Diverticulitis

Simple

The treatment of uncomplicated diverticulitis is relatively straight-forward in most cases. Patients usually respond to broad spectrum antibiotics (ciprofloxocin 500 mg twice daily combined with metronidazole 500 mg 4 times daily) given orally in an outpatient setting. Many practitioners choose to also limit the patient's diet during the first 48 to 72 hours of treatment depending on the severity of symptoms. Diet alterations may include keeping the patient on liquids, with or without high calorie supplements such as Ensure, or simply a low residue diet devoid of fiber. Pain control is important, especially if the patient is ill enough to be admitted to the hospital. If patients respond clinically in the first 48 to 72 hours with significant resolution of symptoms, they are generally transitioned back to a regular diet and eventually to a high fiber diet.

Patients who do not respond to conservative management as an outpatient should be considered for inpatient treatment with IV antibiotics and possibly more severe diet restrictions with the addition of parenteral nutrition. Morphine should be avoided as it has the side effect of increasing colonic intralumenal pressure, which can actually worsen the inflammatory process. Meperidine or Toradol are better choices for analgesia in patients with acute diverticulitis. Repeat CT imaging should also be considered as a lack of resolution of symptoms may indicate a complication, such as abscess or free perforation, that needs to be addressed. Failure to resolve an acute, uncomplicated episode of diverticulitis is an indication for elective resection. However, in our experience it is unusual for patients to fail to respond to aggressive treatment with IV antibiotics and complete bowel rest with the addition of TPN in the absence of complicated disease.

After resolution of the acute inflammatory process, the colon should be imaged to rule out the possibility of cancer and to evaluate the extent of disease. Colonoscopy is probably the best test, especially in patients over 50 years of age who have never been screened for colon cancer. Barium enema may suffice in younger patients, although the presence of any mucosal abnormalities would necessitate an endoscopic study for further examination and biopsy if appropriate.

Complicated

Any complication associated with diverticulitis is an indication for resection of the diseased segment, although the goal should be to approach the procedure in an elective setting after complete bowel prep and proper medical clearance of the patient. If managed properly most patients with complicated diverticulitis, even those with free perforation, can be treated with a single stage procedure that avoids colostomy.

Patients who present with stricture or fistula associated with diverticular disease often do not have signs and symptoms of acute inflammation or active diverticulitis. Stricture is usually the result of recurrent episodes of acute inflammation resulting in thickening and fibrosis of the wall of the colon. Most patients present with signs of partial colonic obstruction that can be documented by both CT or water soluble contrast enema. Patients who develop colonic fistulas as a result of diverticular disease can present with a variety of complaints depending on the site of the fistula. Air in the urine (pneumaturia) or stool in the urine (fecaluria) are common complaints of patients who present with a colovesical fistula, and, although these are relatively benign complaints, urosepsis can also develop as a result of chronic contamination of the urinary tract. Female patients may complain of vaginal discharge if a colovaginal fistula is present, and weight loss with chronic diarrhea can be the result of a functional intestinal bypass if a proximal enterocolonic fistula is present. Demonstration of the fistula tract on contrast studies may not always be successful, even with an obvious clinically symptomatic fistula.

Treatment of both stricture and fistula consists of elective resection of the diseased colonic segment with primary anastomosis. Due to the often chronic nature of these complications, diet alterations and long term antibiotic therapy are often not needed in the preoperative period. However, if the fistula or stricture is associated with acute inflammation, TPN, bowel rest, and antibiotics are indicated prior to surgery. Management of the affected secondary organ in fistula disease can vary depending on the size of the fistula. Small defects in the bladder or vagina can be closed primarily if there is minimal surrounding inflammation. Placement of a drain in the area is suggested and if the bladder is repaired primarily, an indwelling foley catheter should be left in place for 5 to 7 days. Placement of ureteral stents is recommended when approaching any case of complicated diverticular disease to aid in identification of the ureters and to ensure that if ureteral damage occurs it will be identified. Colonic stenting has no place in the long term treatment of stricture secondary to diverticular disease but may be used as a temporizing measure to allow for mechanical preparation prior to elective colon resection.

Patients who present with abscess or free perforation as a result of diverticular disease are generally more acutely ill and have signs and symptoms of acute diverticulitis. Localized abdominal pain may progress to more diffuse peritoneal signs with unstable vital signs if free perforation is present. Abscess should be suspected if patients fail to respond to appropriate therapy for presumed uncomplicated diverticulitis. The ultimate goal in treatment of colonic perforation and abscess is resection of the affected segment. In the past this was accomplished with a two or three stage procedure that involved temporary diversion of the fecal stream. However, the advent of radiologic techniques for drainage of abscess and more aggressive preop-erative and operative management of these patients, the treatment of perforation and abscess associated with diverticular disease has certainly been in evolution.

The current approach to an abscess associated with diverticular disease is generally antibiotics, bowel rest, and drainage of larger abscesses via interventional radiologic techniques. After an abscess is diagnosed by CT scan patients are made NPO and started on appropriate IV antibiotic therapy. Small abscesses (< 4cm) will often resolve with this approach alone and after 5 to 7 days of therapy, patients should be re-evaluated with a second CT scan to ensure resolution. Persistent abscesses my require drainage, whereas those that are resolving will likely continue to do so with continued medical management alone. Larger abscesses (> 4 cm) should be drained early in the course of treatment, as they are unlikely to resolve with medical therapy alone. The length of time needed for bowel rest will vary from case to case but if patients are improving after 5 to 7 days of bowel rest and IV antibiotics, they can usually be transi-tioned to a liquid diet with high calorie shake supplements and oral antibiotics. Timing of elective resection will vary but should be delayed until complete resolution of the abscess, and significant improvement of the surrounding inflammatory process can be documented a soft, nontender abdomen on physical examination is reassuring. Colonoscopy should also be considered prior to elective resection in those patients who have not had a full colonic evaluation in the past 12 months.

Free intraperitoneal perforation of the colon associated with acute diverticulitis has generally been treated with emergent resection of the colon with diversion of the fecal stream (Hartmann's procedure, Figure 103-4). This approach has been met with a great deal of success with respect to patient survival. However, it does result in a colostomy and the need for a second major abdominal procedure in order to restore intestinal continuity. We have recently been approaching this situation differently in an attempt to manage free perforation associated with acute diverticulitis with a single stage procedure that can be performed electively and avoids colostomy. Most patients who present with free intraperitoneal air associated with acute diverticulitis are stable and despite the free perforation have only localized peritoneal signs. Many of these patients are noted to have free air only because of improvements in diagnostic techniques such as CT scanning. It is our belief that in most of these patients the area of perforation has already been sealed secondary to surrounding inflammation and that the only treatment required is strict bowel rest and antibiotic therapy in the initial stages of presentation. Most of these patients can then be converted from an emergent surgical setting to an elective setting without the need for a colostomy. Certainly, patients with feculent peritonitis (grade 4 perforation, Figure 103-5) or those that are unstable are not candidates for this approach. However, those that are candidates can be managed by following the

FIGURE 103-4. Hartmann resection. Reprinted with permission from Kodner IJ et al, 1993.

Perforated Diverticulitis CT Grading System

Grade 1 Localized free air (peri-colonic) without abscess

• Grade 2 Small (< 2 cm) collections of distant free air OR

• Grade 3 Larger (> 2 cm) collections of distant free air OR

• Grade 4 Free air with non-loculated free fluid in the peritoneal cavity (feculent peritonitis)

FIGURE 103-5. Computed tomography (CT) grading system for perforated diverticulitis.

algorithm outlined in Figure 103-6. It should be stressed that if at any point in the algorithm the patient becomes unstable or is not responding appropriately to therapy, this approach should be abandoned and the patient should be taken to the operating room for a Hartmann's procedure. If conversion of a case of free perforation to an elective procedure is successful, as mentioned with the treatment of abscess disease, the patient should have colonic clearance preoperatively and consideration should be given to placement of ureteral stents preoperatively.

The exact management must be determined by not only the presence of either recurrent or complicated disease but also by the overall health and living situation of the patient. For example, a very young man with a single episode of severe inflammation requiring hospitalization should be considered for an elective resection after the acute episode resolves due to the high likelihood of future problems in his lifetime. Likewise, a frail elderly person who lives in a remote area and had cardiac instability after one episode of an acute diverticular bleeding should also be considered for elective resection if it is felt that the risk of complication from future bleeding is greater than the risk of surgery. Because of the increasing numbers of planned immune suppression (ie, organ transplantation) patients who are at increased risk from the ravages of colonic diverticular perforation, elective colonic resection is often advocated prior to the initiation of the compromised state.

The indications for surgery are further confused by notoriously variable data. Results of resection after one relatively minor episode of inflammation will obviously be superior to those where the indication for resection is either serious septic complications or life threatening bleeding. It is important that the ultimate decision to proceed with elective resection for diverticular disease be one made by both the physician and informed patient who knows the options for operative and nonoperative management and the risks and benefits of each approach.

Grade 1-3 Perforation

With No Abscess i

Broad Spectrum Antibiotics and NPO (Consider TPN in Patients with Poor Nutritional Status) for 48 Hours

With Abscess

< 4 cm

No Improvement

No Improvement

Re CT After a Total of S days of Therapy

Re CT Immediately

Consider OR if Patient Does not Improve After 4 Days

Re CT After S Days of Therapy (no drain in place)

Resolution of Free Air Without Abscess 1

Resolution of Free Air with Abscess

Oral Antibiotics with Liquid Diet for 10-14 Days t

Abscess Protocol

Oral Antibiotics with Liquid Diet for 10-14 Days

Abscess Protocol

FIGURE 103-6. Algorithm for managing diverticulitis with free perforation. CT = computed tomography; NPO = nothing by mouth; OR = operating room; TPN = total parenteral nutrition.

FIGURE 103-6. Algorithm for managing diverticulitis with free perforation. CT = computed tomography; NPO = nothing by mouth; OR = operating room; TPN = total parenteral nutrition.

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