The gastroenterologist's view

The traditional view that recurrent episodes of diverticulitis lead to progressively complicated disease resulting in a disadvantageous course, more difficult, complicated operations and lethal outcomes did not stand the test of evidence. Only a minority of patients with acute diverticulitis will ever require surgery, and if so, this occurs during or early after the first episode. Complications and recurrence of disease after surgery are enumerable. Strong indicators favoring sigmoid colectomy are major abscess, free air, and fistula, i.e. perforating disease. This occurs predominantly at the initial presentation, frequently in younger or immunosuppressed patients. Important differential diagnoses must be considered both for initial diagnosis of diverticulitis and for recurrent episodes. Conservative management of recurrent diverticulitis is safe and best guided by gastroenterological expertise. Sophisticated ultrasound experience as a part of this competence allows detailed evaluation of the local status and the best evidence in the literature for diagnosing diverticulitis is on US. In practice, however, the question of perforating diverticulitis is adequately answered by subtle CT scan. Medical therapy is usually the treatment of choice for recurrent diverticulitis. Avoidance of drugs bearing the hazard of perforation (e.g. NSAIDs) is emphasized, and smoking is strongly discouraged. A mathematical model based on published data shows that patients with recurrent diverticulitis overall (only) profit from surgery if they are hit by four episodes during the course of disease. This is where theory and reality (should) meet.