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Clinical Review State of the Art Review

Management of colonic diverticulitis

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n72 (Published 24 March 2021) Cite this as: BMJ 2021;372:n72

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Re: Management of colonic diverticulitis

Dear Editor

As mentioned in the above article, Diverticulosis is indeed a very common condition that may present to a primary care clinic or a hospital emergency department in the West. However, as a practitioner in the Eastern Hemisphere with different environments and lifestyles, we see less Diverticulosis as a cause of left iliac fossa(LIF) pain originating from sigmoid colon.

Sigmoid Diverticulosis in its various spectrum of complications is just one possible differential diagnosis but not the most common. It is more common to discover the final diagnosis of these groups of patients to be mere Sigmoid Colitis. This Sigmoid Colitis is presumed to be infective in nature when it responds to a course of antibiotics and the common inflammatory and immune markers are usually tested negative.
They tend to occur in younger group of patients as compared to Diverticulosis.The common associating symptom is constipation, raising the possibility to its importance in the pathogenesis.

Sigmoid Diverticulosis will be the second most common colonic cause of LIF pain in our practice.It is much more common than the rare Inflammatory Bowel Disease.

Plain abdominal Xray is useful to confirm fecal ladenness of constipation in sigmoid colitis. Ultrasound is a preferred initial cross sectional imaging study due to its promptness and the purpose is to rule out
a very common urinary stone presenting as LIF pain, rather than positively diagnosing sigmoid diverticulosis. LIF pain associated with local peritonism and raised inflammatory markers strongly suggest sigmoid diverticulosis. In this situation, CT scan will positively confirm the diagnosis of sigmoid diverticulosis with its varying degrees of associated complications.

As stated in the article, the purpose of colonoscopy in patients with diverticulosis is to rule out concomitant malignancy which may present with similar symptoms. The recommendations in the above article to do colonoscopy on almost all patients that present with all degrees of diverticulitis were based on the discovery of colon cancers in some of these patients. However, the analysis of data were all based on the degrees of diverticulitis. Analysis based on age may exclude younger patients from fruitless colonoscopy(1). We believe, colonoscopy should be reserved for patients with risk factors for development of colon cancers like smoking and history of polyps, family history of colonic malignancy and age more than 50.

Although Hinchley's Classifications seem academically useful, its utility in decision algorithm to manage individual patients in practice is quite limited. The emphasis on individuation of clinical decision was made by Hinchley et al themselves in their original paper(2). We find that even abscess bigger than 3cm may be managed conservatively as long as the peritonism remains local and patients show progressive clinical and bio-markers improvements.

References;

1.Meyer J, Orci LA, Combescure C, et al. Risk of Colorectal Cancer in Patients With Acute Diverticulitis: A Systematic Review and Meta-analysis of Observational Studies. Clin Gastroenterol Hepatol2019;17:1448-1456.e17. doi:10.1016/j.cgh.2018.07.031 pmid:30056181

2.Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12:85–109 [PubMed] [Google Scholar]

Competing interests: No competing interests

03 April 2021
Hamid M Sain
Surgeon
ColumbiaAsia Hospital Seremban
292 Jalan Haruan 2, Oakland Commercial Centre, Seremban, NSDK 70300, MAlaysia