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2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting

WSES · 2020 · international

Source and licence

Authors
Massimo Sartelli, Dieter G Weber, Yoram Kluger et al.
Title
2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting
Journal
World Journal of Emergency Surgery : WJES, 2020
DOI
10.1186/s13017-020-00313-4
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC7206757

Licence statement of the original publication

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

What is the best imaging technique in patients with suspected ALCD? What is the role of ultrasound (US) in patients with ALCD?

  • We suggest to use US in the initial evaluation of patients with suspected ALCD where it is performed by an expert operator. It has wide availability and easy accessibility. A step-up approach with CT performed after an inconclusive or negative US may be a safe approach for patients suspected of acute diverticulitisweak recommendation based on moderate-quality evidence, 2B

Are immunocompromised patients with ALCD at risk for failure of standard, non-operative treatment?

  • We suggest that immunocompromised patients with ALCD be considered at high risk for failure of standard, non-operative treatmentweak recommendation based on very low-quality evidence, 2D

Could patients with uncomplicated ALCD be treated as outpatient?

  • We suggest management in an outpatient setting for patients with uncomplicated ALCD and no comorbidities. We suggest re-evaluation within 7 days. If the clinical condition deteriorates, re-evaluation should be carried out earlierweak recommendation based on moderate-quality evidence, 2B

What is the best treatment for patients with a small diverticular abscess (< 4–5 cm)? What is the best treatment for patients with large diverticular abscess?

  • We suggest to treat patients with large abscesses with percutaneous drainage combined with antibiotic treatment; whenever percutaneous drainage of the abscess is not feasible or not available, we suggest to initially treat patients with large abscesses with antibiotic therapy alone, clinical conditions permitting. Alternatively, an operative intervention is requiredweak recommendation based on low-quality evidence, 2C

Should laparoscopic lavage and drainage be recommended in patients with diffuse peritonitis due to diverticular perforation?

  • We suggest performing laparoscopic peritoneal lavage and drainage only in very selected patients with generalized peritonitis. It is not considered as the first line treatment in patients with peritonitis from acute colonic diverticulitisweak recommendation based on high-quality evidence, 2A

Should primary anastomosis with or without protecting stoma be preferred instead of Hartmann’s procedure in patients with diffuse peritonitis from diverticular perforation?

  • We recommend Hartmann’s procedure (HP) for managing diffuse peritonitis in critically ill patients and in selected patients with multiple comorbiditiesstrong recommendation based on low-quality evidence, 2B

Should damage control surgery with staged laparotomies be recommended in patients with acute peritonitis due to diverticular perforation?

  • We suggest damage control surgery (DCS) with staged laparotomies in selected unstable patients with diffuse peritonitis due to diverticular perforationweak recommendation based on low-quality evidence, 2C

What factors should be considered in planning elective resection in cases of acute diverticulitis treated non-operatively?

  • We suggest evaluating patient-related factors and not number of previous episodes of diverticulitis in planning elective sigmoid resectionweak recommendation based on very low-quality evidence, 2D

What is the optimal antibiotic therapy for patients with diffuse peritonitis due to diverticular perforation? What is the optimal duration of antibiotic therapy after surgical source control in diffuse peritonitis due to diverticular perforation?

  • We suggest to choose the empirically designed antibiotic regimen on the basis of the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patternsstrong recommendation based on moderate-quality evidence, 1B
  • We suggest a 4-day period of postoperative antibiotic therapy in complicated ALCD if source control has been adequateweak recommendation based on moderate-quality evidence, 2B

Abstract

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Contents of the original publication

The section headings of the original.

  • Introduction
  • Methods
  • Which classification should be used in patients with ALCD?
  • What is the best way to make a diagnosis of ALCD?
  • What is the best imaging technique in patients with suspected ALCD? What is the role of ultrasound (US) in patients with ALCD?
  • Are immunocompromised patients with ALCD at risk for failure of standard, non-operative treatment?
  • Should antibiotics be recommended in immunocompetent patients with uncomplicated acute diverticulitis?
  • Could patients with uncomplicated ALCD be treated as outpatient?
  • What is the best treatment for patients with acute diverticulitis with CT findings of pericolic gas?
  • What is the best treatment for patients with a small diverticular abscess (< 4–5 cm)? What is the best treatment for patients with large diverticular abscess?
  • Should an early colonic evaluation be planned in patients treated non-operatively for a diverticular abscess? Should an early colonic evaluation be recommended for patients with a CT-proved uncomplicated acute diverticulitis treated non-operatively?
  • What is the role of non-operative treatment in patients with CT findings of distant gas without diffuse intra-abdominal fluid?
  • Should laparoscopic lavage and drainage be recommended in patients with diffuse peritonitis due to diverticular perforation?
  • Should primary anastomosis with or without protecting stoma be preferred instead of Hartmann’s procedure in patients with diffuse peritonitis from diverticular perforation?
  • Should laparoscopic resection be preferred to open resection in patients with diffuse peritonitis due to perforated diverticulitis?
  • Should damage control surgery with staged laparotomies be recommended in patients with acute peritonitis due to diverticular perforation?
  • What factors should be considered in planning elective resection in cases of acute diverticulitis treated non-operatively?
  • What is the optimal antibiotic therapy for patients with diffuse peritonitis due to diverticular perforation? What is the optimal duration of antibiotic therapy after surgical source control in diffuse peritonitis due to diverticular perforation?
  • Which are the principles of the treatment of acute right-sided colonic diverticulitis?
  • Conclusions
  • Contributor Information

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