Diverticulitis

Definition

• Sleisenger and Fordtran's Gastrointestinal and Liver Disease

Epidemiology

• Diverticulitis was historically thought to affect 10-25% of patients with diverticulosis, but more recent population-based data suggest only ~4% risk over an 11-year period.
• Incidence of hospitalization plateaued around 2008 in the US; the proportion requiring surgery declined from 25% to 15% between 2000-2010.
• In Western countries, diverticula - and therefore diverticulitis - predominantly affect the sigmoid colon. In Asian populations, right-sided colonic involvement is far more common.

Pathophysiology

1. A fecolith obstructs the neck of a diverticulum
2. The fecolith abrades the mucosa, causing low-grade inflammation
3. Bacterial overgrowth, localized ischemia, and impaired mucosal defenses develop
4. Bacteria breach the mucosa - the process extends transmurally, leading to microperforation or frank perforation
5. The extent of perforation determines clinical severity:
   • Microperforation - contained by pericolic fat - small pericolic abscess
   • Larger perforation - large inflammatory mass, fibrosis, fistula to adjacent organs
   • Free perforation - bacterial or fecal peritonitis (4 per 100,000/year - uncommon)

• Sleisenger and Fordtran's GI and Liver Disease

Hinchey Classification of Diverticular Perforation

Clinical Features

• Left lower quadrant (LLQ) pain - persistent, often >24 hours - most characteristic
• Fever (low-grade in uncomplicated; high fever/sepsis in complicated disease)
• Change in bowel habits (diarrhea or constipation)
• Anorexia, nausea, vomiting
• Dysuria/urinary frequency ("sympathetic cystitis" from adjacent inflamed sigmoid colon)
• Feculent vaginal discharge (colovaginal fistula)
• BRBPR is NOT a feature of acute diverticulitis

• LLQ tenderness, with guarding and rebound if complicated
• Palpable cylindrical tender mass possible
• Depressed bowel sounds (or increased with obstruction)
• Rectal tenderness or palpable mass (low-lying pelvic abscess)

Differential Diagnosis

Diagnosis

Imaging

• Sensitivity 98%, specificity 99%
• Findings: colonic wall thickening, pericolic fat stranding, localized perforation (micro-perforation), abscess, free air/fluid
• Also the modality of choice for identifying complications and guiding percutaneous abscess drainage

Labs

• CBC: leukocytosis is common but not mandatory - up to 46% have a normal WBC with no left shift
• Urinalysis: if colovesical fistula suspected
• Clinical diagnosis alone may suffice in patients with prior confirmed diverticulitis presenting with identical symptoms

Management

Uncomplicated Diverticulitis

• Liquid diet advancing as tolerated
• Antibiotics: now selective, not routine - The AVOD and DIABOLO randomized trials (>1,100 patients) showed antibiotics do not accelerate recovery or prevent complications/recurrence in uncomplicated disease. The AGA (2015) recommends selective antibiotic use. If used, coverage for gram-negative aerobes AND anaerobes is required.
• Common oral regimens: ciprofloxacin + metronidazole, or amoxicillin-clavulanate

• IV antibiotics + bowel rest
• Improvement expected within 2-4 days; diet advanced once improving
• Discharge with 7-10 day oral antibiotic course (if antibiotics deemed necessary)

Complicated Diverticulitis

Surgical Management

• Only 15-25% of hospitalized patients require surgery.
• Indications for elective surgery now evaluated on a case-by-case basis (not automatically after 2 episodes as was previously recommended). The updated ASCRS (2014) and AGA guidelines moved away from the "2-episode rule."
• A 2025 network meta-analysis (EAES/ESCP) examined surgical options for complicated diverticulitis (PMID: 39733170).
• Standard approach: sigmoid colectomy (2-stage: Hartmann's procedure with later stoma reversal - but reversal only occurs ~50% of the time, even less in elderly patients).
• There is growing discussion about primary anastomosis vs. colostomy at the time of emergency surgery.

Prevention / Lifestyle

• High-fiber diet reduces abdominal symptoms in diverticulosis
• Physical activity is associated with reduced risk of acute diverticulitis
• Previously-advised food restrictions (nuts, seeds, popcorn) have been discredited - no evidence supports them

Recurrence

• Risk of recurrent symptoms after a first attack: 15-30%
• Half of second attacks occur within 1 year of the first

Recent Evidence (2024-2026)

📚 Divertikulitis - Prüfungsvorbereitung

🔷 KOMPAKTZUSAMMENFASSUNG

Definition

• Divertikulose = Vorhandensein von Divertikeln (Ausstülpungen der Darmwand)
• Divertikulitis = Entzündung/Infektion eines Divertikels
• Unkompliziert: lokale Entzündung ± kleiner Abszess (~80% der Fälle)
• Kompliziert: Abszess, Fistel, Obstruktion, freie Perforation

Lokalisation

Pathophysiologie (Kurzformel)

Hinchey-Klassifikation

Klinik - MERKSATZ: "Links - Fieber - Stuhlveränderung"

• Schmerz: linker Unterbauch (LUB), persistierend >24h
• Fieber (subfebrile bis hohes Fieber je nach Schweregrad)
• Stuhlveränderungen: Diarrhö oder Obstipation
• Dysurie/Pollakisurie: "sympathische Zystitis"
• KEIN hellrotes Blut per rectum (BRBPR) bei akuter Divertikulitis!
• Ältere/Immunsupprimierte: subtile Klinik, aber höhere Perforationsrate

Diagnostik

Therapie - Übersicht

Unkompliziert → ambulant möglich
  ├─ Flüssigkost → Kostaufbau
  ├─ Antibiotika: SELEKTIV (nicht routinemäßig!)
  │   └─ Wenn nötig: Gramneg. Aerobier + Anaerobier abdecken
  │       z.B. Ciprofloxacin + Metronidazol
  └─ Kein Nutzen von Bettruhe / NPO allein

Kompliziert → stationär + chirurgische Konsultation
  ├─ Abszess: IV Antibiotika ± CT-gesteuerte Drainage (>3-4 cm)
  ├─ Fistel: elektive Resektion
  ├─ Obstruktion: konservativ → OP wenn nötig
  └─ Perforation Hinchey III/IV: Notfall-OP

Chirurgische Therapie

• Nur 15-25% der hospitalisierten Patienten benötigen OP
• Hartmann-Operation: Resektion + Kolostoma (Standard bei Notfall-OP)
• Stoma-Rückverlagerung: nur in ~50% der Fälle möglich
• Elektive OP: Nicht mehr automatisch nach 2 Episoden - individuelle Entscheidung (ASCRS 2014, AGA)
• Antibiotika verhüten keine Komplikationen/Rezidive (AVOD-Studie, DIABOLO-Studie)

Differenzialdiagnosen - MERKLISTE

1. Appendizitis (v.a. bei rechtsseitiger Divertikulitis)
2. CED (Morbus Crohn, Colitis ulcerosa)
3. Kolorektales Karzinom
4. Ischämische Kolitis
5. Adnexitis / Ovarialzyste / Extrauteringravidität
6. Ureterstein

✅ ÜBUNGSFRAGEN

Frage 1 - Multiple Choice

Frage 2 - Multiple Choice

Frage 3 - Multiple Choice

Frage 4 - Wahr/Falsch

Frage 5 - Kurzantwort

Frage 6 - Klinisches Szenario

Frage 7 - Multiple Choice

Frage 8 - Kurzantwort

🧠 LERNKARTEN - Schnellwiederholung