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SSAT Patient Care Guidelines

Surgical Treatment of Diverticulitis

Introduction
Colonic diverticulosis, which is among the most common diseases of Western civilization, is the result of a low-fiber diet. In the United States, approximately one-third of the population will develop diverticulosis by age 50 years and approximately two-thirds by age 80 years. While the entire colon may be involved, the greatest concentration of diverticulosis is normally found in the sigmoid and descending colon. The acute inflammation of diverticula is known as diverticulitis. Diverticulitis may be broadly classified as uncomplicated versus complicated. Most patients with acute uncomplicated diverticulitis respond to medical management and will not require surgery. Complicated diverticulitis usually requires surgical intervention and includes: patients who do not respond to or who deteriorate during medical management, those with recurrent attacks, and those who have specific complications, such as perforation with diffuse peritonitis, localized abscess, fistula formation (typically colovesical or colovaginal), and/or bowel obstruction.

Symptoms and Diagnosis
Uncomplicated diverticulitis is a clinical diagnosis. Patients typically present with left lower quadrant or suprapubic abdominal pain, constipation, and fever. Associated symptoms may include nausea, vomiting, diarrhea, and dysuria. A history of similar episodes may be elicited. In most cases, the inflammatory process is confined to the colon, its mesentery and adjacent structures or peritoneal surfaces. Therefore, examination may reveal fever, mild tachycardia and left lower quadrant tenderness.

The presentation of complicated diverticulitis is more severe in the acute phase, although patients with isolated fistulas to the genitourinary organs may present with more indolent disease. In the patient with diverticular perforation, a pericolic or pelvic abscess may be present with associated fever and tachycardia. Patients with perforation and diffuse peritonitis usually present with severe generalized abdominal pain and associated paralytic ileus. Diffuse peritonitis may lead to septic shock. High-grade colonic obstruction manifests as colicky abdominal pain, bloating and constipation or obstipation. Abdominal findings reflect the severity and localization of the septic process. The inflamed colon or pericolic abscess causes marked localized tenderness with or without a palpable mass. In cases of diffuse peritonitis, generalized tenderness, involuntary guarding and decreased or absent bowel sounds are noted. The presence of pneumaturia or fecaluria signifies the presence of a colovesical fistula. Severe abdominal distention suggests bowel obstruction. Rectal examination should be performed in all patients, and fullness or tenderness may be appreciated towards the left iliac fossa. Pelvic examination is essential in women with suspected diverticulitis to exclude gynecologic processes, such as an ectopic pregnancy, tuboovarian abscess, or pelvic inflammatory disease, which may present in a similar fashion.

The diagnosis of acute diverticulitis is based upon history, clinical findings and the presence of leukocytosis. Diagnostic imaging is rarely required to make the diagnosis of uncomplicated diverticulitis. However, imaging may be useful if the diagnosis is in doubt, if the patient is more acutely ill and complicated diverticulitis is suspected, or if the patient fails to respond to medical management within the first 48 hours of treatment. An acute abdominal series with supine and upright plain abdominal films and an upright chest x-ray should be performed in patients with severe, acute abdominal pain. These films may show pneumoperitoneum. Marked dilatation of the more proximal colon with bowel wall thickening indicates sigmoid obstruction. For patients with localized disease, CT scanning has replaced barium enema as the imaging procedure of choice. Endoscopic evaluation of the colon is contraindicated in acute diverticulitis, as insufflation of air may cause/exacerbate free perforation and peritonitis. Following resolution of an acute episode, colonoscopy and/or barium enema is indicated 6-8 weeks following hospital discharge to document the extent of colonic diverticula and to exclude colorectal carcinoma. In cases of suspected colovesical fistula, the diagnosis is usually made by clinical history and CT scan.

Treatment
Patients with mild uncomplicated diverticulitis who have the appropriate outpatient support may be initially managed as outpatients on liquid diets and broad spectrum oral antibiotics. Instructions should be clearly understood that worsening of symptoms requires a return to the office, urgent care facility, or emergency department, depending upon the setting. Patients with severe diverticulitis require hospitalization for intravenous hydration, broad-spectrum intravenous antibiotics, and bowel rest. Nasogastric tube decompression may be necessary when obstructive signs and symptoms are present. The initiation of medical therapy usually results in rapid clinical improvement with resolution of pain, fever and ileus within 48-72 hours. Broad-spectrum antibiotics are continued until normalization of the patient’s temperature and white blood cell count, and oral feedings are gradually reintroduced as tolerated. Following resolution of signs and symptoms, patients should consume a high-fiber diet to decrease the likelihood of repeated attacks. Patients with non-perforated acute diverticulitis who fail to improve with aggressive medical therapy should undergo prompt CT scanning of the abdomen. If a macroscopic abscess is not identified, colon resection is indicated. A defined abscess should be treated by CT-guided percutaneous catheter drainage. If this approach is not possible, surgical exploration with drainage of the abscess and colonic resection should be performed. If percutaneous drainage is successful, a subsequent elective colon resection with primary anastomosis may be performed after resolution of the acute inflammatory phase.

Surgical procedures for diverticulitis and its complications may be either elective or emergent. Patients who present with diffuse peritonitis require prompt fluid resuscitation, intravenous antibiotics, and emergency surgical exploration. Resection of the perforated colonic segment with descending end colostomy and closure of the rectal stump (Hartmann procedure) is usually required. In certain circumstances, primary anastomosis with proximal diversion may be performed. In less severe disease and without free perforation, primary resection and anastomosis may be considered.

Historically, guidelines from this Society and others have suggested the following indications for elective operation: (1) two or more acute attacks of diverticulitis successfully treated medically; (2) a single attack requiring hospitalization in a patient less than 40 years of age; (3) one attack with evidence of contained perforation, colonic obstruction, or inflammatory involvement of the urinary tract; and (4) inability to rule out a colonic carcinoma. Newer data have challenged these guidelines, and elective sigmoid resection may not be necessary after any specific number of episodes of uncomplicated diverticulitis, or with any definite age thresholds.

Because the overwhelming majority of patients with acute diverticulitis have sigmoid colon involvement, resections of other portions of the colon are infrequently required. A left hemicolectomy may be necessary for diverticulitis of the descending colon. Isolated cecal or ascending colon diverticulitis, a rare condition usually encountered during emergency operation for presumed acute appendicitis, may require resection.

Patients whose acute diverticulitis is complicated by colovesical or other fistulae rarely require emergent operation. Such patients are best treated medically with subsequent elective fistula takedown, colon resection, and primary anastomosis. Nearly all types of elective surgery for diverticular disease can now be successfully performed using laparoscopic techniques. If significant adhesions, inflammation, bleeding, or other technical difficulties are encountered during laparoscopic surgery, conversion to an open procedure may be indicted. Such conversion is not a complication and may be appropriate to ensure safe completion of the operation.

Risks
Mortality rates after colon resection for diverticulitis are less than 2% for elective resections with primary anastomosis and 5-20% for emergency operation. Complications attending emergency surgery are usually secondary to inadequately controlled sepsis. Expedient management is therefore important in order to control sepsis and lower the potential morbidity and mortality.

Technical complications associated with colonic surgery include bleeding, anastomotic leak with associated infection, and inadvertent injury to adjacent organs, particularly the ureter. These risks occur in less than 5% of patients undergoing elective colectomy. Although the risks of bleeding and adjacent organ injury are increased with emergency operations, avoidance of a primary anastomosis largely eliminates the problem of anastomotic leakage. Because diverticulitis is often present in the elderly, co-morbid conditions such as cardiac and pulmonary disease increase the risk of surgery, especially when performed emergently.

Expected Outcome
Recurrence in patients with successfully managed, uncomplicated diverticulitis is 5-10%, and these patients should consider surgical intervention. For patients undergoing elective operations, a hospital stay of 4-7 days is typical, during which the bowel function normalizes. Following successful resection and anastomosis, recurrent diverticulitis is rare, unless the resection does not extend to the pelvic peritoneal reflection. Patients requiring emergent surgical intervention have higher perioperative morbidity and mortality rates, and may require a second operation for stoma closure.

Qualifications for Performing Surgery for Diverticulitis
The qualifications of a surgeon to perform any operative procedure should be based on training (education), experience, and outcomes. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform emergency as well as elective colectomy. It is highly desirable that the surgeons performing laparoscopic colonic surgery have undergone specific advanced training in this area.

References
Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg. 2005;140(7):681-5.

Bordeianou L, Hodin R. Controversies in the surgical management of sigmoid diverticulitis.J Gastrointest Surg. 2007;11(4):542-8.

Makela JT, Kiviniemi HO, Laitinen ST. Elective surgery for recurrent diverticulitis.Hepatogastroenterology. 2007 Jul-Aug;54(77):1412-6.

Nelson RS, Velasco A, Mukesh BN. Management of diverticulitis in younger patients. Dis Colon Rectum. 2006;49(9):1341-5.

Peppas G, Bliziotis IA, Oikonomaki D, Falagas ME. Outcomes after medical and surgical treatment of diverticulitis: A systematic review of the available evidence.J Gastroenterol Hepatol. 2007 Sep;22(9):1360-8.

Key Words
diverticulitis, acute disease, sigmoid colon, peritonitis, intestinal perforation, colon, colectomy, diverticulosis, colovesical fistula, colon obstruction, patient, guideline

Written 1/22/96
Board Approved 10/8/96
Revised 1-25-97
Revised 2-5-97
Revised 2-24-97
Revised 5-8-97
Revised 5-11-97
Revised 8-23-97
Revised 9/26/99
Revised 11/1/99
Proofed 1/8/00
Revised 5/2003
Revised September 2007
Board Approved 10/08/07

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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