Title:Diverticulitis in immunodeficient patients: our experiencein the management of high-risk patients

Authors:Javier Serrano González, José Luis Lucena de la Poza, LauraRomán García de León, Jesús Gabriel García Schiever, NedaFarhangmehr Setayeshi, Pablo Calvo Espino, Arsenio SánchezMovilla, Victor Sánchez Turrión

DOI: 10.17235/reed.2019.6281/2019Link: PubMed (Epub ahead of print)

Please cite this article as:Serrano González Javier, Lucena de la Poza José Luis, RománGarcía de León Laura, García Schiever Jesús Gabriel,Farhangmehr Setayeshi Neda, Calvo Espino Pablo, SánchezMovilla Arsenio, Sánchez Turrión Victor. Diverticulitis inimmunodeficient patients: our experience in themanagement of high-risk patients. Rev Esp Enferm Dig 2019.doi: 10.17235/reed.2019.6281/2019.

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OR 6281 inglés

Diverticulitis in immunodeficient patients: our experience in the management of

high-risk patients

Javier Serrano González1, José Luis Lucena de la Poza1, Laura Román García de León1,

Jesús Gabriel García Schiever2, Neda Farhangmehr Setayeshi3, Pablo Calvo Espino1,

Arsenio Sánchez Movilla1 and Víctor Sánchez Turrión1

1General Surgery and Digestive Diseases Service. Hospital Puerta de Hierro

Majadahonda. Majadahonda, Madrid. Spain. 2General Surgery and Digestive Diseases

Service. Hospital General Universitario de Ciudad Real. Ciudad Real, Spain. 3General

Surgery and Digestive Diseases Service. Colchester General Hospital. Colchester,

United Kingdom

*This study was partially presented in the XXX National Surgery Congress, Madrid,

2014.

Received: 21/3/2019

Accepted: 4/7/2019

Correspondence: Javier Serrano González. General Surgery and Digestive Diseases

Service. Hospital Universitario Puerta de Hierro Majadahonda. C/ Manuel de Falla, 1.

28222 Majadahonda, Madrid. Spain

e-mail: javierserranogdr@gmail.com

ABSTRACT

Introduction: acute diverticulitis is a very prevalent disease. The need for a more

aggressive management in immunodeficient patients has not been established. We

present the results of our unit with immunodeficient patients diagnosed with acute

diverticulitis and their follow-up.

Objectives: to assess the possibility that a conservative management in this group is as

valid as in the immunocompetent population.

Methods: a retrospective analysis study was performed in our hospital. Forty

immunodeficient patients (transplant, corticoid treatment, dialysis, oncologic, HIV

patients) diagnosed with acute diverticulitis were analyzed. The patients were

managed with a surgical or non-surgical treatment according to their status on

admission. The main analyzed items were the severity of the acute episode and the

need for surgical treatment compared to the cause of immunodeficiency. Other

studied variables included follow-up results and recurrences.

Results: thirty-two of the 40 patients studied received a non-surgical treatment during

the acute episode, eight required emergency surgery (seven had a Hartmann

procedure and one underwent a colon resection and anastomosis). Transplant patients

and those between 40 and 50 years old proved to be higher risk groups. Three patients

subsequently required elective surgery due to complications. Twenty-four patients had

uneventful recoveries.

Conclusions: the frequency of complicated acute diverticulitis is higher in

immunodeficient patients than that of the general population. Non-surgical treatment

seems to be as safe as in immunocompetent patients. Younger and transplanted

patients were higher risk groups for severe acute diverticulitis that required a more

aggressive management initially.

Keywords: Diverticulitis. Colon. Immunodeficiency.

INTRODUCTION

Diverticular disease is defined as the presence of diverticula or pseudodiverticula in

the colonic wall. In Western countries, it is mostly located in the sigmoid colon

followed by the descending colon. The prevalence is influenced by life habits,

especially high-fat, high-protein and low-fiber diets. This has also been observed in

Asian countries, where customs are becoming more similar to those of Western

countries during the last few decades (1,2). Up to 80% of the population over 70 years

old have diverticula (3,4) and around 25% of these cases will develop at least one

episode of acute diverticulitis (AD) during their lifetime (5).

Patients with conditions that compromise their immunological competence are more

and more common in our daily practice as oncologic patients, chronic kidney disease

(CKD) under dialysis and transplant patients, among others. Several studies describe a

more aggressive evolution of recurrent episodes of AD in immunodeficient patients

(ID) (6,7), with a higher ratio of complicated disease than immunocompetent patients

(IC). They require a more active management of the disease due to the risk of more

aggressive episodes, and elective surgical treatment is indicated after the first episode

of non-complicated AD (8-10).

The goal of this study was to analyze the results of the ID patients treated in our

hospital for AD, and to design the best care strategy for these cases.

MATERIALS AND METHODS

An observational retrospective and descriptive study was performed of ID patients

diagnosed with AD, treated in a tertiary hospital between 2008 and 2016. This study

was approved by the Ethics Committee for Clinical Research in our hospital.

Immunodeficient patients were considered as those with chronic corticoid treatment,

solid organ transplant, hematologic neoplasm, solid organ tumor, chronic kidney

disease under dialysis and those with HIV infection. The patients included in the study

were diagnosed with AD after a clinical and analytical evaluation and an

abdominopelvic computed tomography (CT) scan (11,12). ID patients admitted with a

diagnosis of AD but without available data for a proper analysis were excluded from

the study.

The analyzed data included: age at the time of diagnosis, gender, severity of the

disease (using the Modified Hinchey Classification), cause of immunodeficiency (13),

risk factors for a poor outcome (RFPO) (diabetes mellitus, chronic kidney disease

without dialysis, high blood pressure, smoking habit or dyslipidemia) (14-16),

treatment (medical vs surgical), days of admission, need for surgical treatment during

follow-up, complications during hospital stay and recurrences.

Medical treatment consisted of nil per os (NPO), intravenous fluids, wide spectrum

antibiotics and intravenous analgesia (17). Antibiotic treatment for admitted patients

was performed using intravenous piperacilin/tazobactam 4/0.5 g every six hours,

adjusting the dosage to kidney function when necessary. Tigecyclin + ciprofloxacin

were used in patients with an allergy. This treatment continued for at least five days,

followed by oral amoxicillin/clavulanic acid for another 5-7 days (ciprofloxacin +

metronidazole in allergic patients). Emergency surgical treatment (EST) was performed

in patients with generalized peritonitis (stages III and IV of the Hinchey Classification)

or in the case of septic shock. Surgical procedures included the Hartmann procedure or

resection via primary anastomosis; the decision was made by the responsible surgeon

based on their experience, local contamination and the patient’s status and stability (

18-20). Elective colonic resection was indicated in a few cases after conservative

management of the acute episode, depending on the severity of the first episode and

the appearance of subsequent relapses (21). After discharge, the patients underwent

at least a six-month follow-up, with clinical, analytical and radiologic tests. A

colonoscopy was also performed if this had not been performed during the five years

prior to the first episode of AD.

Statistical analysis

Quantitative variables were expressed as absolute values and qualitative variables

were expressed as absolute values and percentages. Statistical analysis was performed

using the IBM® SPSS® Statistics 20 program. The Student’s t test was used to compare

quantitative variables, assuming a p < 0.05 as statistically significant. Chi-squared test

contingency tables were used to analyze qualitative variables. These tables are useful

when analyzing the relationship between two categorical variables, on which only a

nominal measurement can be made. Thus, it is possible to assess the existence of

statistical significant differences between corrected typified residues (CTR). Residues

are the differences between the observed and the expected frequencies in each box of

the table; they are used to understand the association between the compared

elements. CTR have a normal distribution, with a mean of 0 and a standard deviation

of 1. With these tools and a confidence level of 0.95, statistical significant differences

were found when studying the CTR and these differences were statistically significant

when the residues where outside of the interval (-1.96; 1.96). The positive or negative

result of this residue shows the direct or inverse relationship between the categories.

RESULTS

During the study period, 578 patients were analyzed and all were admitted to our unit

after being diagnosed with AD. Forty-six patients of these were analyzed and six were

excluded due to insufficient data (Fig. 1). Of the 40 analyzed patients (6.9% of the total

patients admitted with AD), 21 were male (52%) and 19 female (48%) with an average

age of 63 years old, ranging from 43 to 85 years old.

Among the different causes for ID, the cohort was divided in 14 patients (35%) who

had previously received a transplant: six had a kidney transplant (43% of all patients

with a transplant), five bi-pulmonary (36%), two liver (14%) and one heart (7%); four

patients (10%) had a chronic kidney disease with dialysis and six (15%) had

hematologic neoplasms; two had acute myeloid leukemia (33%), one prolymphocytic

leukemia (17%), one multiple myeloma, one B lymphoma and one T lymphoma; eight

patients (20%) were actively receiving treatment for a solid tumor; six patients (15%)

were receiving treatment with corticoids, including one with systemic erythematosus

lupus, one with Sjögren’s syndrome, one for psoriasic arthropaty, two cases of

rheumathoid arthritis and one case of polychondritis; and two patients (5%) had an

active HIV infection.

Among the RFPO, ten patients had high blood pressure (25%), five were diabetic

(12.5%), four were active smokers (10%), two were dyslipidemic (5%) and two had

chronic kidney disease without dialysis (CKDWOD, 5%). Ten patients had no risk factors

that could predict a poor outcome of the disease.

According to the results of the CT scan performed for every patient in the Emergency

Ward, 26 cases (65%) developed a non-complicated AD (Hinchey stage Ia); three

patients (7.5%) were classified as stage Ib, four patients (10%) as stage II, two patients

(5%) had a stage III and five cases (12.5%) had a stage IV AD. One of the cases was

diagnosed with a right AD (patient with a kidney transplant, stage Ia) and the rest were

diagnosed with AD of the descending or sigmoid colon. All received treatment in our

hospital except one, who refused to be admitted.

Of all the patients in our study, 32 (80%) initially received conservative treatment and

eight (20%) required EST (six had undergone a previous transplant and two were

oncologic patients). Resection of the affected colonic segment with a colostomy was

performed in all cases, except for one case in which a resection and primary

anastomosis was performed. With regard to the severity of the AD cases that required

EST, one patient (12%) was a stage II, two were stage III (25%) and five patients (63%)

were classified as a stage IV. All patients diagnosed with a stage III or stage IV AD were

treated with EST (Table 1).

Three of the patients who initially received a non-surgical management (NSM) with

antibiotics underwent surgical treatment during the first year of follow-up after the

acute episode. Sigmoidectomy and primary anastomosis were performed in two cases,

one with CKD and a stage II AD with persistent rectorrhagia after the acute episode,

and the other patient underwent chronic corticoid treatment and had persistent

subocclusive episodes after the initial episode was resolved. Another patient with

stage II AD and lymphoma underwent a Hartmann’s procedure.

The average time of admission was 14.5 ± 20 days (4-115), with a median stay of eight

days. Treatment with antibiotics was continued for an average of 17.3 ± 11.1 days (7-

68), with a median of 14.5 days. Twenty-four of the patients (60% of the total) had an

uneventful hospital stay. Among the patients who received NSM, the complications

registered were one respiratory infection (2.5%), five patients (12.5%) relapsed at least

once after being discharged (there were no complicated AD in any of the readmitted

patients) and one patient died (2.5%) (this patient had acute myeloid leukemia and

was admitted with a stage Ia AD). Among those who received EST, complications

included one paralytic ileus (2.5%), one surgical wound infection (2.5%), one intra-

abdominal abscess that required percutaneous drainage (2.5%) and one patient who

required a second surgery (2.5%) due to a dehiscence of the primary anastomosis. In

the second group, one patient (2.5%) who had a pulmonary adenocarcinoma with

brain metastases and underwent a Hartmann's procedure died.

Age and gender

Of the patients who required an EST, 50% were male and 50% were female. The

average age of the patients with EST was 54 years old; the average age in the NSM

group was 65 years old (p = 0.013). When the patients were divided into age groups

(Fig. 2), the group aged 40-50 years was found to have a higher risk of being diagnosed

with stage II (CTR = 3.3) and stage IV (CTR = 2) AD, and a lower tendency of having

stage Ia disease (CTR = -3.3). Furthermore, there were significant differences in this

age group regarding surgical treatment, as EST was more frequently required than

NSM (CTR = 2.4). In addition, eleven out of the 12 cases (91%) older than 70 years of

age were diagnosed of with stage Ia AD (CTR = 2.3).

Cause of immunodeficiency

Patients with hematologic neoplasms, chronic corticoid treatment and CKD had higher

rates of stage Ia AD (100%, 83% and 75%, respectively). Meanwhile, the percentage of

patients with a previous transplant diagnosed with stage Ia non-complicated AD was

43% (CTR = -2.2). These patients had a higher risk of being diagnosed with stage IV AD

(80% of all patients with stage IV AD, CTR = 2.3) (Fig. 3). Regarding the need for an EST,

six patients (75%) had undergone a transplant, which amounted to 43% of the patients

in this group (CTR = 2.7). There were no statistically significant differences with regard

to the relationship between the transplanted organ and the severity of the disease or

the treatment received.

Risk factors for poor outcome of AD

There was a significant association in the CKDWOD group that favored EST (CTR = 2.9).

Both patients with this condition (100%) received an EST.

Recurrences

There were no statistically significant differences in any of the analyzed subgroups (p =

0.4).

DISCUSSION

According to previous studies, ID patients tend to have a more aggressive first episode

of AD, with higher mortality rates compared to IC patients (22). In our study, the

percentage of complicated AD was 35%, which is higher than the rate described in the

scientific literature for IC patients (12% according to the study of Fung et al. and 25%

as reported by Weizman et al.) (23,24). Patients with previous solid organ transplants

have a higher risk of a complicated AD and for the requirement of EST. A correlation

was observed between the younger age groups and a more severe presentation. The

opposite was also observed between more moderate presentations and the older age

groups.

In our experience, NSM with antibiotics, which was the treatment initially used in 80%

of our patients, showed satisfactory results and surgical treatment due to poor

progress was not required in any case. Twenty per cent required EST and Hartmann’s

procedure was the safest technique (25) (88% of the cases with initial EST) in the

context of severe intra-abdominal infection, patients with anastomosis dehiscence risk

factors and, occasionally, in patients with septic shock that required vasoactive drugs

during surgery. There were no cases of laparoscopic drainage and lavage. The

percentage of patients that required surgery was higher than for IC patients who

needed EST (20% vs 7-10%) (26-28). Among the RFPO for AD, the group with CKD

without dialysis had a higher risk of EST, in spite of the small sample size. No other

RFPO were found to be responsible for a higher risk of requiring initial EST, including

DM.

There was a global mortality of 5% during the acute episode for IC patients, which is

higher than in previously reported studies (29). The recurrence rate of 12.5% was

similar to that described in the literature for IC patients (around 10% in the first year)

(30). This percentage seems to be higher in patients with chronic corticoid treatment.

There is still controversy in the literature regarding patient management after an acute

episode has been resolved, with no clear guidelines to determine if elective surgical

treatment is indicated and when (31,32). There is evidence that colonic resection and

primary anastomosis is the preferred procedure when elective surgery is performed

(33,34).

Our study has some limitations. First, this was a retrospective study with a limited

number of patients and therefore, it is more difficult to obtain statistically significant

differences. Thus, further studies with larger sample sizes are needed. Furthermore,

this study was performed following the modified Hinchey classification for AD,

although other more modern classifications could have been used such as those

proposed by Sartelli et al. (35) or Mora et al. (modified Neff classification) (36).

Anyway, we believe our results are equivalent, considering uncomplicated AD

Hinchey’s stage Ia (Sartelli’s “uncomplicated”, modified Neff’s “stage 0”). A higher

proportion of complicated presentations would have required surgical treatment

(Hinchey’s stages Ib-IV, Sartelli’s complicated stages 1-4 and modified Neff’s stages 1-

4).

CONCLUSIONS

There are proportionally more complicated AD in ID patients than in the general

population. However, NST seems to be as safe as in IC patients, with the same

indications for surgical treatment in both groups. Recurrence rates are also similar,

which we believe does not justify performing surgery outside the actual guidelines for

the general population. Younger patients and those with a history of solid organ

transplants are the main groups with a higher risk of developing more severe episodes

that might require a more aggressive management when diagnosed.

REFERENCES

1. Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of

Western civilization. BMJ 1971;2:450-4. DOI: 10.1136/bmj.2.5759.450

2. Loffeld RJ, Van Der Putten AB. Diverticular disease of the colon and concomitant

abnormalities in patients undergoing endoscopic evaluation of the large bowel,

Colorectal Dis 2002;4(3):189e192. DOI: 10.1046/j.1463-1318.2002.00328.x

3. Warner E, Crighton EJ, Moineddin R, et al. Fourteen-year study of hospital

admissions for diverticular disease in Ontario. Can J Gastroenterol 2007;21:97-9. DOI:

10.1155/2007/943460

4. Humes DJ, Spiller RC. Review article: the pathogenesis and management of acute

colonic diverticulitis. Aliment Pharmacol Ther 2014;39:359-70. DOI: 10.1111/apt.12596

5. Biondo S, Parés D, Martí Rague J, et al. Acute colonic diverticulitis in patients under

50 years of age. Br J Surg 2002;89:1137-41. DOI: 10.1046/j.1365-2168.2002.02195.x

6. Brandl A, Kratzer T, Kafka-Ritsch R, et al. Diverticulitis in immunosuppressed

patients: a fatal outcome requiring a new approach? Can J Surg 2016;59(4):254-61.

DOI: 10.1503/cjs.012915

7. Hwang SS, Cannom RR, Abbas MA, et al. Diverticulitis in transplant patients and

patients on chronic corticosteroid therapy: a systematic review. Dis Colon Rectum

2010;53:1699 -707. DOI: 10.1007/DCR.0b013e3181f5643c

8. Dalla Valle R, Capocasale E, Mazzoni MP, et al. Acute diverticulitis with colon

perforation in renal transplantation. Transplant Proc 2005;37:2507. DOI:

10.1016/j.transproceed.2005.06.059

9. Sartelli M, Catena F, Ansaloni L, et al. WSES Guidelines for the management of acute

left sided colonic diverticulitis in the emergency setting. World J Emerg Surg

2016;11(1).

10. Medina Fernández FJ, Díaz Jiménez D, Gallardo Herrera AB, et al. New trends in the

management of diverticulitis and colonic diverticular disease. Rev Esp Enferm Dig

2015;107(3):162-70.

11. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid

diverticulitis. Dis Colon Rectum 2014;57:284-94. DOI:

10.1097/DCR.0000000000000075

12. Andeweg C, Wegdam J, Groenewoud J, et al. Toward an evidence-based step-up

approach in diagnosing diverticulitis. Scand J Gastroenterol 2014;49(7):775-84. DOI:

10.3109/00365521.2014.908475

13. Steele TA. Chemotherapy-induced immunosuppression and reconstitution of

immune function. Leuk Res 2002;26(4):411e414. DOI: 10.1016/S0145-2126(01)00138-

2

14. Böhm S. Risk factors for diverticulosis, diverticulitis, diverticular perforation, and

bleeding: a plea for more subtle history taking. Viszeralmedizin 2015;31(2):84-94. DOI:

10.1159/000381867

15. Turunen P, Wikström H, Carpelan-Holmström M, et al. Smoking increases the

incidence of complicated diverticular disease of the sigmoid colon. Scand J Surg

2010;99(1):14-7. DOI: 10.1177/145749691009900104

16. Papagrigoriadis S, Macey L, Bourantas N, et al. Smoking may be associated with

complications in diverticular disease. Br J Surg 1999;86:923-6. DOI: 10.1046/j.1365-

2168.1999.01177.x

17. Andersen JC, Bundgaard L, Elbrønd H, et al. Danish Surgical Society. Danish national

guidelines for treatment of diverticular disease. Dan Med J 2012;59:C4453.

18. Golda T, Kreisler E, Mercader C, et al. Emergency surgery for perforated

diverticulitis in the immunosuppressed patient. Colorectal Dis 2014;16:723-31. DOI:

10.1111/codi.12685

19. Fozard JB, Armitage NC, Schofield JB, et al. ACPGBI position statement on elective

resection for diverticulitis. Colorectal Dis 2011;13(Suppl 3):1-11. DOI: 10.1111/j.1463-

1318.2010.02531.x

20. Salem L, Flum D. Primary anastomosis or Hartmann’s procedure for patients with

diverticular peritonitis? A systematic review. Dis Colon Rectum 2004;47(11):1953-64.

DOI: 10.1007/s10350-004-0701-1

21. Janes S, Meagher A, Frizelle FA. Elective surgery after acute diverticulitis. Br J Surg

2005;92(2):133e142. DOI: 10.1002/bjs.4873

22. Biondo S, Borao J, Kreisler E, et al. Recurrence and virulence of colonic diverticulitis

in immunocompromised patients. Am J Surg 2012;204(2):172-9. DOI:

10.1016/j.amjsurg.2011.09.027

23. Fung A, Ahmeidat H, McAteer D, et al. Validation of a grading system for

complicated diverticulitis in the prediction of need for operative or percutaneous

intervention. Ann R Coll Surg Engl 2015;97(3):208-14. DOI:

10.1308/003588414X14055925061315

24. Weizman A, Nguyen G. Diverticular disease: epidemiology and management. Can J

Gastroenterol 2011;25(7):385-9. DOI: 10.1155/2011/795241

25. Rosado-Cobián R, Blasco-Segura T, Ferrer-Márquez M, et al. Enfermedad

diverticular complicada: toma de posición sobre tratamiento ambulatorio, intervención

de Hartmann, lavado-drenaje peritoneal y cirugía laparoscópica. Documento de

consenso de la Asociación Española de Coloproctología y Sección de Coloproctología

de la Asociación Española de Cirujanos. Cir Esp 2017;95(7):369-77. DOI:

10.1016/j.ciresp.2017.03.008

26. Cirocchi R, Afshar S, Di Saverio S, et al. A historical review of surgery for peritonitis

secondary to acute colonic diverticulitis: from Lockhart-Mummery to evidence-based

medicine. World J Emerg Surg 2017;12:14. DOI: 10.1186/s13017-017-0120-y

27. Tabbara M, Velmahos G, Butt M, et al. Missed opportunities for primary repair in

complicated acute diverticulitis. Surgery 2010;148(5):919-24. DOI:

10.1016/j.surg.2010.02.015

28. Biondo S, López Borao J, Millan M, et al. Current status of the treatment of acute

colonic diverticulitis: a systematic review. Colorectal Dis 2012;14:e1-11. DOI:

10.1111/j.1463-1318.2011.02766.x

29. Diamant MJ, Coward S, Buie WD, et al. Hospital volume and other risk factors for

in-hospital mortality among diverticulitis patients: a nationwide analysis. Can J

Gastroenterol Hepatol 2015;29(4):193-7. DOI: 10.1155/2015/964146

30. Andeweg CS, Mulder IM, Felt-Bersma RJF, et al. Guidelines of diagnostics and

treatment of acute left-sided colonic diverticulitis. Dig Surg 2013;30:278-92. DOI:

10.1159/000354035

31. Rose J, Parina R, Faiz O, et al. Long-term outcomes after initial presentation of

diverticulitis. Ann Surg 2015;262(6):1046-53. DOI: 10.1097/SLA.0000000000001114

32. Garfinkle R, Kugler A, Pelsser V, et al. Diverticular abscess managed with long-term

definitive nonoperative intent is safe. Dis Colon Rectum 2016;59(7):648-55. DOI:

10.1097/DCR.0000000000000624

33. Jurowich CF, Germer CT. Elective surgery for sigmoid diverticulitis - Indications,

techniques, and results. Viszeralmedizin 2015;31(2):112-6. DOI: 10.1159/000381500

34. Klarenbeek B, Samuels M, van der Wal M, et al. Indications for elective sigmoid

resection in diverticular disease. Ann Surg 2010;251(4):670-4. DOI:

10.1097/SLA.0b013e3181d3447d

35. Sartelli M, Moore F, Ansaloni L, et al. A proposal for a CT driven classification of left

colon acute diverticulitis. World J Emerg Surg 2015;10:3. DOI: 10.1186/1749-7922-10-3

36. Mora López L, Flores Clotet R, Serra Aracil X, et al. The use of the modified Neff

classification in the management of acute diverticulitis. Rev Esp Enferm Dig

2017;109(5):328-34. DOI: 10.17235/reed.2017.4738/2016

Table 1. Comparison between medical treatment vs emergency surgical treatment

Medical treatment Emergency surgical treatment

17 male

15 female

Sex 4 male

4 female

65 years old Average age 54 years old

11 days Average time of

admission

31 days

Hinchey

26 Ia 0

3 Ib 0

3 II 1

0 III 2

0 IV 5

Cause for immunosuppression

8 Transplant 6

6 Solid tumor 2

6 Corticoid therapy 0

6 Hematologic tumor 0

4 CKD 0

2 HIV 0

Patient’s progress

22 No complications 1

5 Recurrences 0

1 Deaths 1

Fig. 1. Management of the patients in our study.

Fig. 2. Emergency surgical treatment in the different age groups.

Fig. 3. Association between the cause of immunodeficiency and the severity of acute

diverticulitis.