Diverticulitis in the frail elderly patient

Diverticular disease in the elderly has a prevalence of up to 65% by 85 years of age. Diagnosis of acute diverticulitis remains an ongoing chal-lenge. In the elderly, the presenting signs and symptoms may be more obscure due to unusual extra-abdominal manifestations of diverticulitis, communication difficulties and peculiar biochemical and radiological changes. The elderly population are at a higher risk of being on medica-tions and polypharmacy and experience a sedentary lifestyle and obesity. Diverticular disease can be divided into segmental colitis associated with diverticulosis (SCAD) and symptomatic uncomplicated diverticular diseases (SUDD). Attempts at classifying diverticular disease were first documented in 1978 by Hinchey et al. Uncomplicated diverticulitis occurs in the absence of complications and represents 70% of patients with acute diverticulitis. The most common acute management of complicated diverticulitis is surgery. This subtype of acute diverticulitis tends to be more prevalent in the elderly, frail population. The definition of frailty has become patient-specific rather than age-specific, encompassing several domains. The most common antibiotic regimen covers gram negative organisms for a duration of 7 to 10 days followed by patient reas-sessment after 3 days and then weekly until complete recovery. One of the major concerns with emergency surgery in the elderly population is postoperative recovery. Elderly patients would benefit from a multidimensional, Comprehensive Geriatric Assessment (CGA) in order to assist in evaluating eventual morbidity. Risks of sepsis and mortality are higher in the elderly. In view of this, a covering ileostomy is recommended in primary anastomosis in the elderly. Damage control surgery may take two routes; limited colonic resection with a covering stoma or no stoma, or lavage and drainage, which may also be performed laparoscopically. Recurrence of diverticulitis, symptoms refractory to medical therapy, obstructive symptoms, presence of fistula/e, and immunocompromise are all indications for elective surgery. Elective surgery for diverticular disease is usually delayed by 6-8 weeks after an acute episode. The LASER trial (2020) and DIRECT trial (2017) both favour elective colonic resection when there are three or more documented episodes of acute uncomplicated diverticulitis in a two-year period. Invasive intervention in patients older than 80 was associated with a poorer prognosis.