features characteristic of Hinchey stage III or IV disease and
are as follows:
Free-air perforation with fecal peritonitis
Suppurative peritonitis secondary to a ruptured abscess
Uncontrolled sepsis
Abdominal or pelvic abscess (unless CT-guided aspiration is possible)
Fistula formation
Inability to rule out carcinoma
Intestinal obstruction
Failing medical therapy
Immunocompromised status
Extremes of age
Recurrent episodes of acute diverticulitis: Elective surgery was previously recommended in any patient who
had 2 or more episodes of diverticulitis that were successfully treated medically; data have since called this
practice into question when the patient is otherwise healthy.
Preoperative preparation with antibiotics should be given in all patients. Single and multiple drug regimens, as
discussed in Medical Care, are appropriate choices. However, for patients with more extensive contamination,
a single drug regimen (with either imipenem/cilastin or piperacillin/tazobactam) or a multiple drug regimen
(with ampicillin, gentamicin, and metronidazole) may be warranted for peritonitis. Bowel preparation is usually
possible for nonemergent situations.
Guidelines from the American Society of Colon and Rectal Surgeons (2006) recommend emergency surgery
for patients with diffuse peritonitis and for those who fail nonoperative management. Also, patients who are
immunosuppressed or immunocompromised are at an increased risk of failing medical therapy or perforation
and should be approached with a lower threshold. [13]
A 2-stage surgical approach is the most common surgical procedure performed today for the emergency
treatment of acute diverticulitis.
A traditional Hartmann procedure is commonly performed, which involves resection of the diseased
segment of bowel, an end-colostomy, and closure of the rectal stump. Typically, 3 months later, a
second procedure can be performed in which the colostomy is reversed and intestinal continuity is
reestablished with the rectal stump; however, this second operation can be technically difficult and is
not performed in many patients. This is the preferred approach in patients with fecal peritonitis and in
most cases of purulent peritonitis.[14, 15]
An alternative to the Hartmann procedure includes resection of the diseased colon, primary
anastomosis (with or without intraoperative colonic lavage), and proximal diverting stoma, either
colostomy or ileostomy. The second procedure in this course would be to close the stoma. This
approach is primarily used when there are relative contraindications to primary anastomosis but no
purulent or feculent peritonitis and there is nonedematous bowel. The advantage is that it avoids the
technically difficult second stage used in the Hartmann procedure.
Extensive and unnecessary dissections, which open up tissue planes to infection and increase blood
loss, have no role.
Examining data from patients who had undergone the Hartmann procedure for acute diverticulitis and
then (after a median 7-month period) had undergone reversal surgery, Fleming and Gillen investigated
the rate of and risk factors for complications linked to the reversal procedure.[15] The authors found
that out of 76 reversal patients, 18 of them (25%) had post-reversal complications.
Fleming and Gillen also found in the above study that risk factors for reversal complications included
being a current smoker, having a low preoperative albumin level, and allowing a prolonged period of
time to pass between the Hartmann and reversal procedures. The authors concluded that despite the
reversal surgery's significant complication rate, offering the operation to appropriately selected patients
is acceptable. They also suggested that preoperative identification of modifiable of risk factors may
benefit patients.
The decision to proceed with elective surgery, typically at least 6 weeks after recovery from acute
diverticulitis, should be made on a case-by-case basis. As recommended by the 2007 WGO guidelines, this
decision should consider age and medical condition of the patient, frequency and severity of attacks, and the
presence of any persistent symptoms after the acute episode. Other appropriate indications for elective
colectomy include inability to exclude carcinoma, after an episode of complicated diverticulitis treated
nonoperatively, or after percutaneous drainage of a diverticular abscess. [1]
Regarding frequency, after one attack, about one third of patients will have a later second attack of
acute diverticulitis. After a second episode, a further one third will have yet another attack. According
to the 2007 WGO guidelines, a repeat episode requires immediate surgery if complications occur, such
as free perforation, obstruction, abscess that is not resolved by percutaneous drainage, fistulas, and
failure to respond to treatment.[1]
Regarding severity, most patients who present with complicated diverticulitis do so at the time of their
first episode. Therefore, once a patient's initial presentation has been determined to be uncomplicated
or complicated, the patient's future episodes are likely to follow a similar course.
A 1-stage surgical approach with resection and primary anastomosis is often possible in elective
settings since the disease is well localized and/or significantly resolved. The bowel must be well
vascularized, nonedematous, tension free, and well prepared. The proximal margin should be an area
of pliable colon without hypertrophy or inflammation. The distal margin should extend to the upper third
of the rectum where the taenia coalesces. Not all of the diverticula-bearing colon must be removed,
since diverticula proximal to the descending or sigmoid colon are unlikely to result in further symptoms.
Patients with Hinchey stage I or II disease can usually have preoperative bowel preparation.
The classic 3-stage surgical approach is now rarely indicated because of high associated morbidity and
mortality and is considered only in critical situations in which resection cannot safely be performed.
In this approach, the initial operation is simply drainage of the diseased segment and creation of a
proximal diversion colostomy, without resection.
The second operation is performed 2-8 weeks later to resect the diseased bowel and perform a
primary anastomosis.
A third operation, performed 2-4 weeks after the second operation, closes the stoma.
Increasing experience with laparoscopic techniques for colon resection suggests that some of its advantages
include less pain, a smaller scar, and shorter recovery time. [16] There is no change in early or late
complications and cost and outcome are comparable to open procedures. This approach is best suited for
patients in whom the episode of acute diverticulitis has resolved and in patients with Hinchey stage I or II
disease.

2 din 6 06.12.2015 16:54

Diverticulitis Treatment & Management: Medical Care, Surgical Care,... http://emedicine.medscape.com/article/173388-treatment

Special considerations exist for some forms of complicated diverticulitis.

For diffuse peritonitis, an appropriate initial empiric antibiotic regimen must include either single agent
therapy with imipenem/cilastin or piperacillin/tazobactam or multiple drug therapy with ampicillin,
gentamicin, and metronidazole.
Obstruction needs to be differentiated from carcinoma, and, even if biopsy results are negative,
resection may be necessary to exclude carcinoma if there is enough suspicion based upon
appearance alone.
Abscesses without peritonitis may be amenable to percutaneous drainage with an elective
single-stage operation after the episode has resolved. Drainage is usually through the anterior
abdominal wall but may be done transgluteally or through the rectum or the vagina, depending on the
location of the abscess. Catheter drainage may be helpful in patients who cannot undergo surgery and
should be left in place until drainage is less than 10 mL in 24 hours. Catheter sinograms can be
performed periodically to monitor the resolution of the abscess cavity before the catheter is removed.
Fistulas generally do not close spontaneously, but they may be managed with an elective 1-stage
procedure in most cases. Also, in the absence of urinary tract obstruction, observation appears safe in
patients with contraindications to surgery.
Patients who are immunosuppressed are at an increased risk of perforation, and surgery is necessary
in almost all patients who are either already immunosuppressed or are about to start
immunosuppressive therapy.

Consultations
See the list below:

Surgical consultation
Gastroenterology consultation

Diet
See the list below:

In mild episodes, a clear liquid diet is advised. Clinical improvement should occur within 2-3 days, and the diet
can then be advanced as tolerated.
Administer nothing by mouth in episodes of moderate-to-severe acute diverticulitis.
Studies imply a high-fiber diet will prevent progression of diverticulosis. However, after patients have become
symptomatic, the benefit of fiber supplementation is less clear. Recommending to patients to avoid seeds and
nuts is currently less common, since it is now thought that seeds and nuts may not play a significant role in
the development of diverticulitis, as believed in the past.
Long-term management probably includes a high-fiber, low-fat diet.

Activity
Normal activity is possible after resolution of the acute episode.

Medication

Contributor Information and Disclosures

Author
Kamyar Shahedi, MD Clinical Instructor, Olive View-UCLA Medical Center, University of California, Los Angeles,
David Geffen School of Medicine

Kamyar Shahedi, MD is a member of the following medical societies: American College of Physicians, American
Medical Association, California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)
Stanley K Dea, MD Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive
View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles
Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated
Training Program in Gastroenterology

Stanley K Dea, MD is a member of the following medical societies: American Society for Gastrointestinal
Endoscopy, Southern California Society of Gastroenterology

Disclosure: Nothing to disclose.

Yuvrajsinh Narendrasinh Chudasama, MD Staff Physician, Department of Internal Medicine, Olive View-UCLA
Medical Center; Assistant Clinical Professor of Medicine, University of California, Los Angeles, David Geffen
School of Medicine

Yuvrajsinh Narendrasinh Chudasama, MD is a member of the following medical societies: American College of
Physicians, American Medical Association

Disclosure: Nothing to disclose.

Duminda B Suraweera, MD Resident Physician, Department of Medicine, Olive ViewUCLA Medical Center

Duminda B Suraweera, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science,
University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha,
American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

3 din 6 06.12.2015 16:54

Diverticulitis Treatment & Management: Medical Care, Surgical Care,... http://emedicine.medscape.com/article/173388-treatment

Chief Editor
BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of
Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver
Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society
for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements
BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of
Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver
Diseases, American College of Gastroenterology, American Gastroenterological Association, and American
Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

David Greenwald, MD Associate Professor of Clinical Medicine, Fellowship Program Director, Department of
Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine

David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of
Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society
for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Norvin Perez, MD Medical Director, Juneau Urgent and Family Care

Norvin Perez, MD is a member of the following medical societies: American College of Emergency Physicians and
American Medical Association

Disclosure: Nothing to disclose.

Waqar A Qureshi, MD Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine,
Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center

Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology,
American College of Physicians, American Gastroenterological Association, and American Society for
Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Ahmed Sherif, MD Staff Physician, Department of Internal Medicine, Montefiore Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

1. [Guideline] World Gastroenterology Organisation (WGO). Practice Guidelines 2007. Diverticular disease.
Available at http://www.worldgastroenterology.org/diverticular-disease.html. Accessed: 10 June 2011.

2. Karatepe O, Gulcicek OB, Adas G, et al. Cecal diverticulitis mimicking acute appendicitis: a report of 4
cases. World J Emerg Surg. 2008 Apr 21. 3:16. [Medline]. [Full Text].

3. Shahedi K, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental
diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol. 2013 Dec. 11(12):1609-13. [Medline].

4. Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and
diverticular bleeding. Gastroenterology. 2009 Jan. 136(1):115-122.e1. [Medline]. [Full Text].

5. Shahedi K, Fuller G, Bolus R, et al. Progression from Incidental Diverticulosis to Acute Diverticulitis.
Gastroenterol. 2012 May. 142(5) Suppl 1:S-144. [Full Text].

6. Strate LL, Modi R, Cohen E, Spiegel BM. Diverticular disease as a chronic illness: evolving epidemiologic
and clinical insights. Am J Gastroenterol. 2012 Oct. 107(10):1486-93. [Medline].

7. Lahat A, Avidan B, Sakhnini E, Katz L, Fidder HH, Meir SB. Acute Diverticulitis: A Decade of Prospective
Follow-up. J Clin Gastroenterol. 2013 Jan 16. [Medline].

8. [Guideline] Miller FH, Bree RL, Rosen MP, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria left lower quadrant pain. [online publication]. Reston (VA): American College of
Radiology (ACR); 2008. [Full Text].

9. Ricciardi R, Baxter NN, Read TE, Marcello PW, Hall J, Roberts PL. Is the decline in the surgical treatment
for diverticulitis associated with an increase in complicated diverticulitis?. Dis Colon Rectum. 2009 Sep.
52(9):1558-63. [Medline].

10. Alonso S, Pera M, Pares D, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis.
Colorectal Dis. 2009 Nov 10. [Medline].

11. Trivedi CD, Das KM. Emerging therapies for diverticular disease of the colon. J Clin Gastroenterol. 2008
Nov-Dec. 42(10):1145-51. [Medline].

12. Stollman N, Magowan S, Shanahan F, Quigley EM. A Randomized Controlled Study of Mesalamine After
Acute Diverticulitis: Results of the DIVA Trial. J Clin Gastroenterol. 2013 Feb 18. [Medline].

13. [Guideline] Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis
Colon Rectum. 2006 Jul. 49(7):939-44. [Medline]. [Full Text].

4 din 6 06.12.2015 16:54

Diverticulitis Treatment & Management: Medical Care, Surgical Care,... http://emedicine.medscape.com/article/173388-treatment

14. Riansuwan W, Hull TL, Millan MM, Hammel JP. Nonreversal of Hartmann's procedure for diverticulitis:
derivation of a scoring system to predict nonreversal. Dis Colon Rectum. 2009 Aug. 52(8):1400-8. [Medline].

15. Fleming FJ, Gillen P. Reversal of Hartmann's procedure following acute diverticulitis: is timing everything?.
Int J Colorectal Dis. 2009 Oct. 24(10):1219-25. [Medline].

16. Rink AD, John-Enzenauer K, Haaf F, et al. Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy

for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption.
Dis Colon Rectum. 2009 Oct. 52(10):1738-45. [Medline].

17. Crowe FL, Appleby PN, Allen NE, Key TJ. Diet and risk of diverticular disease in Oxford cohort of European
Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and
non-vegetarians. BMJ. 2011 Jul 19. 343:d4131. [Medline]. [Full Text].

18. Ambrosetti P, Robert JH, Witzig JA, Mirescu D, Mathey P, Borst F, et al. Acute left colonic diverticulitis in
young patients. J Am Coll Surg. 1994 Aug. 179(2):156-60. [Medline].

19. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome of complicated
diverticular disease. Am J Surg. 2003 Dec. 186(6):696-701. [Medline].

20. Bordeianou L, Hodin R. Controversies in the surgical management of sigmoid diverticulitis. J Gastrointest
Surg. 2007 Apr. 11(4):542-8. [Medline].

21. Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does
not mandate routine elective colectomy. Arch Surg. 2005 Jun. 140(6):576-81; discussion 581-3. [Medline].

22. Caterino JM, Emond JA, Camargo CA Jr. Inappropriate medication administration to the acutely ill elderly: a
nationwide emergency department study, 1992-2000. J Am Geriatr Soc. 2004 Nov. 52(11):1847-55.
[Medline].

23. Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, et al. Complicated diverticulitis: is it time
to rethink the rules?. Ann Surg. 2005 Oct. 242(4):576-81; discussion 581-3. [Medline].

24. Dominguez EP, Sweeney JF, Choi YU. Diagnosis and management of diverticulitis and appendicitis.
Gastroenterol Clin North Am. 2006 Jun. 35(2):367-91. [Medline].

25. Evans JP, Cooper J, Roediger WE. Diverticular colitis - therapeutic and aetiological considerations.
Colorectal Dis. 2002 May. 4(3):208-212. [Medline].

26. Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med. 1998 May 21. 338(21):1521-6.
[Medline].

27. Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol. 2006 May 28.
12(20):3225-8. [Medline].

28. Freeman SR. Diverticulitis. McNally PR, ed. GI/Liver Secrets. Philadelphia, Pa: Hanley & Belfus; 1996.
332-338.

29. Hackethal V. Diverticulitis Surgery Often Avoidable, New Standard Needed. Medscape [serial online].
Available at http://www.medscape.com/viewarticle/819310. Accessed: January 20, 2014.

30. Isselbacher KJ, Epstein A. Diverticular disease. Braunwald E, Longo DL, et al, eds. Harrison's Principles of
Internal Medicine. 14th ed. McGraw-Hill; 1998. 1648-1649.

31. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007 Nov 15. 357(20):2057-66. [Medline].

32. Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ. 2006 Feb 4. 332(7536):271-5.
[Medline].

33. Kazzi AA. Diverticular disease. Medscape Reference. 2006. [Full Text].

34. Kornitzer BS, Manace LC, Fischberg DJ, Leipzig RM. Prevalence of meperidine use in older surgical
patients. Arch Surg. 2006 Jan. 141(1):76-81. [Medline].

35. Marinella MA, Mustafa M. Acute diverticulitis in patients 40 years of age and younger. Am J Emerg Med.
2000 Mar. 18(2):140-2. [Medline].

36. McCarthy DW, Bumpers HL, Hoover EL. Etiology of diverticular disease with classic illustrations. J Natl Med
Assoc. 1996 Jun. 88(6):389-90. [Medline]. [Full Text].

37. Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK. Recent trends in diverticulosis of the right
colon in Japan: retrospective review in a regional hospital. Dis Colon Rectum. 2000 Oct. 43(10):1383-9.
[Medline].

38. Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, et al. Long-term outcome of
conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol. 2005
Jun. 17(6):649-54. [Medline].

39. Novak JS, Tobias J, Barkin JS. Nonsurgical management of acute jejunal diverticulitis: a review. Am J
Gastroenterol. 1997 Oct. 92(10):1929-31. [Medline].

40. Oliver G, Lowry A, Vernava A, Hicks T, Burnstein M, Denstman F, et al. Practice parameters for antibiotic
prophylaxis--supporting documentation. The Standards Task Force. The American Society of Colon and
Rectal Surgeons. Dis Colon Rectum. 2000 Sep. 43(9):1194-200. [Medline]. [Full Text].

41. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol. 1975 Jan. 4(1):53-69.
[Medline].

42. Patel DG, Thomson WG. Diverticulitis and diverticular hemorrhage. Clinical Practice of Gastroenterology.
Philadelphia, Pa: Churchill Livingstone; 1999. 727-732.

43. Pemberton JH, Armstrong DN, Dietzen CD. Diverticulitis. Yamada T, Alpers DH, et al, eds. Textbook of
Gastroenterology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1995. 1876-1888.

44. Poletti PA, Platon A, Rutschmann O, Kinkel K, Nyikus V, Ghiorghiu S, et al. Acute left colonic diverticulitis:
can CT findings be used to predict recurrence?. AJR Am J Roentgenol. 2004 May. 182(5):1159-65.
[Medline].

5 din 6 06.12.2015 16:54

Diverticulitis Treatment & Management: Medical Care, Surgical Care,... http://emedicine.medscape.com/article/173388-treatment

45. Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis Colon
Rectum. 2006 Jul. 49(7):939-44. [Medline].

46. Rampton DS. Diverticular colitis: diagnosis and management. Colorectal Dis. 2001 May. 3(3):149-53.
[Medline].

47. 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 Jun. 170(6):1445-9. [Medline].

48. Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg. 1989 Mar. 26(3):133-89. [Medline].

49. Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A
Systematic Review. JAMA Surg. 2014 Jan 15. [Medline].

50. Ripolles T, Agramunt M, Martinez MJ, Costa S, Gomez-Abril SA, Richart J. The role of ultrasound in the
diagnosis, management and evolutive prognosis of acute left-sided colonic diverticulitis: a review of 208
patients. Eur Radiol. 2003 Dec. 13(12):2587-95. [Medline].

51. Schoetz DJ Jr. Uncomplicated diverticulitis. Indications for surgery and surgical management. Surg Clin
North Am. 1993 Oct. 73(5):965-74. [Medline].

52. Schreyer AG, Furst A, Agha A, Kikinis R, Scheibl K, Scholmerich J, et al. Magnetic resonance imaging
based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis.
2004 Sep. 19(5):474-80. [Medline].

53. Silverman ME, Shih RD, Allegra J. Morphine induces less nausea than meperidine when administered
parenterally. J Emerg Med. 2004 Oct. 27(3):241-3. [Medline].

54. Wu JS, Baker ME. Recognizing and managing acute diverticulitis for the internist. Cleve Clin J Med. 2005
Jul. 72(7):620-7. [Medline].

55. Yacoe ME, Jeffrey RB Jr. Sonography of appendicitis and diverticulitis. Radiol Clin North Am. 1994 Sep.
32(5):899-912. [Medline].

56. Young-Fadok T, Pemberton JH. Clinical manifestations, diagnosis, and treatment of acute diverticulitis.
2000.

Medscape Reference 2011 WebMD, LLC

6 din 6 06.12.2015 16:54