Presentation, Management and Outcome of Acute Sigmoid Diverticulitis Requiring Hospitalization

Álvarez, José Antonio; Baldonedo, Ricardo F.; Bear, I. García; Otero, Jorge Pombo; Pire, Gerardo; Álvarez, Pablo Rebollo; Jorge, Jose I.

doi:10.1159/000111823

Cited by 35 publications

(35 citation statements)

References 35 publications

(46 reference statements)

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“…It is well known that there is a high morbidity and mortality after emergency surgery for diverticular disease (72 and 6%, respectively) [41]. After elective surgery, the figures are also high with morbidity over 50% and mortality between 1 and 5% [36,42].…”

Section: Complications After Elective Surgerymentioning

confidence: 99%

The Surgeon’s View

Senapati

2012

Dig Dis

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Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics.

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Section: Complications After Elective Surgerymentioning

confidence: 99%

The Surgeon’s View

Senapati

2012

Dig Dis

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“…These, however, are not conditioned by antecedent attacks [6,32,36,44]. In fact, the lack of antecedent episodes is statistically more indicative for a complicated course [39].…”

Section: What Are the Prevalence And Prognosis Of Recurrent Diverticumentioning

confidence: 99%

The Gastroenterologist’s View

Lembcke¹

2012

Dig Dis

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The traditional view that recurrent episodes of diverticulitis lead to progressively complicated disease resulting in a disadvantageous course, more difficult, complicated operations and lethal outcomes did not stand the test of evidence. Only a minority of patients with acute diverticulitis will ever require surgery, and if so, this occurs during or early after the first episode. Complications and recurrence of disease after surgery are enumerable. Strong indicators favoring sigmoid colectomy are major abscess, free air, and fistula, i.e. perforating disease. This occurs predominantly at the initial presentation, frequently in younger or immunosuppressed patients. Important differential diagnoses must be considered both for initial diagnosis of diverticulitis and for recurrent episodes. Conservative management of recurrent diverticulitis is safe and best guided by gastroenterological expertise. Sophisticated ultrasound experience as a part of this competence allows detailed evaluation of the local status and the best evidence in the literature for diagnosing diverticulitis is on US. In practice, however, the question of perforating diverticulitis is adequately answered by subtle CT scan. Medical therapy is usually the treatment of choice for recurrent diverticulitis. Avoidance of drugs bearing the hazard of perforation (e.g. NSAIDs) is emphasized, and smoking is strongly discouraged. A mathematical model based on published data shows that patients with recurrent diverticulitis overall (only) profit from surgery if they are hit by four episodes during the course of disease. This is where theory and reality (should) meet.

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“…Owing to the prevalence of diverticulitis, and its high prevalence of perforation in patients older than 60 years, it is very important to get a gastrointestinal history when dealing with anyone presenting with such abdominal complaints. 2,3,6 Since necrotizing infections are considered a surgical emergency, it is also important to find the source of infection and consult surgery services emergently so as not to delay surgical intervention. 5 …”

Section: Discussionmentioning

confidence: 99%

Right-Sided Sigmoid Diverticular Perforation

Little¹,

Culver²

2012

WestJEM

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Diverticulosis is a common disorder among geriatric patients, of whom 10% to 25% go on to develop diverticulitis. Known complications of diverticulitis include formation of phlegmon, fistula, bowel obstruction, bleeding, perforation, and colonic abscess. A less common complication is perforation with formation of an extra-abdominal necrotizing abscess. This case is a report of an 83-year-old female who presented to the emergency department with a necrotizing abdominal wall abscess secondary to right-sided diverticular microperforation.

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Presentation, Management and Outcome of Acute Sigmoid Diverticulitis Requiring Hospitalization

Cited by 35 publications

References 35 publications

The Surgeon’s View

The Surgeon’s View

The Gastroenterologist’s View

Right-Sided Sigmoid Diverticular Perforation

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