Complicated diverticulosis

doi:10.1053/bega.2002.0305

Best Practice & Research Clinical Gastroenterology

Volume 16, Issue 4, August 2002, Pages 649-662

https://doi.org/10.1053/bega.2002.0305 Get rights and content

Abstract

‘Uncomplicated’ diverticulitis can be prevented from progressing into ‘complicated’ diverticulitis by early diagnosis and active medical treatment. Complicated diverticulitis develops from a peridiverticular abscess, to a perforation with peritonitis, to fistulation into adjacent viscera, to luminal narrowing by inflammation or stricture formation causing obstruction. Computer tomography (CT) scanning is the diagnostic imaging modality when diverticulitis is suspected and allows percutaneous drainage of peridiverticular abscesses that will enhance the effect of antibiotic therapy with resolution of the acute episode in 75% of patients. Thus, an emergent or urgent operation is converted to an elective operation and a two-stage operative procedure, namely a temporary stoma and a second operation, is avoided.

Interventional surgery is urgent for perforation and obstruction. While a Hartmann's resection and temporary colostomy has been the favoured operative procedure, under favourable conditions resection with primary anastomosis is preferable. Although a temporary stoma may be required with primary anastomosis, and hence the procedure is a two-stage one similar to a Hartmann's, the closure of the stoma is less demanding and has a lower morbidity. A single-stage resection and anastomosis is the standard elective treatment for symptomatic fistulas and strictures.

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Cited by (25)

Peritonitis and Intraperitoneal Abscesses
2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases
Digestive tumors and pseudotumors that rarely get discussed. Case 1: Colonic diverticulosis
2013, Annales de Pathologie
MR imaging of the colon: "Technique, indications, results and limitations"
2007, European Journal of Radiology
Citation Excerpt :
However, most patients with diverticulosis are asymptomatic without evidence of complications. Just 10–30% of the age group over 60 years develop an acute diverticulitis [16]. Complications of DD beside diverticulitis include stricture, peri-colic abscess, bleeding and perforation.
In the last few years virtual colonography using MR imaging has shown a proceeding development regarding detection and quantification of colorectal pathologies. Dark-lumen MR colonography (MRC) has been a leading tool for the diagnosis of the entire colon and their pathologies. This review article describes some of the underlying techniques of MRC concerning data acquisition, the need for intravenously applied paramagnetic contrast agent, as well as indications, results and limitations of MRC for the detection of colorectal pathologies. In addition, new techniques to improve patient acceptance are discussed.
Applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis
2006, Cirugia Espanola
El objetivo de este estudio es evaluar la aplicabilidad, la seguridad y la eficacia de un protocolo de tratamiento ambulatorio de la diverticulitis aguda no complicada.
Estudio prospectivo longitudinal. Se incluyó a todos los pacientes diagnosticados mediante tomografía computarizada abdominal de diverticulitis aguda no complicada durante un período de 2 años. Se excluyó a los pacientes que no toleraban la ingesta oral, que presentaban comorbilidades importantes o que no disponían de un entorno familiar adecuado. El tratamiento ambulatorio consistió en antibióticos por vía oral durante 1 semana (amoxicilina-clavulánico 1 g/8 h o ciprofloxacino 500 mg/12 h y metronidazol 500 mg/8 h en pacientes con alergia a la penicilina). Además se les indicó una dieta líquida durante los primeros 2 días y paracetamol 1 g/8 h por vía oral.
Se diagnosticó a 53 pacientes con diverticulitis aguda no complicada. Trece pacientes presentaban algún criterio de exclusión, por lo que se inició el tratamiento ambulatorio en 40 pacientes.
Tan sólo 2 pacientes (5%) precisaron ingreso hospitalario después de haber iniciado el tratamiento domiciliario, en un caso por persistencia del dolor y en otro por vómitos. En ambos casos, el tratamiento antibiótico intravenoso resolvió el proceso inflamatorio. En los 38 pacientes restantes (95%) se completó el tratamiento de forma satisfactoria y sin complicaciones.
El tratamiento ambulatorio de la diverticulitis aguda no complicada no sólo es eficaz y seguro, sino también aplicable en la mayoría de los pacientes, siempre que toleren la ingesta oral y dispongan de un entorno familiar adecuado.
The aim of this study was to evaluate the applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis.
All patients diagnosed with uncomplicated acute diverticulitis based on abdominal computed tomography findings during a 2-year period were prospectively included. Patients with vomiting, severe comorbidities, or without an appropriate family environment were excluded. Ambulatory treatment consisted of oral antibiotics for 1 week (amoxicillin-clavulanic 1 g t.i.d. or ciprofloxacin 500 mg b.i.d. plus metronidazole 500 mg t.i.d. in patients with penicillin allergy). A clear liquid diet for the first 2 days and pain control with oral acetaminophen 1 g t.i.d. were also recommended.
Fifty-three patients were diagnosed with uncomplicated acute diverticulitis and 13 patients were excluded. Therefore, ambulatory treatment was initiated in 40 patients. Only two patients (5%) required admission after outpatient therapy was started due to vomiting and persistent abdominal pain, respectively. In both patients, the inflammatory process was successfully resolved by intravenous antibiotic treatment. In the remaining 38 patients (95%), ambulatory treatment was completed without complications.
Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable in most patients with tolerance to oral intake and with an appropriate family environment.
Computed tomography in the imaging of colonic diverticulitis
2004, Clinical Radiology
Colonic diverticulitis occurs when diverticula within the colon become infected or inflamed. It is becoming an increasingly common cause for hospital admission, particularly in western society, where it is linked to a low fibre diet. Symptoms of diverticulitis include abdominal pain, diarrhoea and pyrexia, however, symptoms are often non-specific and the clinical diagnosis may be difficult. In addition, elderly patients and those taking corticosteroids may have limited findings on physical examination, even in the presence of severe diverticulitis. A high index of suspicion is required in such patients in order to avoid a significant delay in arriving at the correct diagnosis. Imaging plays an important role in establishing an early and correct diagnosis. In the past, contrast enema studies were the principal imaging test used to make the diagnosis. However, such studies lack sensitivity and have limited success in identifying abscesses that may require drainage. Conversely computed tomography (CT) is both sensitive and specific in making a diagnosis of diverticulitis. In addition, it is the imaging technique of choice in depicting complications such as perforation, abscess formation and fistulae. CT-guided drainage of diverticular abscesses helps to reduce sepsis and to permit a one-stage, rather than two-stage, surgical operation. The purpose of this review article is to discuss the role of CT in the imaging of diverticulitis, describe the CT imaging features and complications of this disease, as well as review the impact and rationale of CT imaging and intervention in the overall management of patients with diverticulitis.
Right Colon Diverticulitis
2004, Journal de Chirurgie
Les diverticulites du côlon droit sont rares en Occident : elles représentent environ 1 cas/300 appendicectomies contre 1 cas/40 à 1 cas/180 en Asie. La localisation préférentielle des diverticules sur le côlon droit chez les asiatiques est probablement liée à des facteurs génétiques. En Occident comme en Asie la diverticulose du côlon droit est cependant plus souvent responsable d’hémorragie digestive basse que de diverticulite.
Le pic de prévalence est de 40 à 45 ans avec un sexe ratio égal à 1.
Dans 70 à 100 % des cas les patients présentent les symptômes d’une appendicite aiguë, parfois d’une péritonite localisée, rarement d’un abcès du psoas ; une masse inflammatoire de la fosse iliaque droite est trouvée à l’examen clinique dans 1/4 à 1/3 des cas ; les péritonites généralisées, les abcès volumineux et les fistules sont exceptionnels.
La tomodensitométrie hélicoïdale est l’examen d’imagerie le plus performant pour évoquer ce diagnostic ; elle permet d’éliminer de nombreux diagnostics différentiels ; le principal étant un cancer colique droit perforé.
En cas de forme non compliquée et de diagnostic évoqué dès l’imagerie, un traitement conservateur est possible comme au cours d’une sigmoïdite ; une coloscopie réalisée à distance permet d’éliminer d’autres lésions coliques.
Dans la majorité des cas il s’agit d’une découverte opératoire au cours d’une appendicectomie par voie de Mac Burney ; la stratégie chirurgicale dépend alors du degré de suspicion du diagnostic et de l’extension des lésions, allant d’un traitement « conservateur » (appendicectomie), à un traitement chirurgical limité (diverticulectomie) à un traitement chirurgical étendu (résection iléo-caecale ou colectomie droite) ; en cas de forme compliquée (abcès, péritonite localisée) le traitement est souvent d’emblée chirurgical. Une stratégie thérapeutique reste à valider notamment depuis l’avènement de l’approche coelioscopique.
Diverticulitis involving the right colon is uncommon in the Occident ; only one case for every 300 cases of appendicitis occurs in Western countries compared to a ratio of 1/40-1/180 in Asia. The preferential localization of diverticula in the right colon among Asiatics is probably due to genetic factors. In Asia as in the West, a right colon diverticulum is more likely to cause hemorrhage than diverticulitis.
The peak age of symptoms is 40-45 years and the sex ratio is 1:1.
The patient most commonly presents with symptoms suggestive of acute appendicitis, acute localized peritonitis, or, more rarely, a psoas abscess. Clinical exam reveals an inflammatory mass in the right lower quadrant in 30 % of cases ; diffuse peritonitis, large abscesses, and fistulae are rare.
Helical CT scan is the best tool for extablishing the diagnosis and also helps to rule out other possible etiologies in the differential diagnosis––particularly a perforated right colon cancer.
In noncomplicated cases with convincing evidence for the diagnosis by CT scan, a conservative (non-surgical) treatment with antibiotics is possible ; a later stage colonoscopy will rule out other colonic lesions.
More commonly, the correct diagnosis is only made after embarking on an appendectomy via a McBurney incision ; the surgical strategy thereafter depends on the level of suspicion regarding the diagnosis and the extent and complexity of the diverticulitis. Therapeutic options may be conservative (appendectomy), limited (diverticulectomy, or extensive (ileocecal resection or right hemicolectomy). For complicated disease (abscess, localized perforation), an aggressive surgical approach is warranted.
Surgical strategies need to be validated, particularly in the light of the increasing use of the laparascopic approach for suspected appendicitis.

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Regular ArticleComplicated diverticulosis

Abstract

Clinics in Gastroenterology

American Journal of Surgery

American Journal of Medicine

American Journal of Surgery

Surgical Clinics of North America

Urology

Lancet

Gastrointestinal Endoscopy

Gastroenterology Clinics of North America

American Journal of Surgery

Current management of diverticulitis

Advances in Surgery

Diverticular disease of the colon; surgical perspectives in the past decade

Diseases of the Colon and Rectum

Diverticular disease of the colon

New England Journal of Medicine

Two kinds of diverticular disease

Annals of the Royal College of Surgeons of England

Diverticulitis; management patterns in a community hospital

Southern Medical Journal

Natural history of diverticular diseases. When to operate?

Diseases of the Colon and Rectum

Colonic diverticulosis in patients under age 40: need for earlier diagnosis

American Journal of Surgery

Complications of diverticular disease of the colon in young patients

Diseases of the Colon and Rectum

Practice parameters for sigmoid diverticulitis:

Diseases of the Colon and Rectum

Uncomplicated diverticulitis – indications for surgery and surgical management

Surgical Clinics of North America

Clinical behaviour of complicated right-sided and left-sided diverticulosis

Diseases of the Colon and Rectum

Acute diverticulitis: a complicated problem in the immunocompromised patient

Archives of Surgery

Treatment of diverticular disease of the colon

Archives of Surgery

Acute diverticulitis

New England Journal of Medicine

Radiological investigation in acute diverticulitis

British Journal of Surgery

Prospective evaluation of ultrasonography in acute colonic diverticulitis

British Journal of Surgery

Sonography in acute colonic diverticulitis – a prospective study

Diseases of the Colon and Rectum

Appendicitis and diverticulitis

Randomised prospective comparison of cefoxitin and gentamicin–clindamycin in the treatment of acute colonic diverticulitis

Clinical Therapy

A prospective randomised controlled trial of cefoxitin versus clindamycin–aminoglycoside in mixed anaerobic–aerobic infections

Surgery, Gynaecology, Obstetrics

Can sonography diagnose acute colonic diverticulitis in patients with acute intestinal inflammation? – a prospective study

Journal of Clinical Ultrasound

Accuracy of grey scale ultrasound diagnosis of abdominal and pelvic abscesses in 220 patients

Lancet

Incidence, outcome and proposed management of isolated abscesses complicating acute left-sided colonic diverticulitis: a prospective study of 140 patients

Diseases of the Colon and Rectum

Diverticular abscesses: percutaneous drainage

Radiology

Computed tomographic scan-guided drainage of intra-abdominal abscesses

Diseases of the Colon and Rectum

Surgical management of perforated colonic diverticulitis

Archives of Surgery

Surgical management of complicated diverticulitis: The Lahey Clinic experience, 1967–1982

Diseases of the Colon and Rectum

Emergency surgery for diverticular disease complicated by generalised and faecal peritonitis: a review

British Journal of Surgery

Sigmoid diverticulitis with perforation and generalised peritonitis

Diseases of the Colon and Rectum

Treatment of perforated sigmoid diverticulitis: a prospective randomised trial

British Journal of Surgery

Mannheim Peritonitis Index – prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index

Theoretical Surgery

Prediction of outcome using the Mannheim Peritonitis Index in 2003 patients

British Journal of Surgery

Multicentre randomised clinical trial of primary versus secondary sigmoid resection in generalised peritonitis complicating sigmoid diverticulitis

British Journal of Surgery

Surgical management of complicated colonic diverticulitis

British Journal of Surgery

Regular Article
Complicated diverticulosis