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Diverticulitis

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General Information

Description

  • localized inflammation of colonic diverticula (outpouchings of the colonic lumen) is known as diverticulitis1,2
  • complicated diverticulitis refers to inflammation of colonic diverticula associated with perforation, bleeding, obstruction, fistula, phlegmon, or abscess1,2

Also called

  • acute diverticulitis
  • acute colonic diverticulitis
  • acute sigmoid diverticulitis
  • sigmoid diverticulitis

Definitions

  • diverticula are small outpouchings/herniations from the hollow structures in the body including large or small intestines
    • true diverticula are outpouchings that include all the layers of the intestinal wall (mucosa, submucosa, muscle layer, and serosa)
    • pseudodiverticula (also called false diverticula) are outpouches consisting of only the mucosa and submucosa (innermost wall layers) poking through the muscle layer, covered by serosa
    • References - 1,2,3
  • diverticulosis refers to presence of diverticula without inflammation, but has potential to be symptomatic with acute bleeding1
  • diverticulitis refers to inflamed diverticula1
    • uncomplicated diverticulitis is localized inflammation
    • complicated diverticulitis is diverticular inflammation associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation (see also Complications section)
  • symptomatic uncomplicated diverticular disease (SUDD)

References

General references used

  1. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20OpenInNewfull-textOpenInNew, summary can be found in Am Fam Physician 2013 May 1;87(9):612s1OpenInNewfull-textOpenInNew
  2. Feingold D, Steele SR, Lee S, et al; Clinical Practice Guideline Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94OpenInNew
  3. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9OpenInNew, technical review can be found in Gastroenterology 2015 Dec;149(7):1950OpenInNew

Recommendation grading systems used

  • American Gastroenterological Association (AGA) recommendations use Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
    • GRADE categories of quality of evidence
      • High - very confident that true effect lies close to that of estimate of effect
      • Moderate - moderate confidence in estimate of effect; true effect likely to be close to estimate of effect, but possibility that it is substantially different
      • Low - limited confidence in estimate of effect; true effect may be substantially different from estimate of effect
      • Very low - very little confidence in estimate of effect; true effect likely to be substantially different from estimate of effect
    • GRADE categories of strength of recommendation
      • Strong
        • most individuals should receive recommended course of action
        • formal decision aids not likely needed to help individuals make decisions consistent with their preferences and values
      • Conditional
        • different choices will be appropriate for different patients
        • decision aids may be useful in helping individuals make decisions consistent with their preferences and values
        • clinicians should expect to spend more time with patients when working toward decision
    • Reference - AGA guideline on the management of acute diverticulitis (26453777Gastroenterology 2015 Dec;149(7):1944OpenInNew), technical review can be found in 26453776Gastroenterology 2015 Dec;149(7):1950OpenInNew
  • American Society of Colon and Rectal Surgeons (ASCRS) grading system for recommendations
    • strength of recommendation grades
      • Grade 1 - strong recommendation - benefits clearly outweigh risks and burdens (or vice versa) for most, if not all, patients
      • Grade 2 - weak recommendation - benefits and risks closely balanced and/or uncertain
    • quality of evidence grades
      • Level A - high-quality evidence - randomized trials without factors that reduce quality of evidence, or well-done observational studies with very large magnitude of effect
      • Level B - moderate-quality evidence - downgraded randomized trials or upgraded observational studies
      • Level C - low- or very low-quality evidence - observational studies or case series

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Brian C. Weiner, MD, MS, FACP, AGAF (Deputy Editor of Gastroenterology; Clinical Associate Professor, Medicine, Gastroenterology/Hepatology/Nutrition, University of Florida, Florida, United States)
  • Dr. Weiner declares no relevant financial conflicts of interest.
  • Zbys Fedorowicz, MSc, DPH, BDS, LDSRCS (Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain)
  • Dr. Fedorowicz declares no relevant financial conflicts of interest.
  • Alan Ehrlich, MD (Executive Editor; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States)
  • Dr. Ehrlich declares no relevant financial conflicts of interest.
  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T113975, Diverticulitis; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T113975. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

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    General Information

    • Description

    • Also called

    • Definitions

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    Epidemiology

    • Geographic distribution

    • Incidence/Prevalence

    • Possible risk factors

    • Factors not associated with increased risk

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    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

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    History and Physical

    • Clinical presentation

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    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

    • Urine studies

    • Stool studies

    • Imaging studies

  • KeyboardArrowRight

    Management

    • Management overview

    • Treatment setting

    • Diet

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      Medications

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        Antibiotics

        • Antibiotic recommendations and suggested regimens

        • Antibiotic efficacy in uncomplicated diverticulitis

        • Antibiotics comparative efficacy

        • Antibiotics route and duration comparisons

      • Treatment of symptomatic uncomplicated diverticular disease

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      Surgery and procedures

      • Indications and recommendations for surgery

      • Laparoscopic surgery

      • Surgery for peritonitis complicating diverticulitis

    • Consultation and referral

    • Management of abscess

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      Follow-up

      • Ruling out colorectal cancer after acute diverticulitis

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    Complications and Prognosis

    • Complications

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      Prognosis

      • Morbidity and mortality

      • Recurrence

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    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • Recommendations

      • Dietary prevention

      • Rifaximin

      • 5-aminosalicylic acid (5-ASA) drugs/mesalamine/mesalazine

      • Other medications

      • Exercise

    • Screening

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    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • European guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Brian C. Weiner MD, MS, FACP, AGAF
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Affiliations

Deputy Editor of Gastroenterology, DynaMed; Massachusetts, United States; Clinical Associate Professor, Medicine, Gastroenterology/Hepatology/Nutrition, University of Florida; Florida, United States

Conflicts of Interest

Dr. Weiner declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians
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