Acute Colonic Diverticulitis - Surgical Management - UpToDate

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Acute colonic diverticulitis: Surgical management

AUTHOR: John H Pemberton, MD
SECTION EDITOR: Martin Weiser, MD
DEPUTY EDITOR: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2024.

This topic last updated: Aug 22, 2022.
INTRODUCTION
Diverticular disease of the colon is an important cause of hospital admissions and a significant
contributor to health care costs in industrialized nations [1,2]. In Western countries, the
majority of patients present with sigmoid diverticulitis [3,4].
Most patients with acute sigmoid diverticulitis are treated medically; surgery is only indicated
when diverticulitis is either not amenable or is refractory to medical therapy ( algorithm 1) [5-
8]. Approximately 15 percent of patients will require surgery for diverticular disease [7]. In the
United States, diverticular disease is the leading indication for elective colon surgery [9]. For
patients who require surgery for diverticulitis, the choice of techniques depends upon the
patient's hemodynamic stability, extent of peritoneal contamination, and surgeon
experience/preference [10].
Surgical treatment of acute colonic diverticulitis and its acute complications (perforation,
abscess formation, or intractability) is described here. Diverticular fistulas, bleeding, and
stricture/obstruction, which are typically subacute or chronic sequelae of diverticulitis, are
discussed in other topics:
● (See "Diverticular fistulas".)
● (See "Colonic diverticular bleeding".)
● (See "Large bowel obstruction".)
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The diagnosis and medical management of acute diverticulitis are discussed separately. (See
"Clinical manifestations and diagnosis of acute colonic diverticulitis in adults" and "Acute colonic
diverticulitis: Triage and inpatient management".)
PERFORATION
While most patients with freely perforated diverticulitis require surgery, the choice of
techniques largely depends upon the extent of peritoneal contamination as assessed by the
Hinchey classification system [11]:
● Stage I – Pericolic or mesenteric abscess

● Stage II – Walled-off pelvic abscess
● Stage III – Generalized purulent peritonitis
● Stage IV – Generalized feculent peritonitis
In general, the majority of microperforations (not included in the Hinchey classification),

Hinchey I perforations, and Hinchey II perforations can be managed nonoperatively, while most
Hinchey III and IV perforations require surgical intervention.
Free (frank) perforation — Acute diverticulitis with free (frank) perforation (Hinchey III or IV) is
a life-threatening condition that mandates emergency surgery [7,8,12-14]. The primary goal of
surgery is to obtain source control by removing the perforated colonic segment; the secondary
goal of surgery is to restore intestinal continuity [15-19], the feasibility of which is predicated
upon a patient's hemodynamic stability and the degree of peritoneal contamination.
Unstable patients — For patients who are hemodynamically unstable due to perforated
diverticulitis and who do not have the physiologic reserve to tolerate a colon resection and
reconstruction, damage control surgery should be expedited to obtain source control of their
sepsis, delaying less critical portions of the operation until after appropriate resuscitation
[14,20,21]. (See "Overview of damage control surgery and resuscitation in patients sustaining
severe injury".)
While damage control surgery always consists of peritoneal lavage, temporary abdominal
closure, and a second look, some surgeons also perform a limited colonic resection, then either
leave the colon stapled off in situ or construct a colostomy (ie, Hartmann's procedure with
temporary abdominal closure) [20]. In a study of 58 patients with perforated diverticulitis with
generalized peritonitis, the use of damage control strategies resulted in a 9 percent mortality
rate, while 44 of 53 surviving patients were stoma free [22].
Stable patients with feculent peritonitis — For stable patients with feculent peritonitis (ie,
Hinchey IV diverticulitis), we suggest Hartmann's procedure [14]. Primary anastomosis is
generally contraindicated because of the peritoneal contamination and inflammation.
Hartmann's procedure involves resecting the diseased colonic segment, creating an end
colostomy and a rectal stump, and then reversing the colostomy in the future ( figure 1) [16].
Because creating a mucous fistula by bringing the distal end of the transected bowel through
the abdominal wall is often not possible after resecting the entire sigmoid colon, many
surgeons mark the rectal stump with a long nonabsorbable suture and tack it to the anterior
abdominal wall or sacral promontory to help identify the rectal stump at the second-stage
operation.
Subsequent closure of the colostomy is a technically difficult operation associated with high
morbidity and mortality rates [23,24]. As a result, colostomy closure is only performed in
approximately 50 to 60 percent of all patients after a Hartmann's procedure [25-27]. In the
author's practice, patients with fecal contamination of the abdominal cavity at the index
operation are usually reversed after approximately one year; those without fecal contamination
can usually be reversed sooner in three to four months. Colostomy reversal should be
approached cautiously for patients with obesity and a short rectal remnant because the
operation is technically difficult and the functional outcomes (eg, bowel control) are typically
poor.
Stable patients with purulent peritonitis — For stable patients with purulent peritonitis (ie,
Hinchey III diverticulitis), Hartmann's procedure is also the most commonly performed
procedure [28]. However, the surgeon may choose to restore bowel continuity with or without
fecal diversion based on patient and intraoperative factors as well as their own experience [10].
Primary anastomosis with proximal diversion — Some European authors have

advocated primary anastomosis with proximal diversion (PAPD) ( figure 2) in select patients
with Hinchey III perforated diverticulitis [14]. Limited data suggest that it may have similar
mortality, lower morbidity, and lower stoma rate at 12 months compared with Hartmann's
procedure.
● In a randomized trial of 62 patients with left-sided colonic perforation due to Hinchey III or
IV diverticulitis, patients treated with a primary anastomosis with diverting ileostomy,
compared with patients treated with a Hartmann's procedure, had similar mortality (9
versus 13 percent) and morbidity rates (75 versus 67 percent) after the first operation [29].
However, a greater percentage of patients treated with a primary anastomosis with
diverting ileostomy underwent stoma reversal (90 versus 57 percent), and reversal of the
diverting ileostomy in those patients required less operative time (73 versus 183 minutes)
and a shorter length of hospital stay (six versus nine days) and resulted in fewer serious
complications (0 versus 20 percent) compared with colostomy reversal in patients treated
with a Hartmann's procedure.
● In another French trial (DIVERTI), 102 patients with Hinchey III or IV perforated
diverticulitis were randomly assigned to primary anastomosis or Hartmann's procedure
[30]. At 18 months, the mortality and morbidity rates were similar between the two
groups, but patients who underwent primary anastomosis were much less likely to still
have a stoma (4 versus 35 percent). Two-thirds of patients underwent primary
anastomosis with a protective stoma and one-third without it. That decision was not
randomized but made by surgeons intraoperatively. Although the morbidity rate was
lower without a protective stoma, this result was likely biased, as all but one patient
without a stoma had Hinchey III disease.
● A third multinational trial comparing primary anastomosis (without diversion) with

Hartmann's procedure in patients with Hinchey III or IV perforated diverticulitis failed to
reach any conclusion after closing prematurely due to poor accrual [31].
A 2018 systematic review and meta-analysis of randomized trials (including the three above)
found that primary resection and anastomosis had similar major complication and mortality
rates compared with Hartmann's procedure. However, patients were more likely to be stoma
free (relative risk [RR] 1.4, 95% CI 1.18-1.67) and to avoid major complications related to the
stoma reversal procedure (RR 0.26, 95% CI 0.07-0.89) after primary resection and anastomosis
than after Hartmann's procedure [32]. A 2019 systematic review and meta-analysis of 22
observational studies and the three trials reached a similar conclusion that both procedures
were acceptable [33].
The two procedures have been compared in several large administrative database studies as
well.
● In an analysis of over 130,000 patients undergoing either primary anastomosis with

diverting loop ileostomy or Hartmann's procedure for acute diverticulitis (not stratified by
Hinchey classification, but about 90 percent underwent surgery for perforation), the
mortality (2.9 versus 7.6 percent) and morbidity rates (49 versus 55 percent) were
comparable [34]. Although patients who underwent Hartmann's procedure were generally
sicker (eg, more likely to be in septic shock [11 versus 5 percent]), primary anastomosis
with diverting loop ileostomy was not associated with increased mortality or morbidity
when compared with Hartmann's procedure in multivariate analysis. The majority of
patients underwent Hartmann's procedure, and only 7.6 percent underwent primary
anastomosis with diverting ileostomy.
● An administrative database study of over 10,000 patients undergoing urgent or

emergency colon surgery for diverticulitis found that both postoperative mortality (15
versus 7.4 percent) and morbidity rates (58.2 versus 39.5 percent) were significantly higher
when noncolorectal surgeons performed primary anastomosis with proximal diversion
compared with Hartmann's procedure, while the postoperative mortality (3.7 versus 5.3
percent) and morbidity rates (48.2 versus 43.4 percent) were comparable between the two
procedures when performed by colorectal surgeons [35,36].
● In a third study of 34,126 patients who required nonelective diversion for acute
diverticulitis in a United States nationwide cohort, 95 percent underwent Hartmann's
procedure; 5 percent underwent primary anastomosis with proximal diversion [37]. By
inverse probability treatment weight analysis, the odds of mortality, complications, and
nonhome discharge were similar for proximal diversion compared with Hartmann's
procedure. Proximal diversion was associated with a higher rate of readmission within 90
days (22 versus 14 percent) but a greater chance of ostomy reversal than Hartmann's
procedure (hazard ratio 1.46, 95% CI 1.08-1.99).
Rarely performed procedures — Drainage procedures are rarely performed because they do
not definitively address the underlying diverticular disease, and some studies suggest poorer
outcomes in patients undergoing lavage. However, they may be useful in treating septic
patients who are too ill to tolerate a resectional procedure.
Laparoscopic lavage — In the 1990s, laparoscopic lavage and drainage were introduced
to avoid laparotomy and fecal diversion in patients with complicated diverticulitis [38-41].
Compared with other surgical options, laparoscopic lavage has been shown to decrease stoma
rate within 90 days (RR 0.18; 95% CI 0.12-0.27); however, it does not decrease one-year mortality
rate and actually increases short-term morbidity rate due to higher complication and
reintervention rates [14,42]. Therefore, laparoscopic lavage should only be performed in
selected patients with Hinchey III (purulent) perforated diverticulitis and by experienced
surgeons, after they are counseled regarding the higher complication and reintervention rates.
Hinchey IV (feculent) perforated diverticulitis should be treated with Hartmann's procedure,
while Hinchey I or II (abscess) diverticulitis is likely to respond to nonoperative management.
(See 'Localized perforation (ie, abscesses)' below.)
Although earlier retrospective studies found a low mortality rate of 2 percent and avoidance of
a permanent stoma in the majority of patients who underwent laparoscopic lavage [43],
subsequent randomized trials performed against resectional procedures in the 2000s reported
conflicting results:
● In the SCANDIV trial, 199 patients suspected of having perforated diverticulitis based upon
detection of free air by abdominal computed tomography (CT) scan were randomly
assigned to undergo emergency laparoscopic lavage or sigmoidectomy [44]. Compared
with sigmoidectomy, laparoscopic lavage achieved similar mortality (13.9 versus 11.5
percent) and severe morbidity rates (30.7 versus 26 percent) at 90 days. However, patients
who were treated with laparoscopic lavage were more likely to require reoperation (20.3
versus 5.7 percent) for complications such as secondary peritonitis (six versus zero
patients) or missed sigmoid cancer (four versus zero patients). A follow-up study of trial
participants found that, at five years, the rates of morbidity, mortality, and secondary
procedures (including stoma reversal) were equal between the two groups, and there were
no differences in quality-of-life measures [45]. There were more diverticulitis recurrences
in the lavage group but higher stoma prevalence rates in the resection group.
● The LOLA trial, which included 90 patients with purulent perforated diverticulitis, showed
that laparoscopic lavage produced a higher combined major morbidity and mortality rate
within 30 days compared with sigmoidectomy (39 versus 19 percent) [46]. At 12 months,
the rates were comparable between the two groups (65 percent for lavage versus 63
percent for sigmoidectomy).
● The DILALA trial randomly assigned 83 patients to laparoscopic lavage or Hartmann's

procedure after a laparoscopic diagnosis of purulent perforated diverticulitis [47,48]. The
mortality rates were similar at both 90 days (8 versus 11 percent) and one year (14 versus
15 percent); the major morbidity rates were similar at 30 (13 versus 18 percent) and 90
days (21 versus 25 percent). The reoperation rates were similar at 30 days (13 versus 17
percent). At one year, however, fewer patients required reoperation after laparoscopic
lavage (28 versus 63 percent). In addition, laparoscopic lavage resulted in shorter
operative time (1 versus 2.5 hours) and hospital stay (6 versus 9 days for index admission;
8 versus 14 days at one year). At two years, still fewer patients required one or more
reoperations after laparoscopic lavage than after Hartmann's procedure (42 versus 68
percent), while the mortality rate (14 versus 18 percent) and total days of hospital stay (18
versus 24) were statistically similar between the two groups [49].
Although laparoscopic lavage has the purported advantages of reduced morbidity and
mortality, a systematic review and meta-analysis of randomized trials (including the three
above) found that major complications were more frequent after laparoscopic lavage than
sigmoidectomy, whereas postoperative mortality rates (RR 1.03; CI 0.45-2.34) were not different
between the two procedures [32,42]. Weighing the lower stoma rate against the higher risks of
complication and reoperation, we do not recommend routine laparoscopic lavage for Hinchey
III or IV perforated diverticulitis. Hartmann's procedure remains our standard treatment for
Hinchey III or IV perforated diverticulitis.
Laparoscopic lavage was originally intended for purulent (Hinchey III) but not feculent (Hinchey
IV) perforated diverticulitis. But in common practice, it is often difficult to exclude fecal
peritonitis and/or sigmoid carcinoma during the preoperative evaluation. If a surgeon chooses
to perform laparoscopic lavage, they must exclude fecal perforation (Hinchey IV) or a visualized
perforation by diagnostic laparoscopy and either colon cancer or ongoing colonic air leak (from
perforation) by intraoperative sigmoidoscopy.
Patients who undergo laparoscopic lavage should be advised that a reoperation (usually
Hartmann's procedure) may be necessary if laparoscopic lavage fails to control the sepsis or a
sigmoid carcinoma is later found. In a multicenter, prospective, noncomparative study (the LLO
study), 212 patients underwent laparoscopic lavage for laparoscopy-confirmed Hinchey III
perforated diverticulitis [50]. The short- and long-term success rates of laparoscopic lavage in
this cohort of patients were 74.5 percent (discharged without further surgery or readmission in
60 days) and 65.4 percent (no surgery for the initial admission or recurrence), respectively. Only
one patient had a colon cancer, which required reoperation. Since one-quarter of patients will
not have sepsis control with laparoscopic lavage alone, those who undergo laparoscopic lavage
must be able to tolerate persistent or recurrent infection. Thus, frail, septic patients or those
with major comorbidities are not good candidates for laparoscopic lavage [41]. A fit patient with
previous acute diverticulitis and without severe sepsis may be a better candidate for the
procedure [50].
In a British registry-based study of 499 propensity score-matched patients undergoing

emergency surgery for Hinchey III perforated diverticulitis, laparoscopic lavage was associated
with fewer overall complications within 90 days, as defined by the Comprehensive Complication
Index (CCI) score, and shorter hospital stay at both index admission and in total within 90 days
[51]. Patients who underwent laparoscopic lavage had more infectious complications and
readmissions, whereas those who underwent resection suffered more cardiovascular and other
complications.
Three-stage procedure — A legacy procedure for colonic perforation includes three

stages: the first stage of draining but not resecting the diseased segment and construction of a
proximal diverting stoma, the second stage of resecting the diseased segment with a primary
anastomosis under the protection of the proximal stoma, and the third stage of closing the
proximal stoma. Until the 1980s, the three-stage procedure was felt to be the safest approach
to perforated diverticulitis.
Since then, the three-stage procedure has been largely replaced by other procedures (eg, the
Hartmann's procedure) with lower postoperative mortality rates (26 versus 7 percent) [52,53]. In
contemporary practice, the three-stage procedure is only performed when inflammation
precludes safe pelvic dissection of the colon from critical sidewall structures (eg, iliac vessels
and ureters) or when the patient is unstable. Drainage and fecal diversion in these situations
can serve as a temporizing measure to allow treatment of infection and inflammation before
further surgery or transfer to a more experienced center. (See "Large bowel obstruction",
section on 'Diverticular disease'.)
Localized perforation (ie, abscesses) — Localized perforations present acutely as a mesocolic

or pelvic abscess (Hinchey I or II). Hinchey I or II diverticulitis is characterized by one or more
localized abscesses in the pericolonic, mesenteric, or pelvic locations. In contemporary practice,
diverticular abscesses are typically treated with percutaneous image-guided drainage or with
intravenous antibiotics if the abscess is too small (<4 cm) or inaccessible to percutaneous
drainage. Surgery may be indicated for patients who deteriorate or fail to improve within two to
three days of percutaneous intervention or antibiotic therapy as a persistent intra-abdominal
abscess is unlikely to respond to further nonoperative management. (See "Acute colonic
diverticulitis: Triage and inpatient management".)
Patients with a localized perforation can usually tolerate a preoperative bowel preparation.
Thus, if the phlegmon or abscess can be resected with the colonic segment, a primary
anastomosis can be performed in these patients. (See 'Colon resection with primary
anastomosis' below.)
If there are concerns about either contamination or inflammation involving the surrounding
tissue (eg, with a large pelvic abscess) but the bowel is not edematous, a primary anastomosis
with or without a protective ostomy, depending upon the condition of the local tissue, can be
performed. This is preferred to a Hartmann's procedure as a protective stoma is easier to
reverse than an end colostomy with a rectal stump [54,55]. (See 'Primary anastomosis with
proximal diversion' above.)
Microperforation — Microperforation, usually indicated by one or a few extraluminal air

bubbles on CT images, and phlegmon are not considered complicated diverticulitis and thus
can be managed nonoperatively with intravenous antibiotics and bowel rest [10]. (See "Acute
colonic diverticulitis: Triage and inpatient management".)
Those with extraluminal air bubbles only on initial CT may develop an abscess on subsequent
studies. In one study, the rate was 19 percent [56]. Patients with microperforation and an
associated abscess should be treated accordingly as having complicated disease. (See "Acute
colonic diverticulitis: Triage and inpatient management".)
PERSISTENT SYMPTOMS
Patients may require colon surgery for diverticulitis because of persistent or chronic symptoms
that interfere with quality of life. There is high-quality evidence that elective resection may
improve short-term functional outcomes and quality of life for those who remain symptomatic
despite optimal medical therapy [57].
● Failure of medical treatment – Patients who deteriorate or fail to improve after three to
five days of inpatient intravenous antibiotics may require surgery during the same
hospitalization as further medical therapy is unlikely to resolve their diverticulitis. (See
"Acute colonic diverticulitis: Triage and inpatient management", section on 'Failure of
inpatient medical treatment'.)
● Chronic smoldering diverticulitis – Patients with acute diverticulitis who initially respond to
medical treatment but subsequently develop recurrent symptoms, such as left lower
quadrant abdominal pain, alteration in bowel movements, and/or rectal bleeding, are
described as having chronic smoldering diverticulitis. If the symptoms persist for longer
than six weeks, patients should be referred for surgical evaluation. However, since patients
with irritable bowel syndrome or other functional gastrointestinal disorders may present
similarly, patients with chronic symptoms after an acute diverticulitis attack must be
evaluated carefully before being offered surgery. (See "Acute colonic diverticulitis: Triage
and inpatient management".)
Colon resection with primary anastomosis — A one-stage procedure (ie, colon resection with
primary anastomosis) is typically performed for patients with persistent or chronic symptoms
from diverticulitis, as long as they can tolerate a bowel preparation preoperatively. (See 'Bowel
preparation' below.)
To qualify for a one-stage resection, the bowel must be well vascularized and nonedematous
and the anastomosis should be tension free and well prepared. The distal resection margin is
typically placed in the upper third of the rectum, where the teniae coli converge. The proximal
margin is placed where the colon becomes soft and nonedematous. It is not necessary to resect
all diverticula-bearing colon proximal to the intended anastomosis to prevent recurrence, since
diverticula in the transverse or descending colon rarely cause further symptoms [58]. (See
'Operative considerations' below.)
For patients with persistent or chronic symptoms of diverticulitis, intraoperative findings of free
perforation may alter the operative plan to either a Hartmann's procedure (for Hinchey III or IV
diverticulitis) or addition of a protective ostomy (for Hinchey I or II diverticulitis with
surrounding inflammation or infection). In addition, as an unprotected primary anastomosis is
also relatively contraindicated for patients with significant medical comorbidities, poor
nutritional status, immunosuppression, or other factors that could lead to anastomotic
complications [59], surgeons may also choose to protect the anastomosis in patients with one
or more of the risk factors.
Open versus minimally invasive approach — A one-stage colon resection for diverticulitis
can be performed open or minimally invasively (laparoscopic or robotic). The minimally invasive
approach is preferred when feasible. Evidence suggests that laparoscopic surgery in this setting
can be performed safely with superior short-term outcomes and comparable long-term
outcomes [14,60-70].
At least three randomized trials have also been performed:
● In the Sigma trial (2009; 104 patients), laparoscopic surgery performed for Hinchey I and II
diverticulitis was associated with a 15 percent reduction in major complication rates, less
pain, improved quality of life, and shorter hospitalization, but a longer operating time
compared with open surgery [71]. At six months, the advantage of laparoscopic surgery in
major complication rate had increased to 27 percent [72]. A separate economic analysis
showed that the total health care costs of laparoscopic and open surgery were similar [73].
● A second randomized trial (2010; 113 patients) found that, compared with open surgery,
laparoscopic surgery resulted in a significantly shorter duration of postoperative ileus (76
versus 106 hours) and length of hospital stay (five versus seven days). However, the
reduction in postoperative pain was less impressive (4 versus 5 on a visual analog pain
scale), perhaps because patients were blinded to the surgical approach [74]. At 30 months,
the only remaining benefit of the laparoscopic approach was slightly improved cosmetic
outcomes (9 versus 8 on a 10 point scale) [75]. The median hospital cost was not different.
● A third randomized trial (2011; 143 patients) found that patients who underwent
laparoscopic versus open surgery had similar complication rates and reported similar
quality of life during the early postoperative period and at 12 months [76].
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A 2017 Cochrane review of the above three randomized trials found insufficient evidence to
either support or refute the superiority of laparoscopic surgery over open surgery for
diverticular disease [77]. Additionally, in a meta-analysis of 19 nonrandomized studies
comparing 1014 patients undergoing elective laparoscopic surgery with 1369 patients
undergoing open surgery, open surgery was associated with significantly higher rates of wound
infection (relative risk [RR] 1.85, 95% CI 1.25-2.78), blood transfusion (RR 4.0, 95% CI 1.67-10.0),
postoperative ileus (RR 2.70, 95% CI 1.52-5.0), and incisional hernia (RR 3.70, 95% CI 1.56-8.33)
[78]. The rates of serious complications (eg, anastomotic leak or stricture, inadvertent
enterotomy, small bowel obstruction, intra-abdominal bleeding, or abscess formation) were
comparable between the groups.
Data suggest that laparoscopic surgery for sigmoid diverticulitis can be safely performed in
patients with obesity [79] and older adult patients [80].
Laparoscopic surgery for diverticular disease can be performed with the standard multiport
technique or with a technique called single-incision laparoscopic colectomy (SILC). Studies
showed that SILC is feasible and safe when performed by experienced surgeons [81,82]. In a
prospective study of 330 patients with diverticular disease, patients who underwent SILC had
lower peak pain scores compared with patients who underwent a standard laparoscopic
procedure (4.9 versus 5.6) [81]. The techniques of single-incision laparoscopic surgery are
discussed elsewhere. (See "Abdominal access techniques used in laparoscopic surgery", section
on 'Single-incision laparoscopic surgery'.)
OBSTRUCTION
Patients who present with colonic obstruction attributable to acute diverticulitis should undergo
surgical resection of the involved colonic segment or proximal fecal diversion if a resection
cannot be performed safely. Because acute diverticulitis and colon cancer can both cause
colonic obstruction and are difficult to distinguish by abdominopelvic CT ( image 1), surgery
in this setting is required to rule out cancer and also to relieve symptoms of obstruction.
Colonic obstruction due to diverticular disease is rarely complete, which allows bowel
preparation to be attempted. Alternatively, on-table lavage can be used to clean out the fecal
load, which may also permit a primary anastomosis.
Endoluminal stenting may not be helpful for colonic obstruction caused by diverticulitis. In a
systematic review, treating benign colorectal obstructions (most due to diverticulitis) with self-
expanding stents resulted in more cases of perforation (12 versus 4 percent), stent migration
(20 versus 10 percent), and recurrent obstruction (14 versus 7 percent) than stenting malignant
colorectal obstructions [83]. When stenting was used as a bridging therapy to surgery, only 43
percent of patients with diverticulitis successfully avoided a stoma. (See "Enteral stents for the
management of malignant colorectal obstruction".)
FISTULA
As a result of diverticulitis, a fistula can develop between the colon and another pelvic organ,
such as the bladder (65 percent), vagina (25 percent), small bowel (7 percent), uterus (3
percent), or other sites. Diverticular fistulas rarely close spontaneously and therefore require
surgical correction. The management of diverticular fistulas is discussed separately. (See
"Diverticular fistulas".)
BLEEDING
Colonic diverticular bleeding is the most common cause of overt lower gastrointestinal bleeding
in adults. In most cases, the bleeding will stop spontaneously. However, if the bleeding persists,
endoscopic, radiologic, or surgical intervention may be required. Segmental colectomy is
performed when the source of bleeding can be localized with colonoscopy or angiography;
subtotal colectomy is reserved for patients who continue to bleed without a documented site of
bleeding; blind segmental resection should not be performed, due to a high rebleeding rate
(approximately 40 percent). (See "Colonic diverticular bleeding".)
RISK REDUCTION (ELECTIVE SURGERY)
The 2020 American Society of Colorectal Surgeons (ASCRS) guidelines recommend elective
surgery to patients who had a prior episode of complicated diverticulitis and those who are
immunosuppressed regardless of symptoms because such patients could develop serious
complications or die from recurrent attacks of diverticulitis [10].
Elective surgery is typically performed 10 to 12 weeks after an episode of acute diverticulitis

when all infection and inflammation have resolved; earlier surgery has been associated with a
higher conversion rate and a longer hospital stay [84]. In a retrospective study of 332 patients,
those who underwent laparoscopic surgery prior to three months after the last acute episode
were more likely to have residual inflammation (31 versus 11 percent), abdominal morbidities
(21 versus 5 percent), and longer hospital stay (7.7 versus 5 days) compared with those who
underwent surgery after three months [85]. A primary anastomosis without protective ostomy
(ie, a one-stage procedure) is the standard procedure for diverticulitis. (See 'Colon resection
with primary anastomosis' above.)
Patients with prior complicated attack — The 2020 ASCRS guidelines [10] recommend
elective surgery for patients with one prior episode of complicated diverticulitis because some
studies show that such patients are at a greater risk of developing complications or dying from
a recurrent attack and therefore would benefit from early elective surgery [86,87].
As an example, in a retrospective study of over 200,000 patients admitted for diverticulitis, 85

percent were managed medically, of whom 16 percent suffered a recurrent attack [86]. The
following complications of the initial episode of diverticulitis were independent predictors of
mortality during the recurrent episode: bowel obstruction (hazard ratio [HR] 1.33, 95% CI 1.06-
1.65), abscess (HR 2.18, 95% CI 1.60-2.97), peritonitis (HR 3.14, 95% CI 1.99-4.97), sepsis (HR
1.88, 95% CI 1.29-2.73), and fistula (HR 3.50, 95% CI 2.17-5.66). The mortality rate with elective
surgery after the initial episode was substantially lower than the mortality rate with emergency
surgery during the recurrent episode (0.3 versus 4.6 percent).
Healed diverticular abscess — Whereas surgery is almost always indicated for complications
such as fistula, obstruction, stricture, and free perforation, the optimal management of a healed
diverticular abscess is less certain [88], as some evidence suggests that it is not as significant a
risk factor for future complicated recurrence. Thus, for patients with a healed diverticular
abscess, we suggest basing the decision to operate on the persistence of symptoms and effect
on quality of life, rather than mandating surgery solely to avoid recurrent attacks. This is
especially true if the patient is medically complicated. The 2018 European Association of
Endoscopic Surgery (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) consensus guidelines also suggested against routine surgery solely to prevent future
attacks following a single episode of Hinchey I/II acute diverticulitis successfully treated
nonoperatively [14].
Some studies report that recurrence after nonoperative treatment of diverticular abscesses is
common (up to 61 percent) [87,89] or that most such patients (65 percent) will require surgery
eventually for one reason or another [90]. Other data suggest that recurrence is infrequent (25
percent) [91-93] and that most can be managed nonoperatively [56,94,95], with only about 12
percent requiring nonelective resection [91,96].
The discrepancy between studies may originate from an imprecise definition of true recurrence
(as opposed to unresolved index episode) [97]. Hence, we suggest basing the decision to
operate on a patient's persistent symptoms as we would do for all colonic diverticular diseases,
rather than solely on a history of diverticular abscess if it has completely healed. (See 'Persistent
symptoms' above.)
Patients who are immunocompromised — Most surgeons would offer elective surgery to
immunocompromised patients after a single attack of diverticulitis because they often require
emergency surgery due to an atypical and delayed presentation. Elective surgery is associated
with lower morbidity and mortality rates compared with emergency surgery in these and other
patients. (See "Acute colonic diverticulitis: Triage and inpatient management".)
PERIOPERATIVE CONSIDERATIONS
Antibiotics — Patients undergoing emergency or urgent surgery for acute diverticulitis should
already be on antibiotics ( table 1 and table 2 and table 3), the duration of which is
discussed separately. (See "Antimicrobial approach to intra-abdominal infections in adults",
section on 'Duration of therapy' and "Acute colonic diverticulitis: Triage and inpatient
management", section on 'Intravenous antibiotics'.)
Patients undergoing elective surgery for diverticular disease should receive prophylactic
antibiotics within one hour of skin incision. The choice of antibiotics is discussed elsewhere
( table 4). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Bowel preparation — In general, we recommend mechanical bowel preparation and oral

antibiotics before all resectional colorectal procedures when feasible. Preoperative bowel
preparation is possible for all patients undergoing elective surgery and selected patients
undergoing urgent surgery for Hinchey I or II diverticulitis. The indications for bowel
preparation and the choice of agents are further discussed elsewhere. (See "Overview of colon
resection", section on 'Bowel preparation'.)
Stoma marking — Before surgery, patients should be advised of the possibility of a stoma, and
the potential stoma site should be marked by a stoma therapist when available.
Prophylactic ureteral stent placement — There is no evidence for or against prophylactic

ureteral stent placement. Surgeons may use it selectively based on imaging and patient
characteristics (eg, for complex, chronic, or fistulous diverticular disease where anatomic
distortion by the diverticular phlegmon is expected) [14]. (See "Overview of colon resection",
section on 'Prophylactic ureteral stenting'.)
Patient positioning — We prefer a modified lithotomy or a split leg position, which permits
intraoperative proctoscopy and the use of a circular stapler in case an anastomosis is
performed.
Enhanced recovery protocol — Fast-track recovery protocols have been shown to

incrementally improve outcomes of gastrointestinal surgeries, including elective colon surgery
for diverticular disease. As an example, a retrospective study showed that managing patients
according to a fast-track recovery protocol shortened the time from surgery to first solid meal
(2.3 versus 3.6 days), first bowel movement (2.6 versus 3.5 days), and hospital discharge (3
versus 5 days), compared with traditional postcolectomy care [98]. In addition, patients on a
fast-track recovery protocol also suffered fewer complications (15 versus 26 percent). Fast-track
protocols in colorectal surgery are discussed elsewhere. (See "Enhanced recovery after
colorectal surgery".)
OPERATIVE CONSIDERATIONS
● We prefer anatomic resection of the sigmoid colon with ligation of the inferior mesenteric
artery (IMA). An anatomic resection ensures proper mobilization of the colon, hence the
formation of a tension-free anastomosis.
● The descending colon should be fully mobilized to provide sufficient colonic length to
ensure a tension-free anastomosis. Although routine splenic flexure mobilization has not
been shown to decrease either perioperative morbidities [99] or recurrences [100], it may
be required to further increase colonic length in selected patients. In several studies,
splenic flexure mobilization was performed in about half of the patients [99,100].
● The colon should be transected in an area proximal to the involved segment/phlegmon

that is devoid of gross inflammation. It is not necessary to resect all diverticula.
● Distal transection should occur at or below the rectosigmoid junction where the teniae coli
coalesce, at the level of the sacral promontory. A colorectal anastomosis has a four times
lower risk of disease recurrence compared with a colosigmoid anastomosis [100].
● Either a hand-sewn or stapled anastomosis can be performed based on surgeon

preference, as there is no difference in outcomes [100]. For stapled anastomoses, the
stapler not reaching and effacing the staple line of the rectal stump is indicative of residual
sigmoid colon. In this situation, the residual sigmoid colon should be resected to prevent
recurrences, as opposed to advancing the stapler out the anterior wall of the rectum [14].
An intraoperative leak test should be performed to evaluate the integrity of the
anastomosis.
● As there is no evidence to support routine peritoneal drainage [101], whether to leave

such a drain is left to the surgeon's discretion.
OUTCOMES
There have been few studies directly comparing the medical and surgical treatment of
diverticulitis. In a multicenter trial (DIRECT) of 109 patients who either had three or more prior
episodes of diverticulitis in the past two years or had chronic smoldering symptoms after a
single episode, elective laparoscopic colon surgery resulted in superior quality-of-life scores at
six months and five years compared with conservative management despite inherent surgical
complications (11 percent anastomotic leak; 15 percent reintervention) [57,102] and was found
to be cost effective at five years [103]. About half of the patients managed conservatively
ultimately required surgery due to severe ongoing complaints [102].
In the LASER trial, which included 85 patients with either ≥3 episodes of recurrent diverticulitis,
complicated diverticulitis, or chronic pain after diverticulitis, the Gastrointestinal Quality of Life
Index (GIQLI) score improved 11.8 points in patients randomized to sigmoid resection and 0.2
points in patients randomized to conservative treatment between baseline and six months.
However, 10 percent of those who underwent resection suffered severe complications
(abscesses and anastomotic leaks) [104].
The mortality rates after colon surgery for diverticular disease range from 1.3 to 5 percent
depending upon the severity of illness and the presence of comorbidities [15,105]. Emergency
surgery for acute perforated diverticulitis has been associated with a mortality rate of 15 to 25
percent and a morbidity rate of up to 50 percent [15-18,53,106]. Specific complications of colon
surgery are discussed elsewhere. (See "Management of anastomotic complications of colorectal
surgery" and "Management of intra-abdominal, pelvic, and genitourinary complications of
colorectal surgery".)
The incidence of postoperative complications following elective surgery for diverticular disease
varies widely from 5 to 38 percent [71]. Laparoscopic surgery conveys a lower risk of
postoperative complications compared with open resection [78].
Patients are typically cured of their diverticular disease after surgery. However, 15 percent will
develop new diverticula in the remaining colon, and 2 to 11 percent will require repeat surgery
[58,107,108]. Recurrences are more likely if the distal resection margin is not extended on to the
rectum.
After surgery, up to 27 percent of patients may complain of persistent abdominal pain in the
same location as their prior diverticular disease. Such patients require further evaluation by
gastroenterologists as these symptoms are more attributable to coexisting functional intestinal
disorders (eg, irritable bowel syndrome) rather than recurrent diverticulitis. (See "Clinical
manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable
bowel syndrome in adults".)
In a retrospective study of 17,368 patients from the National Surgical Quality Improvement
Program data (2012 to 2018) who underwent colectomy for acute diverticulitis, cancer was
found in 164 (0.94 percent) [109]. Eighty-four percent of patients had locally advanced tumors
(T3-4), and 37 percent had positive lymph nodes. In multivariate analysis, cancer was associated
with sepsis, weight loss, and low albumin.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Colonic diverticular
disease".)
SUMMARY AND RECOMMENDATIONS
● Prevalence – Although most patients with acute diverticulitis can be treated medically,
approximately 15 percent will require surgery for various indications. (See 'Introduction'
above.)
● Frank perforation – Most patients with frankly perforated diverticulitis require surgery,
and the preferred procedure depends upon the degree of perforation, the patient's
hemodynamic stability, the extent of peritoneal contamination, and surgeon
experience/preference. (See 'Perforation' above.)
• For unstable patients with perforated diverticulitis, we suggest damage control surgery
with a limited resection or drainage-only procedure, rather than a formal resection and
anastomosis (Grade 2C). (See 'Unstable patients' above.)
• For stable patients with feculent peritonitis (Hinchey IV perforated diverticulitis), we

suggest a Hartmann's procedure, rather than a procedure involving a primary
anastomosis or a nonresectional drainage procedure (Grade 2C). (See 'Free (frank)
perforation' above.)
• For stable patients with purulent peritonitis (Hinchey III perforated diverticulitis),
Hartmann's procedure is most commonly performed, but it is reasonable to perform a
primary anastomosis with or without a diverting ostomy based on patient and
intraoperative factors and surgeon experience. (See 'Stable patients with purulent
peritonitis' above.)
• For stable patients with a localized perforation (Hinchey I or II diverticulitis) not

amenable to nonoperative therapy, we suggest a primary anastomosis with or without
a protective ostomy, depending upon the condition of the local tissue, rather than a
Hartmann's procedure (Grade 2C). (See 'Localized perforation (ie, abscesses)' above.)
• Microperforation and phlegmon are not considered complicated diverticulitis and

should receive initial medical treatment; most can be managed nonoperatively. (See
"Acute colonic diverticulitis: Triage and inpatient management".)
● Smoldering diverticulitis – Patients with persistent or chronic symptoms despite medical

therapy require urgent or semielective surgery. Most can undergo colon resection with
primary anastomosis. The approach (open versus minimally invasive) is typically
determined by surgeon experience. We suggest minimally invasive surgery when the
requisite expertise is available (Grade 2C). (See 'Persistent symptoms' above.)
● Elective surgery – For asymptomatic patients with a prior episode of complicated

diverticulitis or those who are immunocompromised, we suggest elective surgery to avoid
the risk of future recurrence (Grade 2C). An exception is asymptomatic patients with a
healed diverticular abscess, who are at lower risk for developing another complicated
attack. Elective surgery is typically performed 10 to 12 weeks after an episode of acute
diverticulitis when all infection and inflammation have resolved, and a primary
anastomosis without protective ostomy (ie, a one-stage procedure) is standard. (See 'Risk
reduction (elective surgery)' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate acknowledge Tonia Young-Fadok, MD, who contributed to earlier
versions of this topic review.
Use of UpToDate is subject to the Terms of Use.
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(DIRECT-Trial). Ann Surg 2019; 269:612.
103. Bolkenstein HE, de Wit GA, Consten ECJ, et al. Cost-effectiveness analysis of a multicentre
randomized clinical trial comparing surgery with conservative management for recurrent
and ongoing diverticulitis (DIRECT trial). Br J Surg 2019; 106:448.
104. Santos A, Mentula P, Pinta T, et al. Comparing Laparoscopic Elective Sigmoid Resection With
Conservative Treatment in Improving Quality of Life of Patients With Diverticulitis: The
Laparoscopic Elective Sigmoid Resection Following Diverticulitis (LASER) Randomized
Clinical Trial. JAMA Surg 2021; 156:129.
105. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of
diverticular disease. Ann R Coll Surg Engl 1994; 76:117.
106. Morris CR, Harvey IM, Stebbings WS, Hart AR. Incidence of perforated diverticulitis and risk
factors for death in a UK population. Br J Surg 2008; 95:876.
107. Wolff BG, Ready RL, MacCarty RL, et al. Influence of sigmoid resection on progression of
diverticular disease of the colon. Dis Colon Rectum 1984; 27:645.
108. Corman ML. Colon and Rectal Surgery, 3rd ed, JB Lippincott, Philadelphia 1993. p.817.
109. Hassab TH, Patel SD, D'Adamo CR, et al. Predictors of underlying carcinoma in patients with
suspected acute diverticulitis. Surgery 2021; 169:1323.
Topic 94995 Version 29.0
GRAPHICS
Management of acute colonic diverticulitis
CT: computed tomography; NPO: nil per os.
* Criteria for inpatient management (only need to meet one):

Complicated diverticulitis
Sepsis or systemic inflammatory response syndrome evidenced by more than one of the following:
Temperature >38°C or <36°C, heart rate >90 beats per minute, respiration rate >20 respirations per
minute, white blood cell count >12,000/mL or <4000/mL, C-reactive protein >15 mg/dL
Severe abdominal pain or diffuse peritonitis, and/or failure to reduce abdominal pain in the
emergency department to <5 on a visual analog scale
Microperforation (eg, a few air bubbles outside of the colon without contrast extravasation or
phlegmon)
Age >70 years
Significant comorbidities (eg, diabetes mellitus with organic involvement [eg, retinopathy,
angiopathy, nephropathy], a recent cardiogenic event [eg, acute myocardial infarction, angina,
heart failure], or recent decompensation of chronic liver disease [≥Child B] or end-stage renal
disease)
Immunosuppression (eg, poorly controlled diabetes mellitus, chronic high-dose corticosteroid use,
use of other immunosuppressive agents, advanced human immunodeficiency virus infection or
acquired immunodeficiency syndrome, B or T cell leukocyte deficiency, active cancer of
hematologic malignancy, or organ transplant)
Intolerance of oral intake secondary to bowel obstruction or ileus
Noncompliance with care/unreliability for return visits/lack of support system
Failure of outpatient treatment
¶ The choice of intravenous antibiotics depends on disease severity. Refer to UpToDate topic for details.
Δ Oral antibiotics for diverticulitis include amoxicillin-clavulanate, ciprofloxacin/metronidazole,

levofloxacin/metronidazole, or trimethoprim-sulfamethoxazole/metronidazole. Refer to UpToDate topic
for dosages.
Graphic 107989 Version 8.0
Resection of diverticular disease
Two-stage procedures are used in emergency situations where there has been peritoneal contamination.
Common among the approaches is that the offending segment of diverticular disease is resected at the
first operation.
(A) Stage 1 consists of the Hartmann's procedure; the diseased sigmoid colon is removed, the fecal
stream is diverted, and the rectum is oversewn. In stage 2, intestinal continuity is reestablished by a
descending colorectostomy.
(B) In stage 1, the diseased sigmoid is removed, and both ends of bowel are brought to the surface, one
as an end colostomy and the other as a mucus fistula. In stage two, intestinal continuity is reestablished
as in panel A.
Loop ileostomy
(A) A segment of intestine is brought out above the abdominal wall assuring a tension-free placement.
(B) An enterotomy is created along the efferent (or distal) end of the loop stoma.
(C) Using absorbable maturation sutures, an everting proximal afferent end (left) and a flush distal
efferent end (right) are created. This will allow the effluent to come through the proximal spout into the
collecting bag system and prevent leakage onto the surrounding skin. The distal flush end will allow
venting.
Diverticular obstruction on hypaque enema
A hypaque enema in a 74-year-old woman with bloating and ribbon-like stools for several years reveals a
persistent area of narrowing (arrow) in the mid-sigmoid colon measuring 2 cm in length. It is not possible
to distinguish between a diverticular stricture and carcinoma radiographically; resection of the affected
segment is mandatory.
Empiric antibiotic regimens for low-risk community-acquired intra-abdominal

infections in adults
Dose
Single-agent regimen
Piperacillin-tazobactam* 3.375 g IV every 6 hours
Combination regimen with metronidazole*
One of the following:
Cefazolin 1 to 2 g IV every 8 hours
or
Cefuroxime 1.5 g IV every 8 hours
or
Ceftriaxone 2 g IV once daily
or
Cefotaxime 2 g IV every 8 hours
or
Ciprofloxacin 400 mg IV every 12 hours or
500 mg PO every 12 hours
or
Levofloxacin 750 mg IV or PO once daily
Plus:
Metronidazole¶ 500 mg IV or PO every 8 hours
For empiric therapy of low-risk community-acquired intra-abdominal infections, we cover streptococci,

Enterobacteriaceae, and anaerobes. Low-risk community-acquired intra-abdominal infections are those
that are of mild to moderate severity (including perforated appendix or appendiceal abscess) in the
absence of risk factors for antibiotic resistance or treatment failure. Such risk factors include recent travel
to areas of the world with high rates of antibiotics-resistant organisms, known colonization with such
organisms, advanced age, immunocompromising conditions, or other major medical comorbidities.
Refer to other UpToDate content on the antimicrobial treatment of intra-abdominal infections for further
discussion of these risk factors.
The antibiotic doses listed are for adult patients with normal renal function. The duration of antibiotic
therapy depends on the specific infection and whether the presumptive source of infection has been
controlled; refer to other UpToDate content for details.
IV: intravenously; PO: orally.
* When piperacillin-tazobactam or one of the combination regimens in the table cannot be used,
ertapenem (1 g IV once daily) is a reasonable alternative.
¶ For most uncomplicated biliary infections of mild to moderate severity, the addition of metronidazole is
not necessary.
Empiric antibiotic regimens for high-risk community-acquired intra-abdominal

Dose
Imipenem-cilastatin 500 mg IV every 6 hours
Meropenem 1 g IV every 8 hours
Doripenem 500 mg IV every 8 hours
Piperacillin-tazobactam 4.5 g IV every 6 hours
Combination regimen with metronidazole
ONE of the following:
Cefepime 2 g IV every 8 hours
OR
Ceftazidime 2 g IV every 8 hours
PLUS:
Metronidazole 500 mg IV or orally every 8 hours
High-risk community-acquired intra-abdominal infections are those that are severe or in patients at high
risk for adverse outcomes or antimicrobial resistance. These include patients with recent travel to areas
of the world with high rates of antibiotics-resistant organisms, known colonization with such organisms,
advanced age, immunocompromising conditions, or other major medical comorbidities. Refer to the
UpToDate topic on the antimicrobial treatment of intra-abdominal infections for further discussion of
these risk factors.
For empiric therapy of high-risk community-acquired intra-abdominal infections, we cover streptococci,

Enterobacteriaceae resistant to third-generation cephalosporins, Pseudomonas aeruginosa, and
anaerobes. Empiric antifungal therapy is usually not warranted but is reasonable for critically ill patients
with an upper gastrointestinal source.
Local rates of resistance should inform antibiotic selection (ie, agents for which there is >10% resistance
among Enterobacteriaceae should be avoided). If the patient is at risk for infection with an extended-
spectrum beta-lactamase (ESBL)-producing organism (eg, known colonization or prior infection with an
ESBL-producing organism), a carbapenem should be chosen. When beta-lactams or carbapenems are
chosen for patients who are critically ill or are at high risk of infection with drug-resistant pathogens, we
favor a prolonged infusion dosing strategy. Refer to other UpToDate content on prolonged infusions of
beta-lactam antibiotics.
The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot
use other beta-lactams or carbapenems (eg, because of severe reactions).
The antibiotic doses listed are for adult patients with normal renal function. The duration of antibiotic
IV: intravenous.
Empiric antibiotic regimens for health care-associated intra-abdominal

Dose
Imipenem-cilastatin 500 mg IV every 6 hours
Meropenem 1 g IV every 8 hours
Doripenem 500 mg IV every 8 hours
Piperacillin-tazobactam 4.5 g IV every 6 hours
Combination regimen
ONE of the following:
Cefepime 2 g IV every 8 hours
OR
Ceftazidime 2 g IV every 8 hours
PLUS:
Metronidazole 500 mg IV or orally every 8 hours
PLUS ONE of the following (in some cases*):
Ampicillin 2 g IV every 4 hours
OR
Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours
For empiric therapy of health care-associated intra-abdominal infections, we cover streptococci,

enterococci, Enterobacteriaceae that are resistant to third-generation cephalosporins and
fluoroquinolones, Pseudomonas aeruginosa, and anaerobes. We include coverage against methicillin-
resistant Staphylococcus aureus (MRSA) with vancomycin in those who are known to be colonized, those
with prior treatment failure, and those with significant prior antibiotic exposure. Empiric antifungal
coverage is appropriate for patients at risk for infection with Candida spp, including those with upper
gastrointestinal perforations, recurrent bowel perforations, surgically treated pancreatitis, heavy
colonization with Candida spp, and/or yeast identified on Gram stain of samples from infected peritoneal
fluid or tissue. Refer to other UpToDate content on treatment of invasive candidiasis.
If the patient is at risk for infection with an extended-spectrum beta-lactamase (ESBL)-producing

organism (eg, known colonization or prior infection with an ESBL-producing organism), a carbapenem
should be chosen. For patients who are known to be colonized with highly resistant gram-negative
bacteria, the addition of an aminoglycoside, polymyxin, or novel beta-lactam combination (ceftolozane-
tazobactam or ceftazidime-avibactam) to an empiric regimen may be warranted. In such cases,
consultation with an expert in infectious diseases is advised.
When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high risk of
infection with drug-resistant pathogens, we favor a prolonged infusion dosing strategy. Refer to other
UpToDate content on prolonged infusions of beta-lactam antibiotics.
The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot
use other beta-lactams or carbapenems (eg, because of severe reactions).
The antibiotic doses listed are for adult patients with normal kidney function. The duration of antibiotic
IV: intravenous.
* We add ampicillin or vancomycin to a cephalosporin-based regimen to provide enterococcal coverage,

particularly in those with postoperative infection, prior use of antibiotics that select for Enterococcus,
immunocompromising condition, valvular heart disease, or prosthetic intravascular materials. Coverage
against vancomycin-resistant enterococci (VRE) is generally not recommended, although it is reasonable
in patients who have a history of VRE colonization or in liver transplant recipients who have an infection
of hepatobiliary source.
Antimicrobial prophylaxis for gastrointestinal surgery in adults
Nature of Common Recommended Usual adult Redose

operation pathogens antimicrobials dose* interval ¶
Gastroduodenal surgery
Procedures Enteric gram- Cefazolin Δ <120 kg: 2 g IV 4 hours

involving entry negative bacilli,
≥120 kg: 3 g IV
into lumen of gram-positive
gastrointestinal cocci
tract
Procedures not Enteric gram- High risk ◊ only: <120 kg: 2 g IV 4 hours
involving entry negative bacilli, cefazolin Δ
≥120 kg: 3 g IV
into lumen of gram-positive
gastrointestinal cocci
tract (selective
vagotomy,
antireflux)
Biliary tract surgery (including pancreatic procedures)
Open Enteric gram- Cefazolin Δ¥ <120 kg: 2 g IV 4 hours

procedure or negative bacilli, (preferred)
≥120 kg: 3 g IV
laparoscopic enterococci,
procedure (high clostridia
OR cefotetan 2 g IV 6 hours
risk) §
Laparoscopic N/A None None None

procedure (low
risk)
Appendectomy ‡
Enteric gram- Cefazolin Δ For cefazolin: For cefazolin:

negative bacilli, <120 kg: 2 g IV 4 hours
PLUS
anaerobes, ≥120 kg: 3 g IV
metronidazole For metronidazole:
enterococci
(preferred) For metronidazole: N/A
500 mg IV
OR cefotetan Δ 2 g IV 6 hours
Small intestine surgery
Nonobstructed Enteric gram- Cefazolin Δ <120 kg: 2 g IV 4 hours

negative bacilli,
≥120 kg: 3 g IV
gram-positive
cocci
Obstructed Enteric gram- Cefazolin Δ For cefazolin: For cefazolin:

negative bacilli, <120 kg: 2 g IV 4 hours
PLUS
anaerobes, ≥120 kg: 3 g IV
metronidazole For metronidazole:
enterococci
500 mg IV
Hernia repair
Aerobic gram- Cefazolin Δ <120 kg: 2 g IV 4 hours

positive organisms
≥120 kg: 3 g IV
Colorectal surgery †
Enteric gram- Parenteral:

negative bacilli,
Cefazolin Δ For cefazolin: For cefazolin:
anaerobes,
PLUS <120 kg: 2 g IV 4 hours
enterococci
metronidazole ≥120 kg: 3 g IV For metronidazole:
500 mg IV
Oral (used in conjunction with mechanical bowel preparation):
Neomycin PLUS ** **
erythromycin
base or
metronidazole
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before
the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to
120 minutes before the initial incision to have adequate tissue levels at the time of incision and to
minimize the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns,
additional intraoperative doses should be given at intervals one to two times the half-life of the drug.
Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg
IV; not to exceed 2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg
IV), or aztreonam (2 g IV) is a reasonable alternative. Metronidazole (500 mg IV) plus an aminoglycoside
or fluoroquinolone is also an acceptable alternative regimen, although metronidazole plus aztreonam
should not be used, since this regimen does not have aerobic gram-positive activity.
◊ Severe obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric
bleeding, malignancy or perforation, or immunosuppression.
§ Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis,
nonfunctioning gallbladder, obstructive jaundice, common bile duct stones, immunosuppression.
¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.
‡ For a ruptured viscus, therapy is often continued for approximately 5 days.
† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.
** In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered:
neomycin (1 g) plus erythromycin base (1 g) OR neomycin (1 g) plus metronidazole (1 g). The oral regimen
should be given as 3 doses over approximately 10 hours the afternoon and evening before the operation.
Issues related to mechanical bowel preparation are discussed further separately; refer to the UpToDate
topic on overview of colon resection.
Data from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infec
(Larchmt) 2013; 14:73.
Contributor Disclosures
John H Pemberton, MD No relevant financial relationship(s) with ineligible companies to disclose. Martin
Weiser, MD Consultant/Advisory Boards: PrecisCa [Gastrointestinal surgical oncology]. All of the relevant
financial relationships listed have been mitigated. Wenliang Chen, MD, PhD No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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30/4/24, 16:46 Acute colonic diverticulitis: Surgical management - UpToDate

Official reprint from UpToDate®

Acute colonic diverticulitis: Surgical management

Literature review current through: Mar 2024.

● (See "Diverticular fistulas".)

● (See "Colonic diverticular bleeding".)

● (See "Large bowel obstruction".)

● Stage I – Pericolic or mesenteric abscess

In general, the majority of microperforations (not included in the Hinchey classification),

Primary anastomosis with proximal diversion — Some European authors have

● A third multinational trial comparing primary anastomosis (without diversion) with

● In an analysis of over 130,000 patients undergoing either primary anastomosis with

● An administrative database study of over 10,000 patients undergoing urgent or

● The DILALA trial randomly assigned 83 patients to laparoscopic lavage or Hartmann's

In a British registry-based study of 499 propensity score-matched patients undergoing

Three-stage procedure — A legacy procedure for colonic perforation includes three

Localized perforation (ie, abscesses) — Localized perforations present acutely as a mesocolic

Microperforation — Microperforation, usually indicated by one or a few extraluminal air

At least three randomized trials have also been performed:

RISK REDUCTION (ELECTIVE SURGERY)

Elective surgery is typically performed 10 to 12 weeks after an episode of acute diverticulitis

As an example, in a retrospective study of over 200,000 patients admitted for diverticulitis, 85

Bowel preparation — In general, we recommend mechanical bowel preparation and oral

Prophylactic ureteral stent placement — There is no evidence for or against prophylactic

Enhanced recovery protocol — Fast-track recovery protocols have been shown to

● The colon should be transected in an area proximal to the involved segment/phlegmon

● Either a hand-sewn or stapled anastomosis can be performed based on surgeon

● As there is no evidence to support routine peritoneal drainage [101], whether to leave

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

• For stable patients with feculent peritonitis (Hinchey IV perforated diverticulitis), we

• For stable patients with a localized perforation (Hinchey I or II diverticulitis) not

• Microperforation and phlegmon are not considered complicated diverticulitis and

● Smoldering diverticulitis – Patients with persistent or chronic symptoms despite medical

● Elective surgery – For asymptomatic patients with a prior episode of complicated

Use of UpToDate is subject to the Terms of Use.

60. Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease:

in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg 2010; 211:485.

Management of acute colonic diverticulitis

CT: computed tomography; NPO: nil per os.

* Criteria for inpatient management (only need to meet one):

Δ Oral antibiotics for diverticulitis include amoxicillin-clavulanate, ciprofloxacin/metronidazole,

Graphic 107989 Version 8.0

Resection of diverticular disease

Graphic 95715 Version 4.0

Graphic 70246 Version 3.0

Diverticular obstruction on hypaque enema

Graphic 67258 Version 2.0

Empiric antibiotic regimens for low-risk community-acquired intra-abdominal

Piperacillin-tazobactam* 3.375 g IV every 6 hours

Combination regimen with metronidazole*

One of the following:

Cefazolin 1 to 2 g IV every 8 hours

Cefuroxime 1.5 g IV every 8 hours

Ceftriaxone 2 g IV once daily

Cefotaxime 2 g IV every 8 hours

Ciprofloxacin 400 mg IV every 12 hours or

500 mg PO every 12 hours

Levofloxacin 750 mg IV or PO once daily

Metronidazole¶ 500 mg IV or PO every 8 hours

For empiric therapy of low-risk community-acquired intra-abdominal infections, we cover streptococci,

IV: intravenously; PO: orally.

Graphic 106948 Version 13.0