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'{{Infobox medical condition (new) | name = Diverticulitis | synonyms = Colonic diverticulitis | image = Diverticula, sigmoid colon.jpg | caption = Section of large bowel (sigmoid colon) showing multiple pouches ([[diverticula]]). The diverticula appear on either side of the longitudinal muscle bundle (taenium) which runs horizontally across the specimen in an arc. | field = [[General surgery]] | symptoms = [[Abdominal pain]], [[fever]], [[nausea]], [[diarrhea]], [[constipation]], [[blood in the stool]]<ref name=NIH2013/> | complications = [[Abscess]], [[fistula]], [[bowel perforation]]<ref name=NIH2013/> | onset = Sudden, age > 50<ref name=NIH2013/> | duration = | causes = Uncertain<ref name=NIH2013/> | risks = [[Obesity]], lack of exercise, [[smoking]], family history, [[nonsteroidal anti-inflammatory drug]]s<ref name=NIH2013/><ref name=Tur2016/> | diagnosis = Blood tests, [[CT scan]], [[colonoscopy]], [[lower gastrointestinal series]]<ref name=NIH2013/> | differential = [[Irritable bowel syndrome]]<ref name=Tur2016/> | prevention = [[Mesalazine]], [[rifaximin]]<ref name=Tur2016/> | treatment = [[Antibiotics]], liquid diet, hospital admission<ref name=NIH2013/> | medication = | prognosis = | frequency = 3.3% (developed world)<ref name=NIH2013/><ref name="UpToDate"/> | deaths = }} <!-- Definition and symptoms --> '''Diverticulitis''', specifically '''colonic diverticulitis''', is a [[gastrointestinal disease]] characterized by [[inflammation]] of abnormal pouches—[[Diverticulum|diverticula]]—which can develop in the wall of the [[large intestine]].<ref name=NIH2013>{{cite web |title= Diverticular Disease |url= http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticular-disease/Pages/facts.aspx |website= www.niddk.nih.gov |accessdate= 12 June 2016 |date= September 2013 |deadurl= no |archiveurl= https://web.archive.org/web/20160613120254/http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticular-disease/Pages/facts.aspx |archivedate= 13 June 2016 |df= }}</ref> Symptoms typically include lower abdominal pain of sudden onset, but onset may also occur over a few days.<ref name=NIH2013/> In North America and Europe the abdominal pain is usually on the left lower side (sigmoid colon), while in Asia it is usually on the right (ascending colon).<ref name=Tur2016/><ref name=Fel2010>{{cite book |last1= Feldman |first1= Mark |title= Sleisenger & Fordtran's Gastrointestinal and liver disease pathophysiology, diagnosis, management |date= 2010 |publisher= MD Consult |location= [S.l.] |isbn= 9781437727678 |page= 2084 |edition= 9th |url= https://books.google.ca/books?id=zEZOqB6r9hwC&pg=PA2084 |deadurl= no |archiveurl= https://web.archive.org/web/20160808143336/https://books.google.ca/books?id=zEZOqB6r9hwC&pg=PA2084 |archivedate= 2016-08-08 |df= }}</ref> There may also be [[nausea]]; and [[diarrhea]] or [[constipation]].<ref name=NIH2013/> Fever or [[blood in the stool]] suggests a complication.<ref name=NIH2013/> Repeated attacks may occur.<ref name=Tur2016/> <!-- Cause and diagnosis --> The causes of diverticulitis are uncertain.<ref name=NIH2013/> Risk factors may include [[obesity]], lack of exercise, [[smoking]], a family history of the disease, and use of [[nonsteroidal anti-inflammatory drug]]s (NSAIDs).<ref name=NIH2013/><ref name=Tur2016/> The role of a low fiber diet as a risk factor is unclear.<ref name=Tur2016/> Having pouches in the [[large intestine]] that are not inflamed is known as [[diverticulosis]].<ref name=NIH2013/> Inflammation occurs in between 10% and 25% at some point in time, and is due to a [[bacterial infection]].<ref name=Tur2016/><ref name=M2014>{{cite book |title= Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases |date= 2014 |publisher= Churchill Livingstone |isbn= 9781455748013 |page= 986 |url= https://books.google.ca/books?id=BseNCgAAQBAJ&pg=PA986 |deadurl= no |archiveurl= https://web.archive.org/web/20160808110310/https://books.google.ca/books?id=BseNCgAAQBAJ&pg=PA986 |archivedate= 2016-08-08 |df= }}</ref> Diagnosis is typically by [[CT scan]], though blood tests, [[colonoscopy]], or a [[lower gastrointestinal series]] may also be supportive.<ref name=NIH2013/> The [[differential diagnosis]] includes [[irritable bowel syndrome]].<ref name=Tur2016/> <!-- Prevent and treatment --> Preventive measures include altering risk factors such as obesity, inactivity, and smoking.<ref name=Tur2016/> [[Mesalazine]] and [[rifaximin]] appear useful for preventing attacks in those with diverticulosis.<ref name=Tur2016/> Avoiding nuts and seeds as a preventive measure is no longer recommended since there is no evidence these play a role in initiating inflammation in diverticula.<ref name=NIH2013/><ref name=NEJM2018>{{cite journal |last1=Young-Fadok |first1=TM |title=Diverticulitis |journal=New England Journal of Medicine |date=October 2018 |volume=379 |issue=17 |pages=1635–42 |doi=10.1056/NEJMcp1800468 |pmid=30354951}}</ref> For mild diverticulitis, [[antibiotic]]s by mouth and a liquid diet are recommended.<ref name=NIH2013/> For severe cases, intravenous antibiotics, hospital admission, and [[complete bowel rest]] may be recommended.<ref name=NIH2013/> [[Probiotic]]s are of unclear use.<ref name=Tur2016/> Complications such as [[abscess]] formation, [[fistula]] formation, and perforation of the colon may require surgery.<ref name=NIH2013/> <!-- Epidemiology and history --> The disease is common in the [[Western world]] and uncommon in Africa and Asia.<ref name=NIH2013/> In the Western world about 35% of people have diverticulosis while it affects less than 1% of those in rural Africa,<ref name=M2014/> and 4 to 15% of those may go on to develop diverticulitis.<ref name="UpToDate"/> The disease becomes more frequent with age, being particularly common in those over the age of 50.<ref name=NIH2013/> It has also become more common in all parts of the world.<ref name=Tur2016/> In 2003 in Europe, it resulted in approximately 13,000 deaths.<ref name=Tur2016/> It is the most frequent anatomic disease of the colon.<ref name=Tur2016/> Costs associated with diverticular disease were around [[US$]]2.4 billion a year in the United States in 2013.<ref name=Tur2016>{{cite journal|last1= Tursi |first1= A |title= Diverticulosis today: unfashionable and still under-researched |journal= Therapeutic Advances in Gastroenterology |date= March 2016 |volume= 9 |issue= 2 |pages= 213–28 |pmid= 26929783 |doi= 10.1177/1756283x15621228 |pmc= 4749857}}</ref> {{TOC limit|3}} ==Signs and symptoms== Diverticulitis typically presents with [[left lower quadrant]] abdominal pain of sudden onset.<ref name=NIH2013/> There may also be [[fever]], [[nausea]], [[diarrhea]] or [[constipation]], and blood in the stool.<ref name=NIH2013/> ==Causes== The causes of diverticulitis are poorly understood, with approximately 40 percent due to genes and 60 percent due to environmental factors.<ref name=Temp2013/> Conditions that increase the risk of developing diverticulitis include arterial hypertension and immunosuppression.<ref name="Bohm2015">{{cite journal|last1=Böhm|first1=Stephan K.|title=Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking|journal=Viszeralmedizin|date=29 April 2015|volume=31|issue=2|pages=84–94|doi=10.1159/000381867|pmid=26989377|pmc=4789955}}</ref> [[Obesity]] is another risk factor.<ref name=Temp2013>{{cite journal|last1=Templeton|first1=AW|last2=Strate|first2=LL|title=Updates in diverticular disease.|journal=Current Gastroenterology Reports|date=August 2013|volume=15|issue=8|pages=339|pmid=24010157|doi=10.1007/s11894-013-0339-z|pmc=3832741}}</ref> Low levels of [[vitamin D]] are associated with an increased risk of diverticulitis.<ref name="pmid26251177">{{cite journal |vauthors=Ferguson LR, Laing B, Marlow G, Bishop K |title=The role of vitamin D in reducing gastrointestinal disease risk and assessment of individual dietary intake needs: Focus on genetic and genomic technologies |journal=Mol Nutr Food Res |volume=60 |issue=1 |pages=119–33 |date=January 2016 |pmid=26251177 |doi=10.1002/mnfr.201500243 }}</ref> ===Diet=== It is unclear what role [[dietary fiber|dietary fibre]] plays in diverticulitis.<ref name=Temp2013/> It is often stated that a diet low in fibre is a risk factor; however, the evidence to support this is unclear.<ref name=Temp2013/> There is no evidence to suggest that the avoidance of nuts and seeds prevents the progression of diverticulosis to an acute case of diverticulitis.<ref name="NEJM2018"/><ref name=Review09>{{cite journal|last=Weisberger|first=L|author2=Jamieson, B|title=Clinical inquiries: How can you help prevent a recurrence of diverticulitis?|journal=Journal of Family Practice|date=July 2009|volume=58|issue=7|pages=381–2|pmid=19607778}}</ref> It appears in fact that a higher intake of nuts and corn could help to avoid diverticulitis in adult males.<ref name=Review09/> ==Pathology== Right-sided diverticula are micro-hernias of the colonic mucosa and submucosa through the colonic muscular layer where blood vessels penetrate it.<ref name=Tur2016/> Left-sided diverticula are pseudodiverticula, since the herniation is not through all the layers of the colon.<ref name=Tur2016/> Diverticulitis is postulated to develop because of changes inside the colon, including high pressures because of abnormally vigorous contractions.<ref name=JAMA2014>{{cite journal|last=Morris|first=AM|author2=Regenbogen, SE |author3=Hardiman, KM |author4= Hendren, S |title=Sigmoid diverticulitis: a systematic review.|journal=JAMA |date=Jan 15, 2014|volume=311|issue=3|pages=287–97|pmid=24430321 |doi=10.1001/jama.2013.282025}}</ref> ==Diagnosis== [[File:Diverticulitis.png|thumb|Diverticulitis in the left lower quadrant as seen on axial view by [[CT scan]] (abnormality is within circled area)]] [[File:Sigmadivertikulitis in der Computertomographie - coronar.jpg|thumb|Diverticulitis on CT scan in coronal view]] [[File:Diverticulitis, very low mag.jpg|thumb|Diverticulitis showing acute purulent inflammation extending into the subserosal adipose tissue.]] People with the above symptoms are commonly studied with computed tomography, or [[CT scan]].<ref name="pmid17895789">{{cite journal |last1=Lee |first1=Kyoung Ho |last2=Lee |first2=Hye Seung |last3=Park |first3=Seong Ho |last4=Bajpai |first4=Vasundhara |last5=Choi |first5=Yoo Shin |last6=Kang |first6=Sung-Bum |last7=Kim |first7=Kil Joong |last8=Kim |first8=Young Hoon |title=Appendiceal Diverticulitis |journal=Journal of Computer Assisted Tomography |volume=31 |issue=5 |pages=763–9 |year=2007 |pmid=17895789 |doi=10.1097/RCT.0b013e3180340991}}</ref> The CT scan is very accurate (98%) in diagnosing diverticulitis. In order to extract the most information possible about the patient's condition, thin section (5&nbsp;mm) transverse images are obtained through the entire abdomen and pelvis after oral and intravascular contrast have been administered. Images reveal localized colon wall thickening, with inflammation extending into the fat surrounding the colon.<ref>{{cite web|url=http://www.claripacs.com/a.php?a=8o|title=CT scan of diverticulitis|publisher=ClariPACS|date=2017|accessdate=19 June 2017}}</ref> The diagnosis of acute diverticulitis is made confidently when the involved segment contains diverticula.<ref>{{cite journal |last1=Horton |first1=KM |last2=Corl |first2=FM |last3=Fishman |first3=EK |title=CT evaluation of the colon: inflammatory disease |journal=Radiographics |volume=20 |issue=2 |pages=399–418 |year=2000 |pmid=10715339 |doi=10.1148/radiographics.20.2.g00mc15399}}</ref> CT may also identify patients with more complicated diverticulitis, such as those with an associated abscess. It may even allow for radiologically guided drainage of an associated abscess, sparing a patient from immediate surgical intervention. [[Barium enema]] and [[colonoscopy]] are [[contraindication|contraindicated]] in the acute phase of diverticulitis because of the risk of perforation.<ref>{{cite journal|pmc=3329267|year=2012|author1=Sai|first1=V. F.|title=Colonoscopy after CT Diagnosis of Diverticulitis to Exclude Colon Cancer: A Systematic Literature Review|journal=Radiology|volume=263|issue=2|pages=383–390|last2=Velayos|first2=F|last3=Neuhaus|first3=J|last4=Westphalen|first4=A. C.|doi=10.1148/radiol.12111869|pmid=22517956}}</ref><ref>{{cite journal|pmid=25822438|year=2015|author1=Tursi|first1=A|title=The role of colonoscopy in managing diverticular disease of the colon|journal=Journal of Gastrointestinal and Liver Diseases|volume=24|issue=1|pages=85–93|url=http://www.jgld.ro/2015/1/15.pdf|deadurl=no|archiveurl=https://web.archive.org/web/20170810232527/http://jgld.ro/2015/1/15.pdf|archivedate=2017-08-10|df=|doi=10.15403/jgld.2014.1121.tur}}</ref> ===Classification by severity=== Four classifications by severity have been published recently in the literature. The most recent and widely accepted is as follows:<ref name="ReferenceA">{{cite journal|last1=Kruse|first1=E|last2=Leifeld|first2=L|title=Prevention and Conservative Therapy of Diverticular Disease.|journal=Viszeralmedizin|date=April 2015|volume=31|issue=2|pages=103–6|pmid=26989379|doi=10.1159/000377651|pmc=4789966}}</ref> *Stage 0 - asymptomatic diverticulosis *Stage 1a - uncomplicated diverticulitis *Stage 1b - diverticulitis with phlegmonous peridiverticulitis *Stage 2a - diverticulitis with concealed perforation, and abscess with a diameter of one centimeter or less *Stage 2b – diverticulitis with abscess greater than one centimeter *Stage 3a – diverticulitis with symptoms but without complications *Stage 3b – relapsing diverticulitis without complications *Stage 3c – relapsing diverticulitis with complications The severity of diverticulitis can be radiographically graded by the [[Hinchey Classification]].<ref>{{cite journal|pmc=3267934|year=2011|author1=Klarenbeek|first1=B. R.|title=Review of current classifications for diverticular disease and a translation into clinical practice|journal=International Journal of Colorectal Disease|volume=27|issue=2|pages=207–214|last2=De Korte|first2=N|last3=Van Der Peet|first3=D. L.|last4=Cuesta|first4=M. A.|doi=10.1007/s00384-011-1314-5|pmid=21928041}}</ref> ===Differential diagnosis=== The [[differential diagnosis]] includes [[colon cancer]], [[inflammatory bowel disease]], [[ischemic colitis]], and [[irritable bowel syndrome]], as well as a number of urological and gynecological processes. ===Complications=== {{unreferenced section|date=July 2017}} In complicated diverticulitis, an inflamed [[diverticulum]] can rupture, allowing [[bacteria]] to subsequently infect externally from the [[colon (anatomy)|colon]]. If the [[infection]] spreads to the lining of the [[abdominal cavity]] (the [[peritoneum]]), [[peritonitis]] results. Sometimes, inflamed diverticula can cause narrowing of the [[bowel]], leading to an [[Bowel obstruction|obstruction]]. In some cases, the affected part of the colon adheres to the [[Urinary bladder|bladder]] or other organs in the [[pelvic cavity]], causing a [[fistula#K: Diseases of the digestive system|fistula]], or creating an abnormal connection between an organ and adjacent structure or other organ (in the case of diverticulitis, the colon and an adjacent organ). Related pathologies may include: * [[Bowel obstruction]] * [[Peritonitis]] * [[Abscess]] * [[fistula#K: Diseases of the digestive system|Fistula]] * [[Bleeding]] * [[Stricture (medicine)|Strictures]] ==Treatment== Most cases of simple, uncomplicated diverticulitis respond to conservative therapy with bowel rest. ===Diet=== People may be placed on a [[low fibre diet]].<ref name="Postgraduate Medicine 2010">{{cite journal |last1=Spirt |first1=Mitchell |title=Complicated Intra-abdominal Infections: A Focus on Appendicitis and Diverticulitis |journal=Postgraduate Medicine |volume=122 |issue=1 |pages=39–51 |year=2010 |pmid=20107288 |doi=10.3810/pgm.2010.01.2098}}</ref> It was previously thought that a low-fibre diet gives the colon adequate time to heal. Evidence tends to run counter to this, with a 2011 review finding no evidence for the superiority of low fibre diets in treating diverticular disease, and that a high-fibre diet may prevent diverticular disease.<ref>{{cite journal|last1=Tarleton|first1=S|last2=DiBaise|first2=JK|title=Low-residue diet in diverticular disease: putting an end to a myth.|journal=Nutrition in Clinical Practice |date=April 2011|volume=26|issue=2|pages=137–42|pmid=21447765|doi=10.1177/0884533611399774}}</ref> A systematic review published in 2012 found no high-quality studies, but found that some studies and guidelines favour a high-fibre diet for the treatment of symptomatic disease.<ref>{{cite journal|last1=Ünlü|first1=C|last2=Daniels|first2=L|last3=Vrouenraets|first3=BC|last4=Boermeester|first4=MA|title=A systematic review of high-fibre dietary therapy in diverticular disease.|journal=International Journal of Colorectal Disease|date=April 2012|volume=27|issue=4|pages=419–27|pmid=21922199|doi=10.1007/s00384-011-1308-3|pmc=3308000}}</ref> While it has been suggested that probiotics may be useful for treatment, the evidence currently neither supports nor refutes this claim.<ref>{{cite journal|last1=Lahner|first1=E|last2=Bellisario|first2=C|last3=Hassan|first3=C|last4=Zullo|first4=A|last5=Esposito|first5=G|last6=Annibale|first6=B|title=Probiotics in the Treatment of Diverticular Disease. A Systematic Review.|journal=Journal of Gastrointestinal and Liver Diseases |date=March 2016|volume=25|issue=1|pages=79–86|pmid=27014757|doi=10.15403/jgld.2014.1121.251.srw}}</ref> ===Antibiotics=== The use of antibiotics in mild cases of uncomplicated diverticulitis is supported with only "sparse and of low-quality" evidence, with no evidence supporting their routine use.<ref name="ReferenceA"/><ref>{{cite journal | pmid = 21523694 | doi=10.1002/bjs.7376 | volume=98 | issue=6 | title=Use of antibiotics in uncomplicated diverticulitis |date=June 2011 |vauthors=de Korte N, Unlü C, Boermeester MA, Cuesta MA, Vrouenreats BC, Stockmann HB | journal=Br J Surg | pages=761–7}}</ref> In spite of this, antibiotics are recommended by several current guidelines. With CT scan evidence of abscess, fistula, or intestinal rupture with peritonitis, antibiotics are recommended and routinely used. ===Surgery=== ====Indications==== Indications for surgery are [[abscess]] or [[fistula]] formation; and intestinal rupture with [[peritonitis]].<ref name=JAMA2014/> These, however, rarely occur.<ref name=JAMA2014/> Surgery for abscess or fistula is indicated either urgently or electively. The timing of the elective surgery is determined by evaluating factors such as the stage of the disease, the age of the person, their general medical condition, the severity and frequency of the attacks, and whether symptoms persist after the first [[acute (medicine)|acute episode]]. In most cases, elective surgery is deemed to be indicated when the risks of the surgery are less than the risks of the complications of the diverticulitis. Elective surgery is not indicated until at least six weeks after recovery from the acute event.<ref>Merck, Sharpe & Dohme. [http://www.merck.com/mmhe/sec09/ch128/ch128c.html "Diverticulitis treatments"] {{webarchive|url=https://web.archive.org/web/20100306032009/http://www.merck.com/mmhe/sec09/ch128/ch128c.html |date=2010-03-06 }} 2010-02-23.</ref> Emergency surgery is indicated for intestinal rupture with peritonitis.<ref>[http://digestive-disorders.health-cares.net/diverticulitis-surgery.php What's the diverticulitis surgery?] {{webarchive|url=https://web.archive.org/web/20100227042539/http://digestive-disorders.health-cares.net/diverticulitis-surgery.php |date=2010-02-27 }} Digestive Disorders portal. Retrieved on 2010-02-23</ref> ====Technique==== The first surgical approach consists of [[segmental resection|resection]] and primary [[anastomosis]]. This first stage of surgery is performed on patients if they have a well-vascularized, nonedematous and tension-free bowel. The proximal margin should be an area of pliable colon without [[hypertrophy]] or inflammation. The distal margin should extend to the upper third of the [[rectum]] where the [[taenia coli|taenia]] coalesces. Not all of the diverticula-bearing colon must be removed, since [[diverticula]] proximal to the descending or sigmoid colon are unlikely to result in further symptoms.<ref>[http://emedicine.medscape.com/article/173388-treatment Diverticulitis: Treatment & Medication] {{webarchive|url=https://web.archive.org/web/20100316191211/http://emedicine.medscape.com/article/173388-treatment |date=2010-03-16 }} eMedicine. 2010-02-23</ref> ====Approach==== Diverticulitis surgery consists of a [[bowel resection]] with or without [[colostomy]]. Either may be done by the traditional [[laparotomy]] or by [[laparoscopic surgery]].<ref>[http://www.diverticulitissurgery.net/ Diverticulitis Surgery] {{webarchive|url=https://web.archive.org/web/20100212111406/http://diverticulitissurgery.net/ |date=2010-02-12 }} 2010-02-23</ref> The traditional bowel resection is made using an open surgical approach, called [[colectomy]]. During a colectomy the patient is placed under [[general anesthesia]]. A surgeon performing a colectomy will make a lower midline incision in the abdomen or a lateral lower transverse incision. The diseased section of the large intestine is removed, and then the two healthy ends are sewn or stapled back together. A colostomy may be performed when the bowel has to be relieved of its normal digestive work as it heals. A colostomy implies creating a temporary opening of the colon on the skin surface, and the end of the colon is passed through the abdominal wall with a removable bag attached to it. The waste is collected in the bag.<ref>{{cite journal |last1=Gupta |first1=Aditya K. |first2=Maria |last2=Chaudhry |first3=Boni |last3=Elewski |title=Tinea corporis, tinea cruris, tinea nigra, and piedra |journal=Dermatologic Clinics |volume=21 |issue=3 |pages=395–400, v |year=2003 |pmid=12956194 |doi=10.1016/S0733-8635(03)00031-7}}</ref> However, most surgeons prefer performing the bowel resection laparoscopically, mainly because postoperative pain is reduced with faster recovery. The laparoscopic surgery is a minimally invasive procedure in which three to four smaller incisions are made in the abdomen or [[navel]]. Alternately, laparoscopic sigmoid resection (LSR) compared to open sigmoid resection (OSR) showed that LSR is not superior over OSR for acute symptomatic diverticulitis. Furthermore, laparoscopic lavage was as safe as resection for perforated diverticulitis with peritonitis.<ref>{{cite journal |last1=Ahmed |first1=Ali Mahmoud |last2=Mohammed |first2=Abdelrahman Tarek |last3=Mattar |first3=Omar Mohamed |last4=Mohamed |first4=Esraa Mowafy |last5=Faraag |first5=Esraa Abdelmon'em |last6=AlSafadi |first6=Ammar Mohammed |last7=Hirayama |first7=Kenji |last8=Huy |first8=Nguyen Tien |title=Surgical treatment of diverticulitis and its complications: A systematic review and meta-analysis of randomized control trials |journal=The Surgeon |date=1 July 2018 |volume=20 |issue=6 |pages=372–383 |doi=10.1016/j.surge.2018.03.011 |pmid=30033140 }}</ref> ====Maneuvers==== All colon surgery involves only three maneuvers that may vary in complexity depending on the region of the bowel and the nature of the disease. The maneuvers are the retraction of the colon, the division of the attachments to the colon and the dissection of the [[mesentery]].<ref>[http://www.surgeryencyclopedia.com/A-Ce/Bowel-Resection.html Bowel resection procedure] {{webarchive|url=https://web.archive.org/web/20100129104417/http://www.surgeryencyclopedia.com/A-Ce/Bowel-Resection.html |date=2010-01-29 }} Encyclopedia of surgery. Retrieved on 2010-02-23</ref> After the resection of the colon, the surgeon normally divides the attachments to the liver and the small intestine. After the mesenteric vessels are dissected, the colon is divided with special surgical staplers that close off the bowel while cutting between the staple lines. ====Bowel resection with colostomy==== When excessive inflammation of the colon renders primary bowel resection too risky, bowel resection with [[colostomy]] remains an option. Also known as the [[Hartmann's operation]], this is a more complicated surgery typically reserved for life-threatening cases. The bowel resection with colostomy implies a temporary colostomy which is followed by a second operation to reverse the colostomy. The surgeon makes an opening in the abdominal wall (a colostomy) which helps clear the infection and inflammation. The colon is brought through the opening and all waste is collected in an external bag.<ref>[http://www.mayoclinic.com/health/diverticulitis/DS00070/DSECTION=treatments-and-drugs Diverticulitis treatments and drugs] {{webarchive|url=https://web.archive.org/web/20100212202412/http://www.mayoclinic.com/health/diverticulitis/DS00070/DSECTION%3Dtreatments-and-drugs |date=2010-02-12 }} Mayo Clinic. 2010-02-23</ref> The colostomy is usually temporary, but it may be permanent, depending on the severity of the case.<ref>{{cite journal|vauthors=Vermeulen J, Coene PP, Van Hout NM, van der Harst E, Gosselink MP, Mannaerts GH, Weidema WF, Lange JF |title=Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure?|journal=Colorectal Disease|date=July 2009|volume=11|issue=6|pages=619–24|pmid=18727727|doi=10.1111/j.1463-1318.2008.01667.x}}</ref> In most cases several months later, after the inflammation has healed, the patient undergoes another major surgery, during which the surgeon rejoins the colon and rectum and reverses the colostomy. ==Epidemiology== Diverticulitis most often affects the elderly. In Western countries, diverticular disease most commonly involves the [[sigmoid colon]] (95 percent of patients). The prevalence of diverticular disease increased from an estimated 10 percent in the 1920s to between 35 and 50 percent by the late 1960s. 65 percent of people over 85 can be expected to have some form of diverticular disease of the colon. Less than 5 percent of those aged 40 years and younger are affected by diverticular disease. Left-sided diverticular disease (involving the sigmoid colon) is most common in the West, while right-sided diverticular disease (involving the ascending colon) is more common in Asia and Africa.<ref name=Fel2010/> Among patients with diverticulosis, 4 to 15% may go on to develop diverticulitis.<ref name="UpToDate">{{Cite web|url=https://www.uptodate.com/contents/colonic-diverticulosis-and-diverticular-disease-epidemiology-risk-factors-and-pathogenesis|title=Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis|last=Pemberton|first=John H|date=16 June 2016|website=UpToDate|archive-url=https://web.archive.org/web/20170314151944/https://www.uptodate.com/contents/colonic-diverticulosis-and-diverticular-disease-epidemiology-risk-factors-and-pathogenesis|archive-date=2017-03-14|dead-url=no|access-date=13 March 2017|url-access=subscription |df=}}</ref> ==References== {{Reflist}} ==External links== {{Medical condition classification and resources | ICD10 = {{ICD10|K|57||k|55}} | ICD9 = {{ICD9|562}} | ICDO = | OMIM = | MedlinePlus = 000257 | eMedicineSubj = med | eMedicineTopic = 578 | DiseasesDB = 3876 | MeshID = D004238 }} * [http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis Diverticulosis and Diverticulitis] at NIDDK * [http://www.mayoclinic.org/diseases-conditions/diverticulitis/basics/definition/con-20033495 Diverticulitis] at [[Mayo Clinic]] * [http://www.pmidcalc.org/25710425 Staging of Acute Diverticulitis] online calc {{Gastroenterology}} [[Category:Diseases of intestines]] [[Category:RTT]] [[Category:RTTEM]]'