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The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly

WSES/SICG et al. · 2022 · international

Source and licence

Authors
Paola Fugazzola, Marco Ceresoli, Federico Coccolini et al.
Title
The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly
Journal
World Journal of Emergency Surgery : WJES, 2022
DOI
10.1186/s13017-022-00408-0
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC8781436

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.

Diagnosis

  • Statement 1.1In the elderly population, we suggest against basing the diagnosis of acute left colonic diverticulitis on only patient clinical signs, symptoms and laboratory tests.Conditional recommendation, very low-quality evidence
  • Statement 1.2We suggest that elderly patients presenting with abdominal guarding or pain in the lower left abdomen on physical examination undergo appropriate imaging for suspected diverticulitis, regardless of the value of leukocytes and of C-reactive protein (CRP).Conditional recommendation, very low-quality evidence
  • Statement 2.1We suggest the use of CT-scan with IV-contrast in all elderly patients with suspected diverticulitis to confirm the diagnosis and to distinguish complicated from non-complicated diverticulitis .Conditional recommendation, very low-quality evidence
  • Statement 2.2In elderly patients with suspected diverticulitis who cannot undergo CT-scan with IV-contrast (i.e. severe acute or chronic kidney disease or contrast allergy), we suggest the use of US, MRI or CT-scan without IV-contrast as alternative diagnostic approaches, according to resources availability.Conditional recommendation, very low-quality evidence

Management

  • Statement 3.1We suggest that antibiotic therapy should be avoided in immunocompetent elderly patients with uncomplicated left colonic diverticulitis (WSES stage 0) without sepsis-related organ failuresConditional recommendation, very low-quality of evidence
  • Statement 4.1We suggest antibiotic therapy administration for elderly patients with localized complicated left colonic diverticulitis with pericolic air bubbles or little pericolic fluid without abscess (WSES stage 1a).Conditional recommendation, moderate quality of evidence
  • Statement 5.1In elderly stable patients with an abscess from acute left colonic diverticulitis (WSES stage 1b-2a) and without peritonitis, we suggest the administration of a broad-spectrum antibiotic therapy.Conditional recommendation, very low quality of evidences
  • Statement 5.2We suggest adding percutaneous drainage to antibiotic therapy in elderly patients with acute left colonic diverticulitis and an abscess larger than 4 cm (WSES stage 2a), when skills and facilities are available. Cultures from percutaneous drainage should be carried out to guide the antibiotic therapy.Conditional recommendation, very low quality of evidences
  • Statement 6.1In elderly patients with acute left colonic diverticulitis and CT findings of distant intraperitoneal free air and no free fluid (WSES stage 2b) we suggest against non-operative management as a viable option.Conditional recommendation, very low quality of evidences
  • Statement 7.1In elderly patients with acute left colonic diverticulitis and diffuse peritonitis (WSES stage 3–4) we recommend against non-operative management as a viable option.Strong recommendation, very low quality of evidences
  • Statement 7.2In elderly patients with acute left colonic diverticulitis and diffuse peritonitis (WSES stage 3–4) we recommend prompt and effective source control surgery.Strong recommendation, very low quality of evidences
  • Statement 8.1We suggest against elective sigmoid resection after a conservatively treated episode of acute left colonic diverticulitis in asymptomatic elderly patients without stenosis, fistulae or recurrent diverticular bleeding.Conditional recommendation, very low-quality evidence
  • Statement 8.2We suggest considering elective sigmoid resection after a conservatively treated episode of acute left colonic diverticulitis in high-risk elderly patients, such as immunocompromised patients (if fit for surgery).Conditional recommendation, very low-quality evidence
  • Statement 8.3We suggest elective sigmoid resection in elderly patients (if fit for surgery) with left colonic diverticular disease complicated with stenosis, fistulae or recurrent diverticular bleeding.Conditional recommendation, very low-quality evidence
  • Statement 8.4We suggest elective sigmoid resection in elderly patients (if fit for surgery) with very symptomatic left colonic diverticular disease, which compromise the quality of life.Conditional recommendation, very low-quality evidence
  • Statement 9.1We suggest planning early colonic evaluation in elderly patients after an episode of acute left colonic diverticulitis.Conditional recommendation, very low-quality evidence

Surgical technique

  • Statement 10.1In elderly patients with acute left colonic diverticulitis and acute peritonitis we suggest against laparoscopic lavage as the preferred surgical approach due to the higher risk of failure to control the source of sepsis.Conditional recommendation, moderate quality evidences
  • Statement 11.1We suggest that in elderly patients with perforated diverticulitis with generalized peritonitis, Hartmann operation and resection with primary anastomosis are both reasonable options.Conditional recommendation, low-quality of evidence
  • Statement 11.2We suggest that in elderly patients with perforated diverticulitis with generalized peritonitis and physiological derangement, Damage Control Surgery (emergency laparotomy, source control and application of open abdomen and abdominal vacuum-assisted closure) may be a viable option.Conditional recommendation, very low quality of evidence
  • Statement 12.1We suggest that in stable elderly patients with perforated diverticulitis with diffuse peritonitis emergency laparoscopic sigmoidectomy can be performed by experienced laparoscopic surgeonsConditional recommendation, very low quality of evidence

Antibiotic therapy

  • Statement 13.1In elderly patients with localized complicated diverticulitis the empirically designed anti-microbial regimen depends on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns.Conditional recommendation, very low quality of evidence
  • Statement 14.1In elderly patients with perforated diverticulitis with diffuse peritonitis the empirically designed anti-microbial regimen depends on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns.Conditional recommendation, very low quality per indirectness
  • Statement 15.1In elderly patients with complicated diverticulitis a short course of antibiotic therapy (3–5 days) after adequate source control is a reasonable option.Conditional recommendation, moderate quality of evidence
  • Statement 15.2In elderly patients with complicated diverticulitis who have ongoing signs of peritonitis or systemic illness (ongoing infection) beyond 5 to 7 days of antibiotic treatment, further diagnostic investigation is indicated.Conditional recommendation, low quality of evidence

Conclusion

  • Statement 8.2We suggest to consider elective sigmoid resection after a conservatively treated episode of acute left colonic diverticulitis in high-risk elderly patients, such as immunocompromised patients (if fit for surgery).Conditional recommendation, very-low quality evidence

Abstract

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Contents of the original publication

The section headings of the original.

  • Background
  • Material and methods
  • Results
  • Diagnosis
  • Management
  • Surgical technique
  • Antibiotic therapy
  • Conclusion

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