Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review

Abstract

Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.

The Multidisciplinary Management of Acute Complicated Diverticulitis

“…This peri- or paracolic abscess formation occurs in 15–40% of ACD cases and is caused by bacteria and inflammatory cells spreading into the mesocolon and peritoneal cavity [32]. Treatment choice in the acute setting depends on clinical presentation, size, and location of the abscess, as well as the amenability for PCD [32]. At present, no definite consensus has been reached on the optimal approach for this patient group, due to the lack of high-quality research [1].…”

“…At present, no definite consensus has been reached on the optimal approach for this patient group, due to the lack of high-quality research [1]. Definitions of a large abscess vary from 2 to 5 cm throughout the literature, but the cutoff value of > 4–5 cm is generally used in publications and guidelines [1, 5, 28, 32]. However, as supported by several international guidelines, small mesocolic abscesses can be treated with antibiotics alone, whereas larger mesocolic or pelvic abscesses require PCD [5].…”

“…In their systematic review, Gregersen et al [32] found that the nonoperative treatment failure rate, regardless of treatment choice, was 19–21% for both PCD and antibiotic treatment, with failure defined as emergency surgery, readmission or mortality within 30 days from initial treatment, residual abscess, or persistent symptoms. However, these results need to be carefully interpreted, because treatment groups may primarily reflect disease severity (indication/selection bias), since antibiotics were mainly used for smaller and primarily Hinchey Ib abscesses, and PCD for larger, Hinchey II abscesses.…”

“…However, these results need to be carefully interpreted, because treatment groups may primarily reflect disease severity (indication/selection bias), since antibiotics were mainly used for smaller and primarily Hinchey Ib abscesses, and PCD for larger, Hinchey II abscesses. Several reasons for treatment failure of PCD have been identified, such as a multiloculated or pelvic abscess occurrence, or patients with significant comorbidities [32, 41]. Jalouta et al [43] found a 77% recurrence-free survival after nonoperative treatment.…”

“…Jalouta et al [43] found a 77% recurrence-free survival after nonoperative treatment. Overall, a pooled recurrence rate of 25.5% is observed in the nonoperative treatment group, consisting of patients treated with antibiotics and/or PCD, whereas PCD and antibiotics alone have a pooled average recurrence rate of 15.9 and 22.2%, respectively [32]. However, the overall recurrence can get as high as 68%, especially in risk groups of patients with abscesses larger than > 5 cm or at pelvic or distant locations [32, 34].…”