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Long-Term Outcome of Mesocolic and Pelvic Diverticular Abscesses of the Left Colon: A Prospective Study of 73 Cases
Abstract
The aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon.
Between October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months.
of the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09).
Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.
... The number of patients with acute diverticulitis complicated by abscess was 16,401. One study only was a randomized controlled trial [63], five studies were prospective observational [13,31,37,53,61], and the remaining 38 were retrospective observational design studies [6, 14-16, 20-24, 30, 32-36, 38-52, 54-60, 62]. Seven of the included 44 studies were published before the year 2000 [13,14,37,45,48,57,58], 16 were published between 2000 and 2010 [6,15,30,31,33,35,39,42,46,47,50,51,[54][55][56]59], and the remaining 21 were published after 2010 [16, 20-24, 32, 34, 36, 38, 40, 41, 43, 44, 49, 52, 53, 60-63]. ...
... One study only was a randomized controlled trial [63], five studies were prospective observational [13,31,37,53,61], and the remaining 38 were retrospective observational design studies [6, 14-16, 20-24, 30, 32-36, 38-52, 54-60, 62]. Seven of the included 44 studies were published before the year 2000 [13,14,37,45,48,57,58], 16 were published between 2000 and 2010 [6,15,30,31,33,35,39,42,46,47,50,51,[54][55][56]59], and the remaining 21 were published after 2010 [16, 20-24, 32, 34, 36, 38, 40, 41, 43, 44, 49, 52, 53, 60-63]. Eighteen studies included patients with acute diverticulitis complicated by abscess only [13, 15, 20-23, 31, 32, 35, 40, 41, 43, 44, 49, 52, 59, 60, 63], whereas the remaining 26 studies also included patients with diverticulitis of other Hinchey classes [6, 14, 16, 24, 30, 33, 34, 36-39, 42, 45-48, 50, 51, 53-58, 61, 62]. ...
... Location of abscess in patients undergoing percutaneous drainage was reported in 4 studies (139 pericolic vs. 72 pelvic) [15,30,31,36]. In these studies, failure rates in pericolic abscesses ranged from 11.5 to 21.6% and in pelvic abscesses ranged from 9.1 to 81.8%. ...
Background
The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.Method
Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan–guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30–90 days of index admission. Data were stratified by three arbitrary time intervals: 1986–2000, 2000–2010, and after 2010. The primary outcome was calculated for those groups and compared.ResultsThirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000–2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).Conclusion
This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.
... CT scan was used to establish the diagnosis of acute diverticulitis complicated by abscess in all included studies. Rates of relapse were reported in 23 included studies (n = 12,391) [6,7,[11][12][13][14][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]. The pooled relapse rate was 18.85% (Fig. 1). ...
... The pooled relapse rate was 18.85% (Fig. 1). Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared to pericolic abscess (51% (31/61) vs. 18% (16/87); p = 0.0001) [11,12,25]. ...
... The pelvis abscess location showed almost three times higher failure rate of nonoperative management compared with pericolic location. This result was similar to a previous study comparing the failure rates of pelvic and pericolic abscess (39% vs 15%) [12]. The higher failure rate of the pelvic abscesses makes intuitive sense as the abscess formation more distant from the site of perforation may entail a more severe form of the disease presentation compared to pericolic abscesses. ...
PurposeThe aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess.Methods
Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30–90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition.ResultsTwenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001).Conclusion
The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.
... Although the incidence of acute diverticulitis (AD) has risen over the past few decades, particularly in younger patients, with 1/5 of them under 50 years old [1], the rate of emergency surgery has been dropping due to a major paradigm shift toward more conservative management approaches [2][3][4]. Evolving data on the natural history of AD has led to increased nonoperative management of the acute episode and long-term expectant strategy [2][3][4][5]. Still, the long-term management strategy after successful nonoperative treatment of AD remains unclear and indications for elective resection are a matter of ongoing debate. ...
... Although the incidence of acute diverticulitis (AD) has risen over the past few decades, particularly in younger patients, with 1/5 of them under 50 years old [1], the rate of emergency surgery has been dropping due to a major paradigm shift toward more conservative management approaches [2][3][4]. Evolving data on the natural history of AD has led to increased nonoperative management of the acute episode and long-term expectant strategy [2][3][4][5]. Still, the long-term management strategy after successful nonoperative treatment of AD remains unclear and indications for elective resection are a matter of ongoing debate. ...
Although the incidence of acute diverticulitis (AD) has risen over the past few decades, particularly in younger patients, the rate of emergency surgery has been dropping due to a major paradigm shift toward more conservative management approaches. The long-term management strategy after successful nonoperative treatment of AD remains unclear, and indications for elective resection are a matter of ongoing debate. Most modern professional guidelines advise considering elective surgery in an individualized approach, particularly after recovery of acute complicated diverticulitis (ACD) with abscess and in patients with recurrence, persisting symptoms, and complications such as abscess, fistula, and stenosis, focusing on the patient’s quality of life, where recurrence, severity, and symptoms are major determinants. However, guidelines are still not clearly standardized for appropriate decision-making, with patients being managed very differently from institution to institution, and surgeon to surgeon, mainly due to a lack of risk stratification for recurrence and severity that have been the scope of numerous studies but still need to be clarified. In this chapter, we explore the current surgical indications for AD, considering this disease’s ongoing prognostic factors, for proper decision-making.
... In conclusion only WSES 2020, based on 5 studies, reported a major cut-off of 4-5 cm as lower abscess diameter for percutaneous drainage [48][49][50][51][52]. ...
... WSES 2020 [48][49][50][51][52] "For patients with a small (< 4-5 cm) diverticular abscess, we suggest an initial trial of non-operative treatment with antibiotics alone (weak recommendation based on lowquality evidence, 2C). ...
... In conclusion only WSES 2020, based on 5 studies, reported a major cut-off of 4-5 cm as lower abscess diameter for percutaneous drainage [48][49][50][51][52]. ...
... WSES 2020 [48][49][50][51][52] "For patients with a small (< 4-5 cm) diverticular abscess, we suggest an initial trial of non-operative treatment with antibiotics alone (weak recommendation based on lowquality evidence, 2C). ...
Background: This systematic umbrella review aims to investigate whether provide an analysis of guidelines regarding the treatment of diverticular abscesses summarizing the evidences from the best available practice. Material and methods: A systematic literature search was performed until using the Cochrane Overviews of Reviews model for search the ‘Clinical Practice Guidelines’; at the end of initial search only 12 guidelines, whose characteristics are reported in the following table were included in this analysis. The quality of the guidelines was assessed by adopting the 2017 updated version of the “Appraisal of Guidelines for Research and Evaluation II” (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. Conclusions: Currently, a lot of scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only, few guidelines, suggest the use of percutaneous drainage for abscess with a diameter greater than 4 cm .The difference among guidelines is the consequence of the different selection of scientific evidences. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.
... Finally, current evidence [46] does not support the administration of antibiotics to improve outcomes in carefully selected healthy patients with uncomplicated ALCD. However, this evidence comes from young patients (mean age in AVOD trial: 57; age range in DIABOLO trial: [48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64]. For this reason, for elderly patients, the recommendation has very low-quality evidence. ...
... The treatment with percutaneous drainage has been considered the preferred treatment option since its dissemination and generally, a size of 4 cm has been considered as the cut-off for the indication to drain [48][49][50][51]. ...
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° (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.
... Approximately 15-20% of patients admitted with acute diverticulitis have an abscess on CT scan [18]. The size of 3-6 cm has been generally accepted (all of low level of evidence) to be a limit between antimicrobial therapy alone versus percutaneous drainage and antimicrobial in the management of diverticular abscesses [18][19][20][21][22]. ...
... Approximately 15-20% of patients admitted with acute diverticulitis have an abscess on CT scan [18]. The size of 3-6 cm has been generally accepted (all of low level of evidence) to be a limit between antimicrobial therapy alone versus percutaneous drainage and antimicrobial in the management of diverticular abscesses [18][19][20][21][22]. ...
Background In recent years, the emergency management of acute left colonic diverticulitis (ALCD) has evolved dramatically despite lack of strong evidence. As a consequence, management strategies are frequently guided by surgeon's personal preference, rather than by scientific evidence. The primary aim of IPOD study (Italian Prospective Observational Diverticulitis study) is to describe both the diagnostic and treatment profiles of patients with ALCD in the Italian surgical departments. Methods IPOD study is a prospective observational study performed during a 6-month period (from April 1 2015 to September 1 2015) and including 89 Italian surgical departments. All consecutive patients with suspected clinical diagnosis of ALCD confirmed by imaging and seen by a surgeon were included in the study. The study was promoted by the Italian Society of Hospital Surgeons and the World Society of Emergency Surgery Italian chapter. Results Eleven hundred and twenty-five patients with a median age of 62 years [interquartile range (IQR), 51-74] were enrolled in the IPOD study. One thousand and fifty-four (93.7%) patients were hospitalized with a median duration of hospitalization of 7 days (IQR 5-10). Eight hundred and twenty-eight patients (73.6%) underwent medical treatment alone, 13 patients had percutaneous drainage (1.2%), and the other 284 (25.2%) patients underwent surgery as first treatment. Among 121 patients having diffuse peritonitis, 71 (58.7%) underwent Hartmann's resection. However, the Hartmann's resection was used even in patients with lower stages of ALCD (36/479; 7.5%) where other treatment options could be more adequate. Conclusions The IPOD study demonstrates that in the Italian surgical departments treatment strategies for ALCD are often guided by the surgeon's personal preference.
... Abscess size of 3-6 cm is generally accepted as a reasonable cutoff determining the choice of treatment [5][6][7][8][9][10]. World Society of Emergency Surgery guidelines recommend antibiotics alone for abscesses with a diameter less than 4-5 cm [11]. ...
... Neither reports the number separately for large abscesses. In studies by Ambrosetti et al. [5] and Kaiser et al. [16], emergency surgery was required for 15% vs. 39% and 19% vs. 32% in Hinchey Ib and Hinchey II diverticulitis, respectively. These studies do not directly report abscess size for operated patients, but pelvic abscesses are generally larger than pericolic. ...
Background:
Diverticular abscess diameter of 3-6 cm is generally accepted as a cutoff determining whether percutaneous drainage is recommended in addition to antibiotics, but this is not based on high-quality evidence. The aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses.
Methods:
This was a retrospective cohort study conducted in an academic teaching hospital functioning as a secondary and tertiary referral center. Altogether, 241 patients with computer tomography-verified acute left-sided colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during 2006-2013. The main measured outcomes were need of emergency surgery and 30-day mortality, and these were compared between antibiotics only and percutaneous drainage groups. Treatment choices, including surgery, were also analyzed for all patients.
Results:
Abscesses under 40 mm were mostly treated with antibiotics alone with a high success rate (93 out of 107, 87%). In abscesses over 40 mm, the use of emergency surgery increased and the use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at 13-18% regardless of the abscess size. There were no differences in failure rate, 30-day mortality, the need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage vs. antibiotics alone, even when groups were adjusted for potential confounders.
Conclusions:
Percutaneous drainage as a treatment for large abscess does not seem to be superior to the treatment with only antibiotics.
... Методы диагностики дивертикулярной болезни ободочной кишки и ее воспалительных осложнений Точная диагностика дивертикулярной болезни и, особенно, ее осложнений, только на основании клинической картины заболевания в большинстве случаев невозможна [1,3,4,8,10,21]. С этой целью в клинической практике применяется целый ряд диагностических методов: ирригоскопия, колоноскопия, УЗИ, КТ и в последнее время МРТ [2,5,7,[11][12][13][14]15,16,21,26,39,40,42,45,56,64]. ...
... Методы диагностики дивертикулярной болезни ободочной кишки и ее воспалительных осложнений Точная диагностика дивертикулярной болезни и, особенно, ее осложнений, только на основании клинической картины заболевания в большинстве случаев невозможна [1,3,4,8,10,21]. С этой целью в клинической практике применяется целый ряд диагностических методов: ирригоскопия, колоноскопия, УЗИ, КТ и в последнее время МРТ [2,5,7,[11][12][13][14]15,16,21,26,39,40,42,45,56,64]. Ирригоскопия и колоноскопия имеют наиболее давнюю историю применения при дивертикулезе ободочной кишки, но обладают рядом недостатков, ограничивающих их диагностические возможности при осложненном течении заболевания. ...
... Follow-up after an episode of diverticulitis is essential to monitor for resolution of symptoms and assess the need for further interventions. Patients should be advised to maintain a high-ber diet and adequate hydration to prevent future episodes of diverticulitis (12). ...
Diverticulitis is a common gastrointestinal condition characterized by the inammation or infection of diverticula, small pouches that can develop in the colon wall. This narrative review provides a comprehensive overview of the pathophysiology, clinical presentation, and management of diverticulitis. The review includes a detailed discussion of the epidemiology, risk factors, and pathogenesis of the disease, highlighting the role of the gut microbiota and potential therapeutic targets. Diagnostic approaches and differential diagnoses are also discussed, emphasizing the importance of clinical assessment, imaging studies, and laboratory tests. Medical management options, including antibiotic therapy, bowel rest, and pain control, are outlined, along with surgical interventions for complicated cases. Finally, the review concludes with a discussion on the future directions of research in diverticulitis, focusing on the need for further understanding of the disease mechanisms and the development of novel therapeutic strategies.
... The collection size of 4 to 5 cm is considered amenable for managing with antibiotics +/-percutaneous drainage [43]. A study by Ambrosetti et al. concluded that 54% of patients treated with percutaneous drainage during the initial episode did not require surgical intervention [44]. ...
Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.
... The noted 59% overall incidence rate of acute complicated diverticulitis in patients diagnosed with COVID-19 represents a marked increase above the published overall incidence rate of 9-25%; however, this should be taken in the context of a more ill patient population in the acute and immediate post-acute infectious setting [14,15]. When examining the literature-reported incidence of individual complications of acute diverticulitis (abscess formation: 16-17%, intestinal perforation: 10%, peritonitis: 1-2%), patients who developed acute complicated diverticulitis within 30 days of COVID-19 infection were noted to have an elevated incidence (abscess formation: 37.0%, intestinal perforation: 39.5%, peritonitis: 14.8%), with intestinal perforation and abscess formation being the most common [14,16,17]. On subanalysis, the overall complication rate was found to be further elevated in patients with severe COVID-19 infection (indicated by the need for hospitalization) or those diagnosed with acute diverticulitis at the time of COVID-19 infection. ...
Background
Gastrointestinal manifestations of coronavirus disease 2019 (COVID-19) are increasingly recognized. Through potentially overlapping pathophysiology, co-occurrence of COVID-19 and first-time acute diverticulitis has been reported. Our study aims to further characterize this association in COVID-19-positive patients within a large tertiary care academic center.
Methodology
Patients diagnosed with COVID-19 who subsequently developed acute diverticulitis within 30 days were identified between 2020 and 2022. COVID-19 and acute diverticulitis were diagnosed by polymerase chain reaction and computed tomography, respectively. Patients with prior history of acute diverticulitis were excluded. Patient characteristics and comorbid conditions were collected. Characterization of the COVID-19 course (treatment setting, medical/ventilatory therapy) and acute diverticulitis (treatment setting, medical/surgical therapy, complications) was performed retrospectively. Subanalysis was performed by COVID-19 vaccination status, the severity of COVID-19, and the timing of acute diverticulitis diagnosis.
Results
A total of 81 patients were identified, with a median duration between COVID-19 diagnosis and acute diverticulitis of 13 days (interquartile range = 2.5-21.0), with 44.4% of patients requiring hospitalization for COVID-19. The all-cause complication rate of acute diverticulitis was noted to be 59.3%, most commonly intestinal perforation (39.5%), abscess formation (37.0%), and peritonitis (14.8%). Although a trend toward increased all-cause complications (65.9%), intestinal perforation (43.9%), and peritonitis (19.5%) was noted in unvaccinated patients, this did not reach significance. Although all-cause complication rate did not differ in patients diagnosed with acute diverticulitis at the time of COVID-19 presentation, a significantly elevated incidence of intestinal perforation (55.9% vs. 27.7%, p = 0.01), peritonitis (29.4% vs. 4.3%, p < 0.01), and the need for emergent surgical intervention (38.2% vs. 10.6%, p < 0.01) was noted.
Conclusions
Our study indicates that patients diagnosed with first-time acute diverticulitis within 30 days of COVID-19 infection have a high complication rate, most commonly intestinal perforation. Additionally, patients diagnosed with acute diverticulitis at the same time as COVID-19 detection had a significantly elevated rate of complications and emergent surgical needs. Given the high complication rate, patients who develop diverticulitis within a short timeframe of COVID-19 infection may benefit from increased clinician vigilance and monitoring.
... 28 CT-guided, interventional abscess relief can improve patient outcomes prior to surgery. [36][37][38] ...
Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.
... Acute diverticulitis affects approximately 4% of patients with diverticulosis [6]. 17% of individuals admitted to the hospital with acute diverticulitis develop diverticular abscesses [7]. Perforation with widespread peritonitis can occur when a diverticular abscess ruptures or when an inflammatory diverticulum ruptures freely. ...
Jejunal diverticulitis is a rare form of diverticulosis that occurs in the jejunum. Ileal diverticula are a type of false diverticula that are mostly asymptomatic and are usually discovered on imaging as incidental findings. Jejunal diverticula are typically difficult to diagnose pre-operatively due to their indolent and asymptomatic nature. The etiology of this condition is unclear, although some are believed to be genetic if diffuse. When symptomatic, patients may present with vague symptoms. This requires a high index of clinical suspicion because imaging results are usually negative. Management often requires surgical intervention in the presence of complications. Our case highlights a rare case of jejunal-ileal diverticulosis with inward involution causing Witzel tube (jejunostomy tube, or J-tube) obstruction and failure, along with partial obstruction of the small bowel.
... The size of 4-5 cm may be a reasonable limit between antibiotic treatment alone, versus percutaneous drainage combined with antibiotic treatment in the management of diverticular abscesses [136][137][138][139]. ...
Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.
... One important unanswered question which remains an issue of equipoise amongst colorectal surgeons is if or when to operate on patients presenting with a diverticular abscess. To date, the largest prospective study that included patients presenting with Hinchey Ib/II was published in 2005 by Ambrosetti et al [18]. Of those presenting with a pelvic abscess, 71% of patients required surgery either acutely or during the follow-up period. ...
Aim
Diverticular disease is an increasingly common problem in western society with a variety of treatment options for those presenting with acute diverticulitis, dependent on clinical presentation. Additionally, there is significant international variability in the index management, and few published data on real‐world clinical practice. The aim of DAMASCUS is to identify areas of practice variability and their potential association with differences in short‐ and medium‐term clinical outcomes.
Methods and analysis
DAMASCUS is an international, collaborative, prospective observational study, recruiting patients from over 200 sites across six continents. The study opened in October 2020, with a rolling start. Identification of new sites will cease in February 2021 and data collection will cease in August 2021. All adult patients diagnosed with acute diverticulitis (radiologically or intraoperatively) at each participating centre will be included. The primary objective of DAMSCUS is to assess for national and international variability in the presentation and index management of acute diverticulitis (medical, interventional radiology and surgical). Secondary objectives include assessing 30‐day and 6‐month clinical outcome data (re‐admission, re‐intervention, morbidity and mortality) and variations in surgical procedures for those undergoing surgery. All data will be recorded and managed using a secure REDCap electronic data capture tool and analysed using Stata (SE) version 16.1. The results will be reported in accordance with the STROBE statement.
Conclusion
By analysing variations in the management of acute diverticulitis and the subsequent outcomes, DAMASCUS will be an important step towards identifying optimal care for patients with diverticulitis.
... Overall the results suggest that percutaneous drainage is a safe option, reducing the need for surgery and a stoma in select patients. In an analysis of 73 patients, Ambrosetti et al. found that 54% of patients treated successfully with percutaneous drainage during their initial presentation did not require subsequent surgical intervention after a median follow-up of 43 months [41]. Those with pelvic abscesses were more likely to need surgery than those with mesocolic abscesses. ...
Purpose
Diverticular disease is a common acquired condition of the lower gastrointestinal tract that may be associated with significant morbidity. The term encompasses a spectrum of pathological processes with varying clinical manifestations. The purpose of this review was to update the reader on modern evidence-based treatment strategies for acute diverticulitis.
Methods
A literature search of the PUBMED database was performed using the keywords ‘diverticulosis’, ‘diverticular disease’ and ‘diverticulitis’. Only articles published in the English language were included.
Results
Evidence-based treatment strategies for acute diverticulitis have evolved over time. Data have questioned the need for antibiotic therapy for Hinchey I disease and the role of percutaneous abscess drainage for Hinchey II. Clinical trials have demonstrated laparoscopic lavage is an appropriate option for select patients with Hinchey III disease and primary resection with anastomosis and defunctioning stoma may be considered in some cases of Hinchey IV disease.
Conclusion
Risk-adapted treatment strategies and operative decision-making for acute diverticulitis are increasingly based on a combination of patient and disease factors.
... The size of 4-5 cm may be a reasonable limit between antibiotic treatment alone, versus percutaneous drainage combined with antibiotic treatment in the management of diverticular abscesses [58][59][60][61][62]. When the patient's clinical conditions allow it and percutaneous drainage is not feasible, antibiotic therapy alone can be considered. ...
Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.
... Overall, about 80-85% of individuals with diverticulosis will remain asymptomatic [2]. Acute diverticulitis occurs in about 4-5% of those with diverticulosis [7,8], of which 85% will manifest as uncomplicated disease [9]. The prevalence of diverticulosis increases progressively with age, affecting about 60% of adults over 60 years of age [5,6]. ...
Purpose of Review
While few diseases are limited solely to the elderly, diverticular disease is clearly more prevalent with increasing age and therefore the aim of this review is to focus on the clinical implications of diverticular disease in the elderly.
Recent Findings
Diverticulitis in the elderly is best managed with an individualized treatment approach including considerations for selective antibiotic usage even in uncomplicated disease. Furthermore, due to the increased prevalence of ischemic colitis in the elderly and the similarities in presentation with diverticular hemorrhage, there needs to be a high index of suspicion and appropriate evaluation for ischemic colitis in patients with hematochezia, particularly if they have abdominal pain.
Summary
The elderly are a vulnerable population where the index of suspicion for complications of diverticular disease should be high.
... Larger abscesses are less common and may be managed by percutaneous drainage on initial presentation or if medical management fails; failure of medical management alone is more likely in patients with abscesses larger than 5 cm in diameter. 33 Whereas some studies have reported that up to 70% of patients with abscesses ultimately undergo surgery, others have shown that fewer than half the patients had recurrent diverticulitis and that recurrences were effectively managed nonsurgically. 34,35 Before colonoscopy became widely performed (and covered by insurance) for screening purposes, this procedure was routinely recommended 6 to 8 weeks after resolution of an acute episode of diverticulitis, to rule out colon cancer. ...
An otherwise healthy 57-year-old man presents with a 48-hour history of pain in the left lower quadrant. He has had three previous episodes of sigmoid diverticulitis that were confirmed by computed tomographic (CT) scan and treated nonsurgically. He has localized tenderness in the left lower quadrant. The body temperature is 101.8°F (38.8°C), the heart rate 110 beats per minute, and the white-cell count 15,600 per cubic millimeter. A CT scan of the abdomen and pelvis with oral and intravenous contrast material shows microperforation of the middle portion of the sigmoid colon, air bubbles in the adjacent colonic mesentery, thickening of the sigmoid wall, and pericolonic fat stranding, without free fluid. How would you manage this patient's condition?
Sigmoid diverticulitis can potentially lead to the development of pelvic abscesses. Mortality rate from intra-abdominal abscesses is as high as 35%, and patients with diverticulitis complicated by an abscess are at a high risk of recurrent diverticulitis. Recently, image-guided drainage has been performed using computed tomography or ultrasonography for the treatment of pelvic abscesses. Standard radiological pelvic abscess image-guided drainage methods consist of transabdominal, transgluteal, or cranio-caudal puncture approaches. However, these standard approaches have technical limitations due to intrapelvic organ structures. Therefore, we performed image-guided drainage using a percutaneous trans-bladder approach with a simpler 1-step puncture method and a less invasive 7-Fr drainage catheter in 2 cases of a 72-year-old female and a 53-year-old female with relapsed pelvic abscesses complicated by sigmoid diverticulitis due to difficulties involving the standard approach. The abscesses in both cases disappeared on follow-up computed tomography scans, demonstrating no pelvic abscess recurrence. Our results showed that trans-bladder image-guided drainage is an effective alternative method for treating pelvic abscesses.
Acute left colonic diverticulitis (ALCD) is one of the most common clinical conditions encountered by surgeons in the acute setting.The diagnosis can often be made based on clinical features alone, but imaging is necessary in more severe presentations to rule out complications such as abscess and perforation. The treatment of diverticulitis depends on the severity of the presentation, presence of complications, and underlying comorbid conditions.KeywordsAcute diverticulitisPeritonitisAbscesses
Acute left colonic diverticulitis (ALCD) is a common clinical condition encountered by physicians in the emergency setting. Clinical presentation of ALCD ranges from uncomplicated acute diverticulitis to diffuse fecal peritonitis. ALCD may be diagnosed based on clinical features alone, but imaging is necessary to differentiate uncomplicated from complicated forms. In fact, computed tomography scan of the abdomen and pelvis is the highest accurate radiological examination for diagnosing ALCD. Treatment depends on the clinical picture, the severity of patient's clinical condition and underlying comorbidities. Over the last few years, diagnosis and treatment algorithms have been debated and are currently evolving. The aim of this narrative review was to consider the main aspects of diagnosis and treatment of ALCD.
Background
Diverticulitis is one of the most diagnosed gastrointestinal diseases in the country, and its incidence has risen over time, especially among younger populations, with increasing attempts at non-operative management. We elected to look at acute diverticular disease from the lens of a failure analysis, where we could estimate the hazard of requiring operative intervention based upon several clinical factors.
Materials and Methods
The National Inpatient Sample (NIS) was queried between 2010 and 2015 for unplanned admissions among adults with a primary diagnosis of diverticulitis. We used a proportional hazards regression to estimate the hazard of failed non-operative management from multiple clinical covariates, measured as the number of inpatient days from admission until colonic resection. We also evaluated patients who received percutaneous drainage, to investigate whether this was associated with decreasing the failure rate of non-operative management.
Results
A total of 830,993 discharges over the study period, of whom 83,628 (10.1%) underwent operative resection during the hospitalization, and 35,796 (4.3%) patients underwent percutaneous drainage. Half of all operations occurred by hospital day 1. Among patients treated with percutaneous drainage, 11% went on to require operative intervention. The presence of a peritoneal abscess (HR 3.20, P < .01) and sepsis (HR 4.16, P < .01) were the strongest predictors of failing non-operative management. Among the subset of patients with percutaneous drains, the mean time from admission to drain placement was 2.3 days.
Conclusion
Overall 10.1% of unplanned admissions for diverticulitis result in inpatient operative resection, most of which occurred on the day of admission. Percutaneous drainage was associated with an 11% operative rate.
Diverticular disease is one of the most common problems encountered by general surgeons and gastroenterologists. The term refers to complications that occur from colonic diverticulosis. In diverticular colonic disease the sigmoid colon is usually the most commonly involved, while right acute colonic diverticulitis is rarer. In establishing the diagnosis of ALCD, objective clinical examination plays an important role in addition to biological paraclinical examinations (C-reactive protein - CRP and increased leukocyte count) and radiological paraclinical examinations: CT abdomen. CRP is a useful tool in predicting the clinical severity of acute diverticulitis. The treatment applied to patients with uncomplicated colonic diverticular disease can be represented by antibiotic therapy, water regime, hydro-electrolytic rebalancing. In patients with multiple comorbidities, hemodynamic instability, the Hartmann procedure is recommended for the treatment of acute peritonitis caused by perforated colonic diverticulitis and in hemodynamically stable patients without comorbidities, colonic resection with primary anastomosis with or without stoma is suggested.
Left-sided colonic diverticulitis represents one of the most common gastrointestinal conditions diagnosed in industrialized societies. Our understanding of the pathophysiology and management of this disease have changed over the past two decades. This chapter will review the epidemiology and pathophysiology of the disease. The current status of medical and surgical management is also discussed.
Diverticular disease is the most common morphological abnormality of the colon. It is increasing in prevalence proportionally to progressive aging and modern alimentary diet. The majority of the diverticular disease affects the sigmoid colon and the segmental inflammatory process can have different outcomes, from self-limited, low-grade inflammation to severe cases evolving to complications such as abscess, fistulas to different organs, free perforation and peritonitis, sepsis, intestinal obstruction, and hemorrhage. In this chapter, we will focus on a few of these complications—focal low-grade inflammation, intra-abdominal abscess, and fistulas.
Introduction:
Although contrast-enhanced abdominal computed tomography (CEACT) is still considered the gold standard for the assessment of suspected acute diverticulitis, in recent years the use of point-of-care ultrasound (POCUS) has been spreading more and more in this setting. The aim of this study is to compare CEACT to POCUS for the diagnosis and staging of suspected acute diverticulitis.
Methods:
This is a prospective study conducted on 55 patients admitted to the Emergency Department of two Italian Hospitals with a clinical suspicion of acute diverticulitis between January 2014 and December 2017. All the patients included underwent POCUS first and CEACT immediately afterwards, with the diagnosis and the staging reported according to the Hinchey (H) classification modified by Wasvary et al. Three surgeons performed all the POCUS and the same two radiologists retrospectively analyzed all the CEACT images. The radiologists were informed of the clinical suspicion but unaware of the POCUS findings. The CEACT was used as the gold standard for the comparison.
Results:
The final cohort included 30 (55%) females and 25 (45%) males. The median age was 62 (24-88) and the median body mass index was 26 (19-42).Forty-six out of 55 patients had a confirmed diagnosis of acute diverticulitis on both POCUS and CEACT, whereas in seven patients the diagnosis was not confirmed by both methods. POCUS sensitivity and specificity were 98% and 88% respectively. POCUS positive and negative predictive values were 98% and 88% respectively. POCUS accuracy was 96%.POCUS classified 33 H1a, 11 H1b, 1 H2 and 1 H3 acute diverticulitis. This staging was confirmed in all patients but three (93%) by CEACT.
Conclusions:
Point-of-care ultrasound appeared a reliable technique for the diagnosis and the staging of clinically suspected H1 and H2 acute diverticulitis. It could contribute in saving time and resources and in avoiding unnecessary radiation exposure to most patients.
Level of evidence:
Level III.
Study type:
Diagnostic test.
La enfermedad diverticular es muy prevalente con gran repercusión económica y médica. A pesar de las múltiples guías para protocolizar el diagnóstico y tratamiento no existe unanimidad en su manejo.Hemos realizado una revisión actualizada con el objetivo de analizar los nuevos estudios de esta enfermedad, para manejarla adecuadamente y realizar el tratamiento más adecuado en cada momento.La enfermedad diverticular tiene un componente hereditario (40%) y presenta una relación directa con la dieta pobre en fibra, la obesidad, el consumo de carne roja, la inactividad, el alcohol y los AINEs. Por su clínica inespecífica, es difícil realizar un diagnóstico diferencial. La ecografía y el TC abdominal son métodos apropiados para el diagnóstico y se recomienda una colonoscopia de manera precoz (4ª-8ª semana) tras el cuadro agudo. La clasificación más seguida es la de Hinchey.En el tratamiento médico de la diverticulosis sintomática no se ha demostrado evidencia clara de ningún medicamento. La diverticulitis aguda no complicada se puede manejar ambulatoriamente y no es necesario el uso de antibióticos en pacientes sin factores de riesgo.En la diverticulitis complicada se tiende a un manejo conservador, aunque en el Hinchey III y IV el tratamiento es quirúrgico, recomendando la resección de la zona afecta y si es posible anastomosis con o sin estoma de protección. No se recomienda el lavado y drenaje en el Hinchey III. Hay que consensuar tratamiento de forma individualizada ya que no se recomienda tratamiento quirúrgico por el número de recurrencias ni por edad del paciente.
Intra-abdominal and anorectal abscesses are common pathologies seen in both inpatient and outpatient settings. To decrease morbidity and mortality, early diagnosis and treatment are essential. After adequate drainage via a percutaneous or incisional approach, patients need to be monitored for worsening symptoms or recurrence and evaluated for the underlying condition that may have contributed to abscess formation.
Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.
Diverticulosis is an anatomic change in the colon that is characterized by outpouching of the mucosa and submucosa through the muscularis. Its prevalence increases with age so most of the elderly patients have this condition. Although diverticulosis is common, diverticular disease, in which there are clinical sequelae, is rare. This collective term includes diverticulitis, diverticular hemorrhage and less well-defined entities such as segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Diverticulitis presents as acute lower abdominal pain, and initial management traditionally includes antibiotics, with surgery reserved for complicated disease, although newer evidence questions the optimal role and timing of both interventions.
Despite the high success rate of initial nonoperative management in patients with a diverticulitis-related pericolonic abscess, about 20% of these patients will require urgent colectomy. While recurrence rates after successful medical management of diverticular abscesses are high, it is within the standard of care to consider both interval elective resection and long-term nonoperative management. In summary, a decision regarding elective resection after successful nonoperative management of diverticular abscess should balance the individual patient's risk of recurrence and the associated potential morbidity and mortality versus the risk of an elective surgery.
Diverticulitis is a common problem resulting in more than 300,000 hospital admissions in the United States each year. Approximately 1% to 4% of patients with diverticulosis develop diverticulitis, and approximately one-third of colectomies and colostomies in the United States are performed for diverticular disease. The clinical presentation varies from mild abdominal pain to generalized peritonitis. The chapter updates our current recommendations and changing guidelines for this common disease.
The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.
Background:
There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis.
Objective:
The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management.
Data sources:
PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019.
Study selection:
Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available.
Interventions:
Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered.
Main outcome measures:
The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model.
Results:
There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias.
Limitations:
There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%).
Conclusions:
Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon.
Prospero:
CRD42019131673.
Purpose: The purpose of this study was to evaluate the disease pattern and treatment of diverticular abscesses.
Methods: Patients treated for diverticulitis (K57) in Västmanland, Sweden were identified for this retrospective population-based study between January 2010 and December 2014. Patients with diverticular abscesses were included. The clinical and radiological data were extracted, and the computed tomography scans were reevaluated.
Results: Of the 75 patients (45 women) with a median age of 62 years (range: 23–88 years), abscesses were localized pericolic in 42 patients (59%) and in the pelvis in 33 patients (41%). The median abscess size was 4.8 cm (range: 1.1–11.0 cm). Six patients (8%) required urgent surgical intervention during the index admission. The median follow-up time was 58 months (range: 0–95 months). During follow-up, 40 patients (58%) had disease recurrence and 35 of these patients (88%) presented with complicated diverticulitis. The median time until re-admission was 2 months (range: 3 days–94 months). Patients with pelvic abscesses developed fistulas more frequently, 3 versus 11 patients (p = .003). Twenty-three percent of patients with pericolic abscesses required surgery compared with 40% of patients with pelvic abscesses (p = .09). No patients had a recurrence of abscesses after a colonic resection.
Conclusion: The majority of patients with diverticular abscesses had recurrences with repeated admissions regardless of abscess location. An unexpectedly high proportion of patients required surgical intervention during the follow-up period. A liberal approach regarding elective surgery for patients with recurrent diverticulitis abscesses who tolerate surgery seems justified.
Es gibt heute zahlreiche wissenschaftliche Untersuchungen zu oralen Probiotika bei unterschiedlichen Erkrankungen sowie zu deren Wirkmechanismen. Inzwischen ist bekannt, dass die Wirksamkeit von probiotischen Bakterien sowohl stamm- als auch krankheitsspezifisch ist.
The understanding of and medical treatment for diverticulitis has evolved significantly in recent years. The progression from asymptomatic diverticulosis to diverticulitis is less than was previously thought. Emerging evidence suggests uncomplicated diverticulitis may not require antibiotics. Despite these changes, the central tenet in the treatment of sigmoid diverticulitis remains unchanged, with a focus on the patient’s clinical status. This is paramount as laboratory and radiographic findings may not predict clinical course. To this end, diverticulitis should be approached in an algorithmic manner and individualized based on the patient’s presentation.
Acute diverticulitis attacks are frequently seen in modern healthcare facilities. The disease presents with a spectrum of symptoms from mild inflammation and abdominal pain to life-threating bowel perforation, sepsis, and peritonitis. Clinical evaluation and medical imaging play an important role in stratifying the disease into different categories based on severity which help guide specific therapies ranging from supportive outpatient care to image-guided percutaneous drainage, to emergent surgery, and to intensive care unit admissions. Antibiotic selection plays an important role in the treatment and prevention of infection and sepsis. Percutaneous drainage is a low-risk technique to achieve source control in most patients with diverticular abscess formation, facilitating a more rapid recovery. Historically many patients with complicated diverticular disease were treated with surgery; however, a better understanding of the pathophysiology and innovative therapies such as percutaneous drainage has allowed patients to be stabilized in the acute setting and undergo a one-stage elective surgery later on.
This multicentre retrospective cohort study included 447 patients with Hinchey Ib and II diverticular abscesses, who were treated with antibiotics, with or without percutaneous drainage. Abscesses of 3 and 5 cm in size were at higher risk of short-term treatment failure and emergency surgery respectively. Initial non-surgical treatment of Hinchey Ib and II diverticular abscesses was comparable between patients treated with antibiotics only and those who underwent percutaneous drainage in combination with antibiotics, with regard to short- and long-term outcomes. Most do not need drainage.
© 2019 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.
Acute diverticulitis is a common ailment that is seen frequently by general and colorectal surgeons. The underlying etiology of diverticulitis remains unknown despite the frequency of this diagnosis. In the emergency setting, patients must be immediately stratified into stable and unstable, as this will determine the treatment pathway. Those that are stable require full work-up to assess the severity of disease. Treatment options can include outpatient antibiotics, inpatient admission and IV antibiotics, abscess drainage, and non-emergent surgery. Those that are unstable require immediate resuscitative efforts and may require emergency operation. While Hartmann’s procedure remains the gold standard, there are several operative options that are available to be utilized in select clinical settings. Elective surgery is frequently required but is beyond the scope of this discussion.
Background
Studies examining long‐term outcomes following resolution of an acute diverticular abscess have been limited to single‐institution chart reviews. This observational cohort study compared outcomes between elective colectomy and non‐operative management following admission for an initial acute diverticular abscess.
Methods
The Statewide Planning and Research Cooperative System was queried for unscheduled admissions for an initial acute diverticular abscess in 2002–2010. Bivariable and propensity‐matched multivariable analyses compared stoma rates and use of healthcare in patients who had an elective resection and those receiving non‐operative management. Diverticulitis recurrence rates were analysed for non‐operative management.
Results
Among 10 342 patients with an initial acute diverticular abscess, one‐third (3270) underwent surgical intervention within 30 days despite initial non‐operative management. Of the remaining 7072 patients, 1660 had an elective colectomy within 6 months. Of 5412 patients receiving non‐operative management, 1340 (24·8 per cent) had recurrence of diverticulitis within 5 years (median 278 (i.q.r. 93·5–707) days to recurrence). Elective colectomy was associated with higher stoma rates (10·0 per cent, compared with 5·7 per cent for non‐operative observation, P < 0·001; odds ratio 1·88, 95 per cent c.i. 1·50 to 2·36), as well as more inpatient hospital days for diverticulitis‐related admissions (mean 8·0 versus 4·6 days respectively, P < 0·001; incidence rate ratio (IRR) 2·16, 95 per cent c.i. 1·89 to 2·47) and higher mean diverticulitis‐related cost (€70 107 versus €24 490, P < 0·001; IRR 3·11, 2·42 to 4·01).
Conclusion
Observation without elective colectomy following resolution of an initial diverticular abscess is a reasonable option with lower healthcare costs than operation.
• We undertook this study to determine whether a computed tomography—guided, percutaneous preoperative drainage of a peridiverticular abscess can safely allow a one-stage procedure in patients requiring surgery for acute diverticulitis. In 17 patients evaluated prospectively by computed tomography, thin-needle aspiration demonstrated purulent fluid collection in 11 patients. Percutaneous catheter drainage was undertaken in eight patients. In the three remaining patients, the abscess was either too small to warrant drainage or no safe access route was present. Seven of eight patients had a single-stage resection within one to three weeks of percutaneous catheter drainage. There were no complications. Our studies suggest that a combined radiological-surgical approach has the potential to reduce morbidity and hospital costs without increasing mortality in the management of perforated colon diverticulitis with associated abscess formation.
(Arch Surg 1986;121:475-478)
In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10–47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary,en blocresection with immediate anastomosis can usually be safely performed. Pelvic and intra-abdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.
The American Journal of Gastroenterology is published by Nature Publishing Group (NPG) on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, the journal aims to be easily accessible, organizing its content by topic, both online and in print. www.amjgastro.com, *2007 Journal Citation Report (Thomson Reuters, 2008)
Background: In the large bowel, resection of the sigmoid colon is the most commonly performed laparoscopic intervention because large bowel lesions often are located in this part of the bowel and the procedure technically is the most favorable one. A number of publications involving case series or the results of highly experienced individual surgeons already have confirmed the feasibility of laparoscopic resection in cases of diverticulitis. The aim of the present prospective multicentric investigation was to check the results obtained by a large number of surgeons performing laparoscopic resection of the sigmoid colon for diverticulitis in various stages of severity.
PURPOSE: The most valuable radiologic examination to be done initially when acute left colonic diverticulitis is suspected is still a matter of controversy. This study compares the performance between water-soluble contrast enema and computed tomography. METHODS: From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a contrast enema and a computed tomography within 72 hours of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiologic examinations showed signs of acute diverticulitis or diverticulitis was surgically removed and histologically proven or both. Diverticulitis was considered moderate when computed tomography showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and contrast enema showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess or extraluminal air or contrast or all three were observed on computed tomography and when one or both of the last two signs were seen on contrast enema. Of 542 patients, 420 who had both computed tomography and contrast enema entered the study. RESULTS: The performance of computed tomography was significantly superior to contrast enema in terms of sensitivity (98vs. 92 percent;P=0.01), which was calculated from patients who had their colon removed and whose diverticulitis was histologically proven, and in the evaluation of the severity of the inflammation (26vs. 9 percent;P=0.02). Moreover, of 69 patients who had an associated abscess seen on computed tomography, only 20 (29 percent) had indirect signs of this complication on contrast enema. CONCLUSIONS: In the diagnostic evaluation of acute left-colonic diverticulitis, computed tomography should be preferred to contrast enema as the initial radiologic examination because of its statistically significant superiority in sensitivity and for its significantly better performance in the detection of severe infection, especially when an abscess is associated with the disease.
Background: With the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease, this consensus development conference set out to summarize the actual state of the art.
Methods: A multidisciplinary panel of international experts (n= 16) was selected to take part in the consensus process. Prior to the conference, all experts were asked to answer a series of questions on diverticular disease. The consensus statement compiled out of these evaluations was modified during a joint meeting of the panel members, then presented for discussion in a public session, and finally revised by the expert panel. The finalized statement was mailed to all panel members for approval (Delphi method).
Results: Asymptomatic diverticulosis, diverticular disease (with actual or recurrent symptoms), and complicated diverticular disease were defined separately. No agreement was reached on whether barium enema or colonoscopy is the better choice as an initial diagnostic tool in uncomplicated cases. In complicated cases, computed tomography is recommended for diagnosis. After two attacks of diverticular disease, elective resection should be considered. For patients in whom a concomitant carcinoma cannot be excluded and those with chronic complications (fistula, stenosis, or bleeding) surgery is also indicated. Laparoscopic sigmoid colectomy is recommended only for uncomplicated and, after percutaneous drainage of abscesses, Hinchey stage I and II cases.
Conclusions: Laparoscopic surgery has already begun to influence the management of diverticular disease, but the randomized controlled trials needed to support therapy decisions are largely missing.
Diverticular disease of the colon now is recognized to be functional disease resulting from altered neuromuscular activity in the colon. Inflammatory complications, when they occur, usually result from inflammation around a single diverticulum. This may lead to the formation of a pericolic or pelvic abscess. Free perforation of these leads to purulent peritonitis. The original communication with the lumen of the bowel usually is obliterated. More rarely, with either rapid evolution or failure of the diverticular neck to obliterate, a free communication develops between the bowel lumen and the peritoneal cavity, leading to fecal peritonitis. Fecal peritonitis results in an extremely high mortality rate. The operative approach for a patient with perforated diverticular disease should be individualized and depends on the stage of the disease present, the general condition of the patient, the experience of the surgeon in colon surgery and the availability of facilities and personnel to provide intensive care. In larger institutions when these conditions are optimal, primary resection of the diseased bowel with or without anastomosis is becoming the procedure of choice. In smaller institutions or if conditions are not optimal, right transverse colostomy with drainage of the perforated segment can be relied on to control the disease with a mortality rate compared to that of primary resection. If free perforation and fecal peritonitis are present, exteriorization or primary resection of the perforated segment must be carried out. We would not recommend primary anastomosis under these circumstances.
In a prospective evaluation of 140 consecutive patients with acute left-sided colonic diverticulitis demonstrated by computerized tomography (CT) in all cases, 22 (16 percent) were found to have an associated abscess without peritonitis. Thirteen of these 22 required surgery (seven during the first stay and six from 2 to 11 months after the acute episode; median, three months). Nine patients were treated conservatively, eight of whom are now totally asymptomatic 24 months after the initial attack (range, 10-47 months). There were 10 mesocolic abscesses (seven treated with antibiotics alone), nine pelvic abscesses (seven requiring surgery), and three intra-abdominal abscesses, all operated upon. These results suggest that mesocolic abscesses can usually be managed conservatively without drainage; should surgery be necessary, en bloc resection with immediate anastomosis can usually be safely performed. Pelvic and intraabdominal abscesses behave more aggressively and usually require a two-stage surgical procedure when initial percutaneous drainage cannot be performed or is felt to be hazardous.
To define the role of percutaneous catheter drainage in the initial management of diverticular abscess, we reviewed 19 patients who were followed for an average of 17.4 months after drainage. All patients had large paracolic or pelvic abscesses with a mean size of 8.9 cm. There were no complications related to catheter placement, and 15 patients (79 percent) required drainage for less than 3 weeks. Sepsis resolved rapidly, and only two patients (11 percent) had persistent fever or leukocytosis beyond the third day of drainage. Routine sinography revealed fistulous communications to the colon in nine patients (47 percent), but only three (16 percent) had grossly feculent drainage. Fourteen patients (74 percent) completed the treatment plan of preoperative catheter drainage followed by single-stage sigmoid colectomy and primary anastomosis without complications. Two patients refused operation, one of whom died 16 days postoperatively from recurrent sepsis and end-stage pulmonary disease. The three patients with fecal fistulas all had inadequate control of infection, suggesting the need for early operation and fecal diversion in such cases. We conclude that preoperative percutaneous catheter drainage obviates the need for colostomy and multiple-stage surgery in approximately three-fourths of patients with large diverticular abscesses.
Twenty-four patients with acute sigmoid diverticulitis and associated pelvic fluid collections seen on computed tomographic scans underwent percutaneous catheter drainage as an adjunct to surgical therapy. Fourteen of the 24 underwent a single-stage surgical procedure within 10 days of drainage. Five patients required two-stage surgical procedures because localized inflammatory changes precluded a primary resection despite the absence of a residual abscess at surgery. Two of the three remaining patients initially had no surgery, but they had recrudescences of their symptoms that required surgical drainage within 8 months. One patient in whom surgical resection was deferred remained asymptomatic 10 months after percutaneous drainage. A retrospective review of 87 patients undergoing surgery for diverticulitis suggested that the percentage of two-stage surgical procedures has decreased in the last 5-10 years, but there remains a substantial number of patients who might benefit from percutaneous catheter drainage of diverticular abscess of the sigmoid colon.
Percutaneous catheter drainage was performed in 16 patients with diverticulitis complicated by abscesses. Each patient had resolution of fever within 72 hours. Eleven patients subsequently underwent simultaneous sigmoid resection and operative anastomosis 10-40 days after percutaneous drainage. One patient required a three-stage procedure after percutaneous drainage, and one patient was too unstable for operation at any time during her course and eventually died of respiratory failure. Three patients did not undergo resection after catheter drainage and have remained asymptomatic for 1-2 1/2 years. Ten of 16 patients had fistulas, eight of which closed spontaneously. Experience with percutaneous drainage of diverticular abscesses suggests that it obviates surgical abscess drainage and permits a single operation (sigmoid resection and closure) to be performed safely. Percutaneous abscess drainage has cost-saving implications, since one or two operations may be avoided in most patients, and in some high-risk elderly patients all operations may be obviated.
We undertook this study to determine whether a computed tomography-guided, percutaneous preoperative drainage of a peridiverticular abscess can safely allow a one-stage procedure in patients requiring surgery for acute diverticulitis. In 17 patients evaluated prospectively by computed tomography, thin-needle aspiration demonstrated purulent fluid collection in 11 patients. Percutaneous catheter drainage was undertaken in eight patients. In the three remaining patients, the abscess was either too small to warrant drainage or no safe access route was present. Seven of eight patients had a single-stage resection within one to three weeks of percutaneous catheter drainage. There were no complications. Our studies suggest that a combined radiological-surgical approach has the potential to reduce morbidity and hospital costs without increasing mortality in the management of perforated colon diverticulitis with associated abscess formation.
This paper includes a brief historic summary of the surgical aspects of diverticular disease and of corresponding developments in the Massachusetts General Hospital from 1911 to the present. The 350 cases observed in 1974-1983 are compared with 338 seen in the previous decade. Major trends include a decrease in hospital admissions for diverticular disease but a sustained number of operations; increased severity of the disease in hospitalized patients manifested by an increased percentage of patients with immunosuppression or serious other diseases (p less than 0.001), an increased number with sepsis and general peritonitis (p less than 0.001); an increased percentage of cases with one-stage resection and anastomosis (p less than 0.02); in patients with general peritonitis, resection of the perforated segment at the time of the original operation was accompanied by the lowest mortality (p less than 0.02); incidental splenectomy appears to be dangerous, with three deaths in eight cases; and overall mortality in the last decade is 6.4%; for emergency cases 10.2%, for urgent 9.7%, and for elective cases 2.4%.
During the past decade, primary resection with anastomosis has gained acceptance in the surgical treatment of complications arising from diverticular disease of the colon. We have reviewed our experience during the past 10 years to determine whether this approach has clinical validity. Of 673 patients followed over a 10-year period, 93 (14%) required operation. Operative indications were generally limited to urgent complications of the disease: abscess (36), bleeding (18), perforation (10), obstruction (10), and fistula (5). A small group of patients underwent operation for recurrent symptoms (7) and for the suspicion of coexistent carcinoma (8). Initial operative management included resection with anastomosis (44), resection and colostomy (26), and diverting colostomy (23). The overall incidence of complications was significant; the most common complication was infectious in nature: abscess (7), fistula (9), wound infection (11), dehiscence (2), and sepsis (5). Complications were more numerous in patients who did not receive primary resection of the diseased segment 2.1 versus 1.1 complications per patient, respectively), and the duration of hospitalization was significantly greater in this group as well. The perioperative mortality rate of our surgical patients was 6.4%; none of these deaths were associated with resection and anastomosis. These data indicate that resection with primary anastomosis is a sound approach in properly selected patients with urgent complications of diverticular disease, and that aggressive surgical management can yield results that are better than those obtained from the use of colostomy alone.
Perforative diverticulitis often requires emergency surgical intervention. The principles of surgical management, such as whether the perforation communicates between the lumen of the colon and the peritoneal cavity or whether a mesenteric or pericolic abscess is present, are explained. The surgical options relative to such disorders as phlegmonous masses, acute diverticulitis with peritonitis, and nonperforated diverticulitis are thoroughly explicated.
It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
The use of laparoscopic peritoneal lavage in conjunction with parenteral fluids and antibiotic therapy in the management of generalized peritonitis secondary to perforated diverticular disease of the colon was assessed.
This cohort comprised 8 patients with generalized peritonitis secondary to perforated diverticular disease of the left colon that was diagnosed laparoscopically. All the patients had purulent peritonitis, but no fecal contamination. They were treated with laparoscopic peritoneal lavage and intravenous fluids and antibiotics.
All patients made a complete recovery, with resumption of normal diet within 5 to 8 days. No patient has required surgical intervention during a 12- to 48-month follow-up. This approach merits further assessment as an alternative to the traditional open surgical management.
The use of computed tomography (CT) in acute left colonic diverticulitis remains controversial. The purpose of this study was to define the value of CT both during the acute phase of inflammation and, later, to indicate secondary complications after successful medical treatment.
Some 423 patients with radiologically or histologically proven diverticulitis were studied prospectively from 1986 to 1995. Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat; it was considered severe when abscess and/or extraluminal air and/or extraluminal contrast were observed.
The sensitivity of CT was 97 per cent. Of 42 patients who failed conservative treatment, 32 had severe diverticulitis on CT, compared with 74 (24 per cent) of 303 who had successful conservative treatment (P < 0.0001). After a median follow-up of 46 months, 60 (20 per cent) of 300 patients had secondary complications despite initially successful conservative treatment: 28 (47 per cent) of these had initial severe diverticulitis on CT compared with 44 (19 per cent) of 236 patients who had no complications (P < 0.0001).
Abscess formation and extracolonic contrast or gas are findings that may be used to predict failure of medical treatment during the first admission and a high risk of secondary complications after initially successful medical management of acute diverticulitis.
Expanding upon our experience with laparoscopic surgery for colonic benign and malignant processes and for bowel obstruction, we have reviewed our experience with minimal access laparoscopic surgery for complicated diverticular disease. We propose an approach of surgical care incorporating diagnostic laparoscopy in those not responding to medical therapy alone.
Our study includes data from two different surgical teams working in separate hospital-and-patient environments. Our theory that laparoscopy could be widely applicable to this complex disease process is borne out by experience in both locations. One hundred forty-eight patients were managed by laparoscopic or laparoscopically assisted methods with 18 patients requiring drainage only without resection.
Our management of 148 of 164 patients (90%) by laparoscopic approach was successful, with a very acceptable morbidity of 5% in the elective cases and decreased ileus (20% of open vs 7% laparoscopic) in acute complicated cases. Elective resections required hospitalization of 4-5 days, demonstrating the benefits of incorporating laparoscopy in the care of these cases, particularly when compared to standard open procedures requiring 8 days' hospitalization.
We believe complications of diverticular disease including abscess, perforation, fistula, and bleeding can potentially be managed in this way by minimal access procedures, decreasing postoperative wound problems, decreasing length of hospitalization and overall morbidity, and improving patient care.
We prospectively evaluated a helical CT technique in which contrast material is administered only through the colon for the imaging of suspected diverticulitis.
One hundred fifty consecutive patients who presented to our emergency department with clinically suspected diverticulitis underwent helical abdominal CT after contrast material was administered only through the colon. CT findings of diverticulitis included diverticula, muscular wall hypertrophy, focal colonic wall thickening, and pericolonic fat stranding. CT results were correlated with clinical follow-up (all patients) and with pathologic findings (41 patients).
A final clinical diagnosis of diverticulitis was made in 64 patients (43%), of whom 62 (97%) had CT results positive for diverticulitis. Of the 86 patients for whom diverticulitis was clinically excluded, all (100%) had CT results that were negative for diverticulitis. CT interpretations had a sensitivity of 97%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 98%, and an overall accuracy of 99%. Alternative diagnoses were noted on CT in 50 (58%) of 86 patients who did not have diverticulitis and included 50 (78%) of the 64 patients in whom an alternative condition other than nonspecific abdominal pain was established.
Helical CT obtained after contrast material administered only through the colon is accurate (99%) for confirming or excluding clinically suspected diverticulitis and for suggesting alternative conditions (78%) when they are present. This CT technique avoids the risks, discomforts, and costs of oral and i.v. contrast material administration and allows immediate scanning.
With the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease, this consensus development conference set out to summarize the actual state of the art.
A multidisciplinary panel of international experts (n = 16) was selected to take part in the consensus process. Prior to the conference, all experts were asked to answer a series of questions on diverticular disease. The consensus statement compiled out of these evaluations was modified during a joint meeting of the panel members, then presented for discussion in a public session, and finally revised by the expert panel. The finalized statement was mailed to all panel members for approval (Delphi method).
Asymptomatic diverticulosis, diverticular disease (with actual or recurrent symptoms), and complicated diverticular disease were defined separately. No agreement was reached on whether barium enema or colonoscopy is the better choice as an initial diagnostic tool in uncomplicated cases. In complicated cases, computed tomography is recommended for diagnosis. After two attacks of diverticular disease, elective resection should be considered. For patients in whom a concomitant carcinoma cannot be excluded and those with chronic complications (fistula, stenosis, or bleeding) surgery is also indicated. Laparoscopic sigmoid colectomy is recommended only for uncomplicated and, after percutaneous drainage of abscesses, Hinchey stage I and II cases.
Laparoscopic surgery has already begun to influence the management of diverticular disease, but the randomized controlled trials needed to support therapy decisions are largely missing.
In the large bowel, resection of the sigmoid colon is the most commonly performed laparoscopic intervention because large bowel lesions often are located in this part of the bowel and the procedure technically is the most favorable one. A number of publications involving case series or the results of highly experienced individual surgeons already have confirmed the feasibility of laparoscopic resection in cases of diverticulitis. The aim of the present prospective multicentric investigation was to check the results obtained by a large number of surgeons performing laparoscopic resection of the sigmoid colon for diverticulitis in various stages of severity.
Between January 8, 1995 and January 1, 1998, the Laparoscopic Colorectal Surgery Study Group recruited 1,118 patients to the prospective multicenter study. Diverticulitis of the sigmoid colon, which accounted for 304 cases, was the most common indication for laparoscopic intervention. In most of these patients undergoing laparoscopic surgery (81.9%), the diverticulitis manifested as acute phlegmonous peridiverticulitis, recurrent attacks of inflammation, or stenosis. Complicated forms of diverticulitis in Hinchey stages I to IV and late complications of chronic diverticular disease with fistula formation and bleeding accounted for only 18.1% of the cases. For the overall group, the conversion rate was 7.2%. Patients with less severe diverticulitis (i.e., those presenting with peridiverticulitis, stenosis, or recurrent attacks of inflammation) had a conversion rate of 4.8% and the rate for complicated cases was 18.2%. Regarding laparoscopically completed interventions, 3 of 282 patients died (1.1%). In the group of patients with peridiverticulitis, stenosis, or recurrent attacks of inflammation the overall complication rate was 14.8%. The group with perforated diverticulitis in Hinchey stages I to IV or those with fistula and bleeding, the corresponding rate was 28.9%, and after conversion it was 31.8%.
Laparoscopic colorectal interventions in sigmoid diverticulitis are, for the most part, carried out as elective procedures for peridiverticulitis, stenosis, or recurrent attacks of inflammation. The conversion, complication, and mortality rates associated with these interventions are acceptable. Laparoscopic procedures in Hinchey stages I to IV sigmoid diverticulitis and in the presence of fistula and bleeding are more likely to be associated with complications, and should be carried out only by highly experienced laparoscopic surgeons.
The classic treatment of generalized peritonitis due to perforation of sigmoid diverticula is based on the principle of a two-stage surgery with a temporary derivation of the colonic transit. This procedure is associated with a prohibitively high immediate and delayed morbidity, especially associated with the abdominal wound. The laparoscopic approach to this complication is less aggressive and allows a second-stage elective laparoscopic resection. Eighteen consecutive patients (ten women and eight men; average age, 53.7 years) underwent emergency laparoscopic treatment for generalized peritonitis due to perforated diverticula. Eight of these patients had previously had diverticulitis attacks. By peritoneal cavity exploration and full peritoneal lavage (average, 15 L), the infected sigmoid lesion was stuck with biologic glue. A drain was inserted at the site of the lesion and in some cases also in other abdominal zones. No colostomy was necessary. Antibiotic treatment was started at diagnosis and continued for a minimum of 7 days. There was no mortality. Morbidity was limited to three patients (two cases of lymphangitis and one of pulmonary disease). No patient had a wound abscess or residual deep collections. The mean hospitalization was 8 days. Fourteen patients underwent elective laparoscopic sigmoid resection with a delay of 3.5 months. One conversion to laparotomy was necessary. The laparoscopic treatment of generalized peritonitis due to perforated sigmoid diverticula is an interesting alternative to the traditional treatment. It is associated with a lower morbidity, a shorter postoperative hospital stay, and an improvement in the patient's quality of life, because colostomy is avoided. It is also associated with economic savings.
The most valuable radiologic examination to be done initially when acute left colonic diverticulitis is suspected is still a matter of controversy. This study compares the performance between water-soluble contrast enema and computed tomography.
From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a contrast enema and a computed tomography within 72 hours of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiologic examinations showed signs of acute diverticulitis or diverticulitis was surgically removed and histologically proven or both. Diverticulitis was considered moderate when computed tomography showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and contrast enema showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess or extraluminal air or contrast or all three were observed on computed tomography and when one or both of the last two signs were seen on contrast enema. Of 542 patients, 420 who had both computed tomography and contrast enema entered the study.
The performance of computed tomography was significantly superior to contrast enema in terms of sensitivity (98 vs. 92 percent; P = 0.01), which was calculated from patients who had their colon removed and whose diverticulitis was histologically proven, and in the evaluation of the severity of the inflammation (26 vs. 9 percent; P = 0.02). Moreover, of 69 patients who had an associated abscess seen on computed tomography, only 20 (29 percent) had indirect signs of this complication on contrast enema.
In the diagnostic evaluation of acute left-colonic diverticulitis, computed tomography should be preferred to contrast enema as the initial radiologic examination because of its statistically significant superiority in sensitivity and for its significantly better performance in the detection of severe infection, especially when an abscess is associated with the disease.
Diverticular disease is common among the elderly. Because of the advanced age and muted symptoms and signs of many of those affected, diagnosis can be difficult. Consequently, great demands are placed on the physician to diagnose and treat clinically evident diverticular disease. Endoscopic, radiologic, and surgical advances have increased the availability of more definitive therapies for patients with complicated diverticular disease and diverticular hemorrhage.
The aim of this study was to compare the performance of the CT and the water-soluble contrast enema (CE) in the diagnosis and the severity of acute left-colonic diverticulitis, and to recognize the impact of CT during the acute phase and after a first acute episode successfully treated medically. From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a CE and a CT within 72 h of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiological exams showed signs of acute diverticulitis and/or diverticulitis was surgically removed and histologically proven. Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and CE showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess and/or extraluminal air and/or contrast were observed on CT and when one or both of the latter signs were seen on CE. Five hundred forty-two patients entered the study; 465 patients (86%) had a CT exam, 439 (81%) had a CE, and 420 (77%) had both exams. The performance of CT is significantly superior to CE in terms of sensitivity (98 vs 92%, p<0.01), and in the evaluation of the severity of the inflammation (26 vs 9%, p<0.02). Moreover, of 69 patients who had an associated abscess seen on CT, only 20 (29%) had indirect signs of this complication on CE. During the acute phase the chances of medical treatment failure are statistically greater when diverticulitis is considered severe on CT than when it is considered moderate (26% for the severe diverticulitis vs 4% for the moderate ones, p<0.0001). After successful medical treatment of the acute episode, patients with severe diverticulitis on the CT had statistically greater incidence of secondary bad outcome than patients with moderate diverticulitis (36 vs 17%, p<0.0001). Computed tomography should be preferred to CE as the initial radiological exam of diverticulitis because of its statistically significant superiority in sensitivity and for its statistically much higher performance in the detection of severe infection, especially when an abscess is associated with the disease. The severity of diverticulitis on CT is statistically predictive of the risk of medical treatment failure during the acute phase and of the chances of bad secondary outcome after a successful medical treatment of the first episode.
Diverticular disease is a common finding in Western countries with an increasing prevalence with age. Many patients with the disorder remain asymptomatic. However, up to 30% of those affected may show clinical signs including pain, bleeding, obstruction, abscess, fistulae and perforation. The purpose of this chapter is to review the epidemiology, pathogenesis, clinical presentation, diagnostic regimens and treatment options for this disorder.
This prospective study evaluated the use of multi-slice CT (MSCT) for detection of clinically suspected left-sided colonic diverticulitis with regard to diagnosis, complications and alternative diagnoses. One hundred twenty patients with clinically suspected acute left-colonic diverticulitis underwent MSCT of the lower abdomen with IV contrast after rectal application of iodic contrast. The MSCT results were compared with histopathological and intraoperative findings or other radiological or endoscopic methods and clinical outcome. Acute diverticulitis was proven in 67 of the 120 (55.8%) patients, which was detected by MSCT with an accuracy of 98% (sensitivity 97%, specificity 98%). Contained perforation or abscess formation were detected with an accuracy of 96% (sensitivity 100%, specificity 91%) and 98% (sensitivity 100%, specificity 97%), respectively. In 31 of 120 (25.8%) patients diagnoses other than diverticulitis caused abdominal pain, which was correctly diagnosed by MSCT in 71%. The MSCT as well as other concurrently performed diagnostic methods showed normal findings and no causes for the patients symptoms in 22 of the 120 (18.4%) patients. Multi-slice CT is reliable in detecting diverticulitis, including extracolic complications, and often reveals other diagnoses; therefore, MSCT is recommended as standard diagnostic procedure in suspected acute diverticulitis.
Laparo-scopic management of generalized peritonitis due to perforated colonic diverticula
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O'Sullivan GC, Murphy O, O'Brien MG, et al. Laparo-scopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996;171: 432–4.