Diagnosis and treatment of chronic and recurrent diverticulitis.

In Western countries the prevalence of diverticular disease has increased over the past century. Although, most patients remain asymptomatic, among those who experience an attack of diverticulitis, one-third will have recurrent symptoms, and a further third will have a subsequent episode. The indications for surgery after treatment of acute diverticulitis is still under debate. Uncomplicated disease less commonly as thought, progresses to a life threatening situation such as free perforation. Among those who develop complicated diverticulitis, it is often their first presentation. Fistula to the urinary tract often require surgery; however, complicated disease such as an abscess or phlegmon can be managed conservatively and subsequent surgery is selective depending on the recovery from the initial episode. Patients with chronic diverticular disease (persistent pain in the absence of inflammation) have greatly improved quality of life with surgery. The question of greater virulence of disease among young patients may no longer be true and recommendations for surgery may parallel that of older patients. Immunocompromised patients should have definitive surgical therapy early on in the course of the disease. Right-sided disease remains uncommon in the Western world and a conservative approach in the absence of free perforation is recommended. In right-sided disease and in young patients, misdiagnosis is common. In the elective setting, a laparoscopic approach is rapidly becoming preferred because of less morbidity and shorter hospital stay. The treatment of diverticular disease is rapidly undergoing reevaluation, and novel therapies and increased conservative approaches are evolving. Prospective randomized trials are needed, but remain difficult owing to the uncertain natural history of the disease.