Acute diverticulitis in 2024: current evidence to prevent onset and recurrence

INTRODUCTION: The worldwide increase in acute diverticulitis (AD) prevalence and the resulting growing economic burden on the healthcare system have driven the scientific community towards standardizing a methodological approach to obtain a prompt diagnosis, optimized treatment, and thus containing costs. By the analysis of currently available evidence, this review could provide effective strategies for efficient AD clinical management and highlights possible innovative therapeutic strategies. EVIDENCE ACQUISITION: A systematic literature search was conducted from October 2014 to October 2024 according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. EVIDENCE SYNTHESIS: The accurate collection of the medical history with investigation of preexisting diverticulosis and known AD risk factors, in combination with careful physical examination, permits a direct AD diagnosis but with proper accuracy. The contextual integration of laboratory data and the use of clinical scores may discourage the use of radiology, which, despite this, remains the only available methodology to exclude complications requiring hospitalization. CT scan with intravenous contrast remains the gold standard both for diagnosis and staging. However, the principal purpose is to prevent AD onset and recurrence (primary and secondary prevention) to reduce the health burden. The intervention on modifiable risk factors reduced AD incidence, whereas the currently available therapeutic options, such as non-absorbable antibiotics, probiotics, and mesalazine, have proven disappointing results. Breakthroughs may arise from recent evidence of a pathogenic role of a transmural colonic oxidative imbalance, likely ascribed to chronic ischemiareperfusion injuries, that could contribute to reduced colonic wall compliance and represent a new possible therapeutic target. CONCLUSIONS: Although progress has been made in the last decade towards more efficient AD management, further efforts are needed to impact its management and healthcare costs efficiently.