Acs0512 Diverticulitis 2004

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 1 12 DIVERTICULITIS John P.Welch, M.D., F.A.C.S., and Jeffrey L. Cohen, M.D., F.A.C.S., F.A.S.C.R.S. Diverticula are small (0.5 to 1.0 cm in diameter) outpouchings of Clinical Evaluation the colon that occur in rows at sites of vascular penetration between the single mesenteric taenia and one of the antimesen- HISTORY teric taeniae. At the sites of most diverticula, the muscular layer is absent [see Figure 1].Technically, such lesions are really pseudodi- Uncomplicated (Simple) Diverticulitis verticula; true diverticula (which are much less common than The classic symptoms of uncomplicat- pseudodiverticula) involve all layers of the bowel wall. Neverthe- ed acute diverticulitis are left lower quad- less, both pseudodiverticula and true diverticula are generally rant abdominal pain, a low-grade fever, referred to as diverticula. irregular bowel habits, and, possibly, urinary symptoms if the The sigmoid colon is the most common site of diverticula: in affected colon is adjacent to the bladder. If the sigmoid colon is 90% of patients with diverticulosis, the sigmoid colon is involved.1 highly redundant, pain may be greatest in the right lower quad- If a diverticulum becomes inflamed as a result of obstruction by rant. Diarrhea or constipation may occur, together with rectal feces or hardened mucus or of mucosal erosion, a localized perfo- urgency. ration (microperforation) may occur—a process known as diver- The differential diagnosis includes gynecologic and urinary dis- ticulitis. The incidence of diverticulitis is about 10% to 25% in orders, perforated colon carcinoma, Crohn disease, ischemic co- patients with colonic diverticula.1 Both diverticulosis and variants litis, and, sometimes, appendicitis. Chronic diarrhea, multiple of diverticulitis may be subsumed under the more encompassing areas of colon involvement, perianal disease, perineal or cuta- term diverticular disease. neous fistulas, or extraintestinal signs are suggestive of Crohn dis- The incidence of diverticular disease increases with age. Diver- ease. Rectal bleeding should raise the possibility of inflammatory ticula are quite common in elderly patients, being present in more bowel disease, ischemia, or carcinoma; such bleeding is uncom- than 80% of patients older than 85 years.2 Consequently, as the mon with diverticulitis alone. Given the prevalence of diverticula, population of the United States continues to age, the overall risk it is not surprising that colon carcinoma may coexist with diver- of diverticular complications continues to increase.3 Before the ticular disease [see Figure 3]. 20th century, diverticular disease was rare in the United States. By 1996, however, 131,000 patients were being admitted to hospitals with diverticulitis each year.4 A diet containing refined carbohydrates and low-fiber sub- Vascular Diverticulum stances, such as is currently widespread in many developed coun- Structure tries (especially in the West), has been associated with the emer- gence of this disease entity.5,6 A low-residue diet facilitates the Antimesenteric development of constipation, which can lead to increased intralu- Taenia minal pressure in the large bowel. In addition, elevated elastin lev- els are commonly noted at colon wall sites containing diverticula,7 and this change causes shortening of the taeniae.1 High-pressure zones or areas of segmentation may develop [see Figure 2], usually in the sigmoid colon, and diverticula begin to protrude at these locations. If microperforation of a thin-walled diverticulum takes place, local or, sometimes, widespread contamination with fecal organisms may ensue. The pericolonic tissue (typically, the mesentery and the pericolic fat) thus becomes inflamed while the mucosa tends to remain otherwise normal. Mesenteric Several factors appear to promote the development of diver- Taenia ticular disease and its complications, including decreased physical activity,8 intake of nonsteroidal anti-inflammatory drugs (NSAIDs),9,10 smoking,11 and constipation from any cause (e.g., Epiploic Antimesenteric diet or medications). The well-known Western afflictions chole- Appendage Intertaenial Area lithiasis, diverticulosis, and hiatal hernia frequently occur together (Saint’s triad). Obesity has been associated with the intake of Figure 1 Illustrated are anatomic findings in a segment of colon low-fiber diets,12 and growing numbers of young, obese patients containing diverticula. Diverticula are located at sites where with diverticulitis are being seen by physicians. blood vessels enter the colonic wall.87

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 2 Patient has suspected diverticulitis History Characteristic findings include • Abdominal pain • LLQ tenderness Management of • Irregular bowel habits • Fever Diverticulitis Obstruction, abscess, fistula, or free perforation is indicative of complicated diverticulitis. Physical examination Uncomplicated diverticulitis: LLQ tenderness with variable guarding and rebound tenderness; possible mass; bleeding (uncommon); localized inflammation; possible phlegmon Complicated diverticulitis: mass; evidence of fistula; abdominal distention; abdominal tenderness, marked in cases of free perforation; hypotension or oliguria; bleeding Physical signs are mild Physical signs are marked Manage on outpatient basis. Obtain CBC and sedimentation rate. Hospitalize patient. Place patient on liquid diet. Institute NPO regimen. Give oral antibiotics. Give I.V. antibiotics. Perform CT scan with contrast to confirm diagnosis. Symptoms resolve Symptoms recur Symptoms worsen Perform colonoscopy Consider surgical or contrast study. treatment. Patient has uncomplicated Patient has complicated Patient has other diverticulitis diverticulitis diagnosis Consider surgical treatment [See Figure 12.] Treat as appropriate. if recurrent. Consider colonoscopy later.

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 3 Acute Diverticulitis Perforation Hemorrhage Muscular Hypertrophy Figure 2 Depicted is a schematic representation of the Obstruction process termed segmentation in the colon. It has been theorized that high-pressure compartments lead to the development of diverticula.88 Pericolic Abscess Complicated Diverticulitis Some cases of diverticulitis are classified as complicated, meaning that the disease process has progressed to obstruction, abscess or fistula formation, or free perforation [see Figure 4]. Complicated diverticulitis may be particularly challenging to manage,13,14 especially because patients may have no known his- Colovesical tory of diverticular disease.15 Lower gastrointestinal bleeding is Fistula also a complication of diverticular disease in 30% to 50% of cases16; in fact, diverticula are the most common colonic cause of lower GI bleeding.16 When diverticular hemorrhage occurs [see Figure 4 Shown are major complications of diverticular disease of the sigmoid colon.89 5:6 Lower Gastrointestinal Bleeding], it is usually associated with diverticulosis rather than with diverticulitis. Approximately 50% of diverticular bleeding originates in the right colon, despite the low incidence of diverticula in this segment of the colon. Patients tend to be elderly13 and to have cardiovascular disease and hyper- tension. Regular intake of NSAIDs may increase the risk of this complication. Although patients may lose 1 to 2 units of blood, the bleeding usually ceases spontaneously,17 and expeditious operative treatment generally is not necessary. The most common form of complicated diverticulitis involves the development of a pericolic abscess, typically signaled by high fever, chills, and lassitude. Such abscesses may be small and localized or may extend to more distant sites (e.g., the pelvis). They may be categorized according to the Hinchey classification of diverticular perforations,18 in which stage I refers to a localized pericolic abscess and stage II to a larger mesenteric abscess spreading toward the pelvis [see Figure 5]. On rare occasions, an abscess forms in the retroperitoneal tissues, subsequently extend- ing to distant sites such as the thigh or the flank. The location of the abscess can be defined precisely by means of computed Figure 3 Barium enema shows a napkin-ring carcinoma tomography with contrast. (arrow) in the middle of multiple diverticula in a redundant Some abscesses rupture into adjacent tissues or viscera, resulting sigmoid colon. in the formation of fistulas.The fistulas most commonly seen in this

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 4 Localized Pericolic Abscess Large Mesenteric Abscess (Hinchey Stage I) (Hinchey Stage II) Free Perforation Free Perforation Causing Fecal Peritonitis (Hinchey Stage III) (Hinchey Stage IV) Figure 5 The Hinchey classification divides diverticular perforations into four stages. Mortality increases significantly in stages III and IV.18 setting (50% to 65% of cases) are colovesical fistulas.This compli- The term malignant diverticulitis has been employed to de- cation is less common in women because of the protection afford- scribe an extreme form of sigmoid diverticulitis that is character- ed by the uterus. Symptoms of colovesical fistulas tend to involve ized by an extensive phlegmon and inflammatory reaction extend- the urinary tract (e.g., pneumaturia, hematuria, and urinary fre- ing below the peritoneal reflection, with a tendency toward quency). Fecaluria is diagnostic of colovesical or enterovesical fistu- obstruction and fistula formation.20 Malignant diverticulitis is seen las. Colovaginal fistulas (which account for 25% of all diverticular in fewer than 5% of patients older than 50 years who are operated fistulas) are usually seen in women who have undergone hysterec- on for diverticulitis.20 The process is reminiscent of Crohn disease, tomies.19 The diseased colon is adherent to the vaginal cuff. Most and CT scans demonstrate extensive inflammation. In this setting, commonly, patients complain of a foul vaginal discharge; however, a staged resection might be preferable to attempting a primary some patients present with stool emanating from the vagina. resection through the pelvic phlegmon. The degree of pelvic About 10% of colon obstructions are attributable to divertic- inflammation may subside significantly after diversion.20 ulitis. Acute diverticulitis can cause colonic edema and a func- A dangerous but rare complication of acute diverticulitis (oc- tional obstruction that usually resolves with antibiotic infusion curring in 1% to 2% of cases) is free perforation,21 a term that and bowel rest. Stricture formation is more common, usually includes both perforation of a diverticular abscess throughout the occurring as a consequence of recurrent attacks of diverticulitis. abdomen leading to generalized peritonitis (purulent peritonitis; Circumferential pericolic fibrosis is noted, and marked angulation Hinchey stage III) and free spillage of stool thorough an open diver- of the pelvic colon with adherence to the pelvic sidewall may be ticulum into the peritoneal cavity (fecal peritonitis; Hinchey stage seen. Patients complain of constipation and narrowed stools. IV).The incidence of free perforations may be increasing, at least in Colonoscopy can be difficult and potentially dangerous in this set- the southwestern United States.22 The overall mortality in this group ting. Differentiating a diverticular stricture from carcinoma may is between 20% and 30%; that for purulent peritonitis is approxi- be impossible by any means short of resection. mately 13%, and that for fecal peritonitis is about 43%.21

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 5 PHYSICAL EXAMINATION colovaginal fistula, a site of granulation tissue and drainage is seen at the apex of the vaginal cuff. In a patient with obstruction, there Uncomplicated Diverticulitis may be marked abdominal distention, usually of slow onset; Physical examination reveals localized abdominal tenderness may or may not be present, but if tears left lower quadrant abdominal tenderness develop in the cecal taeniae, right lower quadrant tenderness is with variable degrees of guarding and typically seen. In a patient with a free perforation, there is marked rebound tenderness. A mass is occasion- abdominal tenderness, usually commencing suddenly in the left ally felt. The stool may contain traces of lower quadrant and spreading within hours to the remainder of blood, but gross bleeding is unusual. the abdomen. Hypotension and oliguria may develop later. Pa- Localized inflammation of the perforated diverticulum and the tients with rectal bleeding usually have no complaints of abdomi- adjacent mesentery is present, and a phlegmon may be seen as nal pain or tenderness, and they may be hypovolemic and hypo- well. Depending on the severity of the physical findings, patients tensive, depending on the rapidity of the bleeding. may be managed either as inpatients or outpatients. Complicated Diverticulitis Investigative Studies In a patient with a pericolic abscess, a mass may be detectable IMAGING on abdominal, rectal, or pelvic examination. In a patient with a The most useful diagnostic imaging study in the setting of suspected diverticulitis is a CT scan with oral and rectal contrast.23 Localized thickening of the bowel wall or inflammation of the adjacent pericolic fat is suggestive of diverticulitis; extraluminal air or fluid collections are sometimes seen together with diverticula [see Figure 6]. The most frequent findings (seen in 70% to 100% of cases) are bowel wall thickening, fat stranding, and diverticula.24 In some cases, small abscesses in the mesocolon or bowel wall are not detected. The diagnosis of carcinoma cannot be excluded defini- tively when there is thickening of the bowel wall [see Figure 7].2 Although CT scanning has tended to replace contrast studies in the evaluation of diverticulitis, the latter may be more useful in differentiating carcinoma from diverticulitis. A contrast study can also be complementary when the CT scan raises the suspicion of carcinoma.23 When diverticulitis is suspected, water-soluble contrast material should be used instead of barium because of the complications that follow extravasation of barium [see Figures 8 and 9]. Furthermore, in the acute setting, only the left colon Figure 6 CT scan shows thickening of the sigmoid should be evaluated. Carcinoma is suggested by an abrupt transi- colon (arrow) caused by acute diverticulitis. tion to an abnormal mucosa over a relatively short segment; diver- a b Figure 7 (a) CT scan shows a thickened left colonic wall and diverticulum (arrow). Diverticulitis was considered the most likely diagnosis. (b) CT scan through an adjacent plane shows deformity of the mucosa, suggesting a possible apple-core lesion (arrow). Subsequent endoscopy revealed a carcinoma that was obstructing the colon almost completely.

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 6 ticulitis is usually characterized by a gradual transition into diseased colon over a longer segment, with the mucosa remaining intact. If the contrast study reveals extravasation of contrast out- lining an abscess cavity [see Figure 9], an intramural sinus tract, or a fistula, diverticulitis is likely.1 Colonoscopy is avoided when acute diverticulitis is suspected, because of the risk of perforation. It may, however, be done 6 to 8 weeks after the process subsides to rule out other disorders (e.g., colon cancer) [see Figure 10]. If diverticular disease is advanced, the endoscopic procedure may be difficult; the diverticular segment must be fully traversed for the examiner to be able to ex- clude a neoplasm with confidence.When major lower GI bleeding occurs, colonoscopy is done to search for polyps, carcinoma, or a site of diverticular bleeding. In the case of massive bleeding, selec- tive arteriography is useful for localizing the source, and superse- Figure 8 Contrast study shows local extravasation from lective embolization frequently quells the hemorrhage. The actual the sigmoid colon (arrow); a diverticulum is visible. risk of bowel ischemia is low when superselective techniques are employed. Bleeding at the time of arteriography may be facilitat- ed by the infusion of heparin or urokinase; however, this is a risky approach that should be taken only when other attempts at local- ization have failed and recurrent bouts of bleeding have occurred. When a colovesical fistula occurs, contrast CT with narrow cuts in the pelvis can be very helpful. The classic findings are sigmoid diverticula, thickening of the bladder and the colon, air in the bladder, opacification of the fistula tract and the bladder, and, possibly, an abscess [see Figure 11]. Cystoscopy is less specific, showing possible edema or erythema at the site of the fistula. A contrast enema helps rule out malignant disease. The diagnostic tests that are most useful for detecting colovaginal fistulas are contrast CT and vaginography via a Foley catheter. Charcoal inges- tion helps confirm the presence of colovesical or colovaginal fistulas. On rare occasions, colocutaneous fistulas may develop, causing erythema and breakdown of the skin. Colouterine fistulas may occur as well; these are also quite rare.25 Management MEDICAL Figure 9 Shown is extravasation into an abscess cavity (arrow) from diverticulitis at the sigmoid colon–descend- Uncomplicated diverticulitis is usually ing colon junction in a postevacuation film. managed on an outpatient basis by insti- tuting a liquid or low-residue diet and administering an oral antibiotic combi- nation that covers anaerobes and gram- negative organisms (e.g., ciprofloxacin with metronidazole or clindamycin) over a period of 7 to 10 days. Provided that symptoms and signs have subsided, the colon may be evaluated more fully several weeks later with a contrast study or colonoscopy if the diagnosis of diverticular disease has not already been established. If symptoms worsen, hospitalization should be considered. Over the long term, patients should be maintained on a high-fiber diet, though it may take months for the diet to have an effect on symptoms.26 If more significant physical findings and symptoms of toxicity develop, hospitalization is warranted [see Figure 12]. Patients are placed on a nihil per os (NPO) regimen, and intravenous fluids and antibiotics are administered (e.g., a third-generation cephalo- sporin with metronidazole) until abdominal pain and tenderness have resolved and bowel function has returned. As a rule, resolu- tion occurs within several days. If there is clinical evidence of Figure 10 Colonoscopic view of several sigmoid diver- intestinal obstruction or ileus, a nasogastric tube is placed. In ticula reveals no evidence of active diverticulitis (e.g., most cases, ileus-related symptoms resolve with antibiotic treat- edema or narrowing). ment. CT scans are useful for establishing the correct diagnosis in

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 7 a b Figure 11 (a) CT scan in a patient with a colovesical fistula shows air in the thickened tract (arrow) adjacent to the sigmoid colon. (b) CT scan through an adjacent plane shows air in the bladder (arrow) as a result of the fistula. No contrast is present in the bladder. the emergency department27; furthermore, the severity of diver- to time surgical treatment so that it takes place during a quiescent ticulitis on CT scans predicts the risk of subsequent medical fail- period 8 to 10 weeks after the last attack. Barium enema or ure.28 Following the sedimentation rate may be helpful in assess- colonoscopy may be employed to evaluate the diverticular disease ing the effectiveness of treatment. It has been estimated that 15% and rule out carcinoma.The bowel can then be prepared mechan- to 30% of patients admitted with acute diverticulitis will require ically and with antibiotics (e.g., oral neomycin and metronidazole surgical treatment during the same admission.1 on the day before operation). If fever and leukocytosis persist despite antibiotic therapy, the Elective resection is a common sequel to successful percuta- presence of an abscess should be suspected. Small (< 5 cm) neous drainage of a pericolic abscess in an otherwise healthy, well- abscesses may respond to antibiotics and bowel rest. Larger nourished patient. The timing of surgery may be guided by the abscesses that are localized and isolated may be accessible to per- extent of the inflammatory changes (as documented by CT scan- cutaneous drainage [see Figure 13].28 Generally, this technique is ning) and the patient’s clinical course. Most patients can be oper- reserved for abscesses greater than 5 cm in diameter in low-risk ated upon within 6 weeks. Elective resection is the preferred patients who are not immunocompromised. It often leads to res- approach to diverticular fistulas as well. Colovesical fistulas are olution of sepsis and the resulting symptoms and signs (e.g., usually resected because of the risk of urinary sepsis and the con- abdominal pain and tenderness and leukocytosis), usually within cern that a malignancy might be overlooked. Preferably, the oper- 72 hours, thereby facilitating subsequent elective surgical resec- ation is done when the acute inflammation has subsided. tion of the colon. In addition, percutaneous drainage offers cost Elective resection is done via either the open route or, increas- advantages, in that it reduces the number of operative procedures ingly, the laparoscopic route33; a few telerobotic-assisted laparo- required and shortens hospital stay. scopic colectomies have also been attempted.34 The learning Access to a pelvic collection may be difficult to obtain, and the curve for laparoscopic colectomy is 20 to 50 cases.35 Obese pa- drainage procedure typically must be done with the patient in a tients with severe colonic inflammation are poorer candidates for prone or lateral position. If the catheter drainage amounts to more laparoscopic resection.33 In our institution, the development of than 500 ml/day after the first 24 hours, a fistula should be sus- hand-assisted procedures has widened the opportunities for uti- pected. Before the catheter is removed, a CT scan is done with lizing minimally invasive surgery [see 5:32 Procedures for injection of contrast material through the tube to determine Diverticular Disease], allowing all types of diverticular resections to whether the cavity has collapsed. If this approach fails (as it usu- be performed more safely. Minimally invasive procedures have ally does in patients with multiple or multiloculated abscesses), an several advantages over conventional procedures: decreased intra- expeditious operation may be necessary.22 An initial surgical pro- operative trauma, fewer postoperative adhesions, reduced postop- cedure is required in about 20% of cases.29 erative pain, shorter duration of ileus, quicker discharge from the hospital, and earlier return to work.36-38 Such procedures can be SURGICAL done safely in obese patients,38 and the conversion rate is now Overall, approximately 20% of patients with diverticulitis require low.35,39 Technical details of the procedures are addressed else- surgical treatment.2,30 Most surgical procedures are reserved for where [see 5:32 Procedures for Diverticular Disease].40,41 patients who experience recurrent episodes of acute diverticulitis Some patients with complicated diverticulitis require emer- that necessitate treatment (inpatient or outpatient) or who have gency resection because of free perforation and widespread peri- complicated diverticulitis. The most common indication for elec- tonitis. In such patients, the American Society of Anesthesiologists tive resection is recurrent attacks—that is, several episodes of acute (ASA) physical status score and the degree of preoperative organ diverticulitis documented by studies such as CT. Estimates of the failure may be significant predictors of outcome.42,43 Unfavorable risk of such attacks range from 30% to 45%. A task force of the systemic factors (e.g., hypotension, renal failure, diabetes, malnu- American Society of Colon and Rectal Surgeons recommended trition, immune compromise, and ascites) play a vital role in sigmoid resection after two attacks of diverticulitis.31 A cost analy- determining patient outcome,43 as does the severity of the peri- sis using a Markov model suggested that cost savings can be tonitis (i.e., extent, contents, and speed of development).44,45 One achieved if resection is done after three attacks.32 Efforts are made of the unfortunate limitations of the Hinchey classification is that

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 8 Patient has complicated diverticulitis Disease has progressed to obstruction, abscess or fistula formation, free perforation, or significant bleeding Obstruction (signaled by Abscess (signaled by localized Fistula (signaled by fecaluria marked abdominal distention) peritonitis and fever) and pneumaturia) Perform diagnostic imaging. Perform diagnostic imaging. Perform diagnostic imaging; look for bladder air. Treat medically. Resect colon and fistula in one- stage procedure. Small bowel Large bowel obstruction obstruction Small abscess Large abscess High-grade: Cecal distention treat surgically. present: treat surgically. Attempt percutaneous drainage. Low-grade: Cecal distention treat medically; absent: treat medically; consider surgical consider surgical treatment if indicated. treatment if indicated. Drainage succeeds Drainage fails Initiate early surgical treatment. Figure 12 Algorithm outlines treatment options Perform elective one-stage resection. for complicated diverticulitis. it does not take comorbidities into account.44 Because the bowel dure) is the gold standard for stage III and especially stage IV.46-48 is not prepared before operation, the surgeon may feel uncom- This recommendation is based on the ﬁnding that an anastomo- fortable doing an anastomosis. On-table lavage may be considered sis involving the left colon is risky when performed under emer- if contamination is minimal, but it adds to the time spent under gency conditions.49 The once-popular three-stage procedures are anesthesia during an emergency procedure. now of historic interest only.There are some reports of successful As a general rule, resection and immediate anastomosis are outcomes for type III and type IV cases after extensive abdominal suitable for Hinchey stage I and perhaps stage II diverticular per- lavage and two-layer anastomoses50 or after on-table lavage of the forations, whereas resection with diversion (the Hartmann proce- colonic contents to allow primary anastomosis.51 Grading of a b Figure 13 (a) CT scan shows a pericolonic abscess (arrow) caused by a contained perforation arising from sigmoid diverticulitis. (b) A pigtail catheter (arrow) has been placed into the abscess cavity by the interventional radiologist.

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 9 Free perforation (signaled by generalized Bleeding (lower GI) peritonitis and rigid abdomen) Initiate urgent surgical treatment. Consider performing diagnostic imaging; look for free air. Massive bleeding Moderate bleeding Administer transfusions. Observe patient. Perform angiography. Perform colonoscopy. Hinchey stage III Hinchey stage IV Perform resection with Perform Hartmann Angiogram is negative Angiogram is positive anastomosis; alternatively, procedure. perform Hartmann procedure. Perform superselective Observe patient. embolization. Consider RBC scanning. Embolization succeeds Embolization fails Observe patient. Treat surgically. comorbidities with classification systems such as APACHE II or wound dehiscence, and abdominal compartment syndrome; the the Mannheim peritonitis index can facilitate decision-making acute respiratory distress syndrome (ARDS); and the multiple with respect to the question of anastomosis versus diversion.52 organ dysfunction syndrome (MODS). The surgeon’s decision must be individualized on the basis of Large bowel obstruction secondary to diverticulitis can lead to each patient’s condition and needs. The literature on this topic is considerable morbidity and may necessitate surgical interven- confusing, in that most of the published reports are small and ret- tion.55 The obstruction is usually partial [see Figures 14 and 15], rospective, with only limited classification of disease severity. allowing preparation of the bowel in many cases. High-grade Currently, surgeons encountering acute diverticulitis are more obstruction represents a complex problem. If the cecum is dilat- likely to do one-stage resections, as opposed to Hartmann proce- ed to a diameter of 10 cm or greater and there is tenderness in the dures, than they once were.43,53 The advantage of the one-stage right lower quadrant, expeditious surgery is necessary because of approach is that the colostomy takedown and the attendant 4% the risk of cecal necrosis and perforation. High-grade obstruction mortality are avoided.54 Furthermore, at least 30% of patients with fecal loading of the colon is usually managed by performing who undergo a Hartmann procedure never return for colostomy a Hartmann procedure, though on-table lavage may be consid- closure. A primary anastomosis can be protected with a proximal ered.22 A survey of GI surgeons in the United States indicated that ileostomy as well.46,55,56 Transverse colostomy and loop ileostomy 50% would opt for a one-stage procedure in low-risk patients with appear to be equally safe, though skin changes may be more prob- obstruction, whereas 94% would opt for a staged procedure in lematic after a colostomy57 and an ileostomy closure tends to be high-risk patients.59 less complex than a colostomy closure. On-table lavage may also Small bowel obstruction may also complicate the clinical pic- be used as an adjunct to anastomosis.58 ture. Mechanical small bowel obstruction may occur as a conse- The risk of complications inherent in operations on the colon quence of adherence of the small bowel to a focus of diverticuli- should always be kept in mind, especially in the relatively few tis, especially in the presence of a large pericolic abscess.Whereas patients undergoing emergency procedures. In this setting, the small bowel obstruction tends to cause periumbilical crampy bowel is unprepared and systemic sepsis may be present. Potential abdominal pain and vomiting, these characteristic manifestations complications include ureteral injuries; anastomotic leakage, may be obscured in part by pain attributed to diverticulitis. The anastomotic stricture, and postoperative intra-abdominal abscess- concern in this situation is that ischemic small bowel may be es; perioperative bleeding involving the mesentery, adhesions, the ignored, with potentially disastrous consequences. Diarrhea splenic capsule, or the presacral venous plexus; postoperative should trigger the suspicion of colonic disease, and formation of a small bowel obstruction; stomal complications; wound infection, fistula into the small bowel should raise the possibility of Crohn

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 10 colonic angiography and attempted superselective embolization prove unsuccessful. In an unstable patient, total abdominal colectomy is necessary if the site of bleeding is unknown, though identification of the bleeding site with intraoperative colonoscopy has been reported. In a stable patient with ongoing bleeding, repeat angiography at a later time is appropriate, or so-called pharmacoangiography (infusion of heparin) can be employed in an attempt to induce bleeding. Special Types of Diverticulitis CECAL DIVERTICULITIS In the United States, diverticulitis rarely involves the cecum or the right colon. Right-side diverticula occur in only 15% of pa- Figure 14 CT scan shows marked thickening of the sig- tients in Western countries, compared with 75% in Singapore.1 moid wall (arrows) in a patient with diverticular disease The incidence of cecal diverticulitis appears to be related to the who presented with symptoms of intractable constipation. number of diverticula present.60 A classification system has been No contrast is present in the lumen (curved arrow). proposed that divides cecal diverticulitis into four grades [see Figure 16] to facilitate comparisons between different clinical series and to help surgeons formulate treatment plans in the OR.60 Some cecal diverticula are true diverticula, containing all layers of the bowel wall, but the majority are pseudodiverticula. Diverticuli- tis of the hepatic flexure and the transverse colon is even less common and can present with symptoms suggesting appendicitis.61,62 Patients with right-side disease tend to be younger and to have less generalized peritonitis than patients with left-side diverticulitis.60,61 Because they typically present with right lower quadrant pain, fever, and leukocytosis, acute appendicitis is usually suspected. CT scans are helpful for differentiating cecal diverticulitis from appendicitis or colon cancer [see Figure 17].63,64 If cecal diverticulitis is suspected (as in a patient who has previously undergone appendectomy or in a patient with known right-side diverticulosis who has experienced similar attacks in the past), medical management with observation and antibiotics is generally the favored strategy, just as with simple sigmoid diverticulitis. In Japan, where right-side diverticulitis is more common, medical treatment has been successfully used for recurrent attacks of uncomplicated right-side diverticulitis.65 After a few weeks, colonoscopy should be performed to rule out a colonic neoplasm. If the patient has significant peritonitis or the diagnosis is unclear, laparoscopy or laparotomy is indicated. It is important that one or the other be done because the mortality associated with delayed treatment of perforated cecal diverticulitis is high. In our institution, laparoscopy is usually employed; if the diagnosis is unclear, laparotomy is recommended. When inflammation is localized and mini- Figure 15 Contrast study shows high-grade retrograde obstruction, multiple diverticula, and a long proximal mal, colectomy is unnecessary, and incidental appendectomy sigmoid stricture. A tiny extraluminal tract (possibly should be considered if the cecum is uninvolved at the base of the intramural) from a diverticulum (arrow) is seen. appendix.66 If desired, the diverticulum may be removed as well. Diverticulectomy should be done only if (1) carcinoma can be ruled out, (2) the resection margins are free of inflammation, (3) disease. CT scanning often helps the surgeon differentiate be- the ileocecal valve and the blood supply of the bowel are not com- tween primary and secondary small bowel obstruction, but ulti- promised, and (4) perforation, gangrene, and abscess are absent.60 mately, exploratory surgery may be required both for diagnosis Localized diverticulectomy, in general, should be reserved for and for treatment. grade I and grade II disease.60 Sometimes, the ostium of the Lower GI bleeding caused by diverticular disease rarely calls for inflamed diverticulum is palpable if the cecum is mobilized surgi- emergency resection, because the bleeding is self-limited in most cally.67 On-table cecoscopy thorough the appendiceal stump has patients (80% to 90%). Furthermore, active diverticulitis is rare also been helpful in establishing the diagnosis in the OR.66 Grade when active bleeding is the presenting symptom. Attempts are III and IV cecal diverticulitis may be difficult to differentiate from made to establish the active bleeding site by means of colonos- carcinoma; resection is favored for these lesions.67 An anastomosis copy, tagged red blood cell nuclear scans, or angiography; barium may be created if contamination is limited, but generally, primary contrast studies have no role to play in this situation. Emergency resection, ileostomy, and a mucous fistula are favored for treat- resection is indicated if the bleeding is life-threatening and if ment of grade IV disease.

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 11 Pus Grade I Grade II Grade III Pus Grade IV Figure 16 Illustrated is a proposed classification of pathologic types of cecal diverticulitis. Grade I is a specific inflamed diverticulum; grade II is a cecal mass; grade III is characterized by a localized abscess or fistula; and grade IV represents a free perforation or a ruptured abscess with peritonitis.59 DIVERTICULITIS IN YOUNG PATIENTS admitting diagnosis of diverticulitis tend to exhibit a wider spec- Diverticulitis in patients younger than 40 years has been a focus trum of disease severity.Young patients appear not to have a high- of considerable attention in the literature, though this group only er rate of recurrent diverticulitis than older patients do, and thus, represents about 2% to 5% of the patients in large series.31 The aggressive resection is not necessary at the time of the first incidence of diverticulitis in young patients may be increasing, and attack.42,68 However, a finding of advanced diverticulitis on CT obese Latino men appear to be at particular risk.68 This predom- scans is a predictor of subsequent disease complications in this inance in males reflects a tendency to underdiagnose acute diver- population.70,71 ticulitis in young women.69 Some authors have asserted that diver- In general, diverticulitis should be approached in the same ticulitis is particularly virulent in young patients; however, current fashion in younger patients as in older patients.71 The pathophys- data tend not to support this concept, suggesting that patients iology of the disease is probably identical. As in the elderly, elec- with mild diverticulitis are misdiagnosed when hospitalized or are tive resection is recommended after recurrent attacks, not after a treated as outpatients. The high rate of early operation in young single attack; with follow-up, the majority of patients hospitalized patients probably reflects misdiagnosis of diverticulitis as acute with acute diverticulitis do not require operation.71,72 appendicitis rather than the development of particularly severe forms of diverticulitis.68 Patients found to have uncomplicated DIVERTICULITIS IN IMMUNOCOMPROMISED PATIENTS acute diverticulitis may, if desired, undergo incidental appendectomy in conjunction with medical treatment of diverticulitis. In view of their known predisposition to infection, immuno- Unlike elderly patients, hospitalized young patients with diver- compromised patients (e.g., chronic alcoholics, transplant ticulitis tend to have few comorbidities other than obesity. patients, and persons with metastatic tumors who are receiving Furthermore, young patients hospitalized for diverticulitis tend to chemotherapy) with diverticulitis are at particular risk. There is have relatively advanced disease, perhaps as a consequence of no evidence that the incidence of diverticulitis is higher in this delayed diagnosis,2 whereas elderly patients hospitalized with an population than in the general population, but it is clear that

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 12 GIANT DIVERTICULA An anatomic curiosity sometimes encountered in patients with diverticular disease is a giant diverticulum, also termed a giant gas cyst or a pneumocyst of the colon.80 These lesions, which may reach diameters of 40 cm, are believed to develop as a consequence of a ball-valve mechanism created by intermittent occlu- sion of the neck by fecal material that traps air in the diverticulum. Most giant diverticula are minimally symptomatic, causing only mild abdominal pain, and perforation is rare. A mobile mass may be palpable, and the gas-filled cyst can be seen on plain abdominal films. As many as two thirds of giant diverticula are opacified during a barium enema and can thereby be differentiated from other abnormalities (e.g., a mesenteric cyst, emphysematous cholecystitis, or a colon duplication). The cyst tends to adhere Figure 17 CT scan shows inflammation in the pericecal densely to adjacent structures (e.g., the bladder and the small area (arrow) and cecal edema, which could represent bowel). The treatment of choice is resection of the colon and the cecal diverticulitis. Because the appendix is not clearly cyst; performing diverticulectomy alone can lead to the develop- visualized, appendicitis cannot be ruled out. ment of a colocutaneous fistula. RECURRENT DIVERTICULITIS AFTER RESECTION immunocompromised patients have higher rates of operation Recurrent diverticulitis is rare after a colectomy for diverticuli- once diverticulitis develops and that their postoperative mortality tis, occurring in 1% to 10% of patients.81 As many as 3% of is higher.73,74 Corticosteroid intake causes a number of significant patients who have undergone resection for diverticulitis will require problems, such as thinning of the colonic wall, lessening of the repeat resection.3 The differential diagnosis includes Crohn dis- physical findings with diverticulitis, and an attenuated inflamma- ease, irritable bowel syndrome, carcinoma, and ischemic colitis. tory response. CT imaging and colonoscopy should be carried out. Particular Any immunocompromised patient with abdominal pain should care should be taken to review pathologic specimens for evidence be evaluated aggressively. Contrast-enhanced CT is the imaging of Crohn disease. study of choice.The risk of perforation is increased in this setting, The only significant determinant of recurrent diverticulitis is as is the risk of postoperative complications such as wound dehis- the level of the anastomosis; the high pressure in the sigmoid cence. For an immunocompromised patient who has recovered colon distal to the anastomosis appears to be responsible. In one from an episode of symptomatic diverticulitis, elective surgical study, the risk of recurrence was four times greater in patients with treatment is recommended. A renal transplant patient with asymp- a colosigmoid anastomosis than in those with a colorectal anasto- tomatic diverticulosis, however, need not undergo prophylactic mosis.82 Reoperation requires a dissection that commences in colectomy. Pretransplantation colonic screening of patients older noninflamed tissue. Dissection may be particularly difficult near than 50 years does not reliably predict postransplantation colonic the pelvic sidewall because of fibrosis; ureteral stenting may facil- complications.75 itate identification of the ureters. ATYPICAL PRESENTATIONS Diverticulitis may give rise to various unusual manifestations Table 1—Unusual Extra-abdominal involving multiple organ systems [see Table 1]. Not surprisingly, Presentations of Diverticulitis90 immunocompromised patients are at particular risk. Retroperitoneal abscesses can track into anatomic planes (e.g., Dermatologic Pyoderma gangrenosum along the psoas muscle) or through the obturator foramen to areas such as the neck, the thigh,76 the knee, the groin,77 and the geni- Ureteral obstruction Urinary Coloureteral fistula talia.78,79 CT scanning is essential to outline the extent of such abscesses. Contrast enemas show the diverticula along with a sinus Thigh abscess Soft tissue tract into the abscess cavity. Cultures of the abscess demonstrate the Necrotizing fasciitis presence of colonic organisms such as Bacteroides fragilis. Definitive Osteomyelitis treatment consists of wide abscess drainage and colon resection. Orthopedic Arthritis Without aggressive surgical management, mortality is high. The protean manifestations of diverticulitis also include pyle- Colouterine fistula Gynecologic Ovarian tumor/abscess phlebitis (which causes liver abscesses), arthritis, and skin changes. Diverticulitis has in fact replaced appendicitis as the Genital Epididymitis most common source of liver abscesses of portal origin. Simple Pneumoscrotum abscesses may be drained percutaneously if they are not too large, Neurologic Coloepidural fistula and multiple loculated abscesses may be managed with open drainage. The main risk factors for mortality from liver abscesses Femoral vein thrombosis Mesenteric vein thrombosis are immunosuppression, underlying malignancy, the presence of Vascular Pylephlebitis multiple organisms, and liver dysfunction. If the decision is made Colovenous fistula to perform a colectomy, the procedure may be done after drainage Fournier gangrene of the liver abscess or simultaneously with drainage during an Perineal Complex anal fistula open procedure.

© 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 12 Diverticulitis — 13 SUBACUTE AND ATYPICAL DIVERTICULITIS relation between diverticular disease and colitis.86 Patients with A small number of patients experience recurrent episodes of chronic lower abdominal pain should undergo imaging studies left lower quadrant abdominal pain that are not accompanied by and endoscopic evaluation, and other disorders (e.g., irritable the classic findings of acute diverticulitis (e.g., fever and leuko- bowel syndrome, inflammatory bowel disease, drug-induced cytosis). The inflammatory changes associated with diverticula symptoms, and bowel ischemia) should be excluded. In most in this subgroup have been referred to as atypical, subacute, or cases of atypical diverticulitis, endoscopic findings are normal.84 smoldering diverticulitis.83,84 In this setting, there is not always In carefully selected patients, colectomy often eliminates the a direct association between endoscopic and clinical findings; abdominal pain, and many of these patients are eventually endoscopic evidence of diverticular inflammation has been seen found to have histologic signs of acute and chronic mucosal in asymptomatic patients.85 It has been suggested that there is a inflammation.84 References 1. Stollman NH, Raskin JB: Diverticular disease of ical entity. Arch Surg 114:1112, 1979 503, 2003 the colon. J Clin Gastroenterol 29:241, 1999 21. Sanford MB, Ryan JA Jr:The proper surgical treat- 36. Dwivedi A, Chahin F, Agrawal S, et al: 2. 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