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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.
Introduction
Colonic diverticulitis – the focus of this chapter-should not be confused with diverticulosis, which denotes the mere presence of asymptomatic or symptomatic colonic diverticula. Diverticulitis is an inflammatory-infective complication, developing in 1% to 3% of individuals who harbor diverticula (1). Diverticulosis, which is also termed ‘diverticular disease’, has been only sporadically mentioned prior to the early 1900's. In 1907, Dr. William Mayo reported the first surgical resection for diverticulitis. Thenceforward, colonic diverticulosis has hugely increased in prevalence, affecting 30% of the Western population by the age of 60, and as high as 65% by age of 85 (2). The striking prevalence in the incidence of diverticulosis in the Western world, and its almost absence in Africa, suggests an environmental etiology. The high-residue diets of Africans produce bulkier feces, resulting in a thinner and more elastic colon. The increasingly low-residue diet of the Western-industrial world, on the other hand, brought about a narrow, spastic-contracted diverticula-prone colon (3).
Anatomically, diverticula represent a “balloon-herniation” of the colonic mucosa. It can involve any part of the colon but in 95% of affected individuals the sigmoid colon is involved, usually exclusively. Because more than half of the aging population is affected with diverticulosis and because most of diverticula remain asymptomatic during the affected individual's life, it is perhaps not correct to consider the mere presence of colonic diverticula as a “disease”. Challenged with the term “diverticular disease”, clinicians attributed to diverticulosis, and still do, various non-specific and often functional gastrointestinal symptoms, justifying low threshold for elective operative treatment, which in the majority of cases was and is unnecessary (4). Bleeding is the most common complication of diverticulosis, most often stemming from right colonic diverticula. Diverticulitis, an inflammatory process developing within and around a diverticulum usually, but no exclusively, affects the sigmoid colon. The rest of this chapter is focused on acute diverticulitis of the sigmoid colon and its acute complications.
Pathophysiology
An attractive speculation is that the inflammatory process starts when fecal mater impacts within a diverticulum, obstructing its narrow neck. The ensuing high intra-diverticulum pressure leads to local inflammation and the formation of a “micro-empyema”. When the mucosal wall of the latter gives away, fecal matter leaks into the adjacent otherwise sterile tissues and spaces. This theory remains unproved; what is known is that most cases of clinically significant diverticulitis involve at least a micro-perforation of colonic mucosa, presumably in a diverticulum. Systemic and local host's defenses are now mobilized to confine the invading peri-colonic infection; their success or failure are responsible for the wide spectrum of disease processes, which may follow (5, 6).
The spectrum of disease (table I) ranges from acute simple diverticulitis, which represents a localized “phlegmon”-without pus formation, and nearly always responds to conservative treatment, to a free intra-peritoneal perforation causing diffuse fecal peritonitis, for which an emergency laparotomy is mandatory. The middle of the spectrum is occupied by a peri-colonic abscess, which may or may not require an operation, and can subsequently perforate into an adjacent viscus (e.g. bladder, vagina), causing a chronic fistula.
Table I
Acute sigmoid diverticulitis: spectrum and treatment.
Clinical manifestation
These varies according to the severity of the process. Acute simple diverticulitis manifests as a “left sided appendicitis”. Note, however, that the sigmoid colon may be redundant and mobile, with symptoms and signs of local inflammation presenting anywhere at the lower abdomen. Physical findings range from local tenderness and “fullness” to full-blown peritonitis. A diverticular “mass” may be palpable per rectum. The presence of temperature and high white cell count denotes active inflammation.
Level of evidence
The diagnostic and therapeutic approach to acute diverticulitis will be discussed in details. However, in this day and age of evidence-based medicine (and surgery) it is important to note the quality of evidence (or the lack of it) on which this chapter is based. Critically reviewing 316 publications on acute diverticulitis, O'Kelly and Krukowski found that only one represented a prospective-controlled study, the rest reflecting retrospective case-series or “expert opinions” (7). It must be also emphasized that in the majority of patients suffering from acute diverticulitis an operation is not needed, but when indicated it is life-saving and should not be delayed. Against this setting of low-level evidence we will suggest a practical diagnostic and therapeutic approach to acute diverticulitis. We will emphasize that the punishment (treatment) should be tailored to the crime (severity of the disease).
Diagnosis
The majority of patients present with a left lower abdominal pain and tenderness, with or without fever and leukocytosis. They suffer from simple phlegmonous diverticulitis and will respond to a few days of conservative treatment. A minority, which presents from the beginning with an “acute abdomen”, with or without evidence of free air on plain abdominal X ray, requires usually an urgent operation. It is the group of patients who fall “in between” the two groups mentioned above that may require special investigations. The two main diagnostic procedures, which may be used, are a contrast enema (8) and a CT scan (9).
Contrast enema
This should be a low-pressure-“gentle” enema using water-soluble contrast (e.g. gastrografin). It may demonstrate diverticula, mucosal edema, luminal irregularity and occasional extravasation of contrast. It may also document an associated sigmoid obstruction or a fistula into an adjacent organ. The presence of extra-luminal contrast and/or air denotes “severe” acute diverticulitis (9).
Do note that radiologists have an irritating habit of preferring barium as a contrast medium. But barium may be dangerous; if leaking into the free peritoneal cavity it “protects” the bacteria, enhancing their virulence. Once spilled barium is difficult to eliminate even during subsequent surgery. Forbid your radiologists using barium in this situation!
With the availability of the CT scan (see below) we currently do not find any indications to perform a contrast study in acute diverticulitis other than to document obstruction. CT is more expensive but has a few advantages over the enema.
CT scan
A “routine” CT is performed using oral contrast. This should be “enhanced” adding a gentle rectal enema with water-soluble contrast. By avoiding the use of Intra-venous contrast, visualization of extra-colonic contrast material or contrast within bladder would be presumptive evidence for either bowel perforation or a colo-vescical fistula, respectively (10). Air bubbles within the urinary ladder signify a fistula.
Ambrosetti et al in Geneva (11) devised criteria to grade acute diverticulitis on CT in a clinically meaningful way:
Simple attack: bowel wall thickness of more than 5 mm with signs of inflammation of the pericolic fat.
Severe attack: In addition to the above: abscess, extraluminal gas or leakage of contrast. The authors' experience showed that the sensitivity of CT for diagnosis of diverticulitis was 96%, compared to 87% for water soluble contrast enema (p < 0.0001). Severe diverticulitis was found in 139 patients (30%) by CT and in 45 patients (11%) by water soluble contrast enema (p < 0.0001). Age < or = 50 years, severe diverticulitis in the initial CT and associated pelvic abscess were found to be statistically significant parameters to predict the risk of secondary complications after a first episode of diverticulitis successfully treated medically. About half of the patients found on CT to have a “severe attack” required an operation during the current admission or subsequent to it.
Note however that half of the patients stratified by CT as “severe” diverticulitis do not require an operation. This suggests that a “routine” CT in all patients with acute diverticulitis is not indicated. It should be reserved, selectively, for patients who fail to improve after a day or two of conservative therapy- in order to diagnose an abscess or fistulization. The CT findings are to be used together with the clinical picture in tailoring the proper management.
Non operative treatment
Ambulatory vs. hospital management
Traditionally, patients with simple, phlegmonous diverticulitis are admitted to the hospital; they are kept nil per mouth and on IV fluids. Wide spectrum antibiotics are given and continued until local and systemic inflammatory manifestation subsides. The colon however contains feces and will contain feces even after a few days of starvation. So what is the rational of the “traditional” regimen? We contend that in the absence of an associated intestinal ileus you may feed your patient or at least provide him with oral fluids instead of the IV. The same is also true concerning antibiotics: a perfectly adequate “coverage” of anaerobic and aerobic colonic bacteria can be achieved using oral agents. So if IV therapy is not necessary-why admit the patient at all? And, in fact, mild acute diverticulitis can be managed with oral antibiotics on an outpatient basis. Patients who manifest significant local and systemic inflammatory findings deserve an admission and appropriate supportive and resuscitative measures.
Pharmacological treatment
Specific drugs
The choice of suitable antibiotics is wide; monotherapy or combination therapy may be used, provided the chosen drug(s) are effective against the usual fecal flora-including gram negative aerobic bacteria (e.g. E.Coli) and the colonic anaerobes (e.g. B. Fragilis). There is no evidence that Streptococcus. Fecalis (Entrococcus) must be covered as well (6). Numerous agents are available and none has been shown to be superior. Thus, the clinician should choose the cheapest and safest regimen. Our personal preference includes an oral combination of metronidazole and ciprofloxacine for “mild” disease. When intra-venous therapy is needed we would use a combination of metronidazole with any agent which is active against enteric aerobes.
Duration
This is based more on gut feeling than on evidence for no studies examined the duration of antibiotic administration in the non-operative management of surgical infections. Rational dictates, however, that treatment should be administered until clinical symptoms and signs of active inflammation disappear. For an in depth discussion on the duration of administration consult a recent monograph dedicated to this issue (12).
Culture
Antibiotic management of acute diverticulitis is empiric-based on the predictable spectrum of pathogens involved in the process (e.g. we know which bacteria are present in feces). Thus, we do not culture any specimens obtained from the tissues involved in the process of acute diverticulitis.
Efficacy
Out of the 410 patients prospectively studied by Ambrosetti and Morel (9) 76% responded to non-operative management and 132 were operated during their hospitalization. Krukowski's personal series is even better: 93 out of 110 patients (85%) admitted with acute diverticulitis responded to non-operative treatment-two died (7).
Management of ‘diverticular abscesses’
When local and systemic signs of acute diverticulitis fail to improve on conservative treatment further action is needed. Spreading peritonitis and increasing systemic inflammation accompanied by tachycardia, tachypnea, hypovolemia with oliguria, hypoxia or acidosis, indicates an operation. But in a “non toxic” patient with localized abdominal findings a CT is indicated. What to do when an abscess is visualized on CT?
Ambrosetti et al. (13), routinely CT scanning their 140 acute diverticulitis patients, found “diverticular abscesses” in 22 (16%). Ten of the abscesses nested within the sigmoid mesocolon, 9 were ‘pelvic’ and the rest ‘intra-abdominal’. The “best” therapeutic approach to CT- detected abscesses is controversial. In North America, an immediate recourse to CT-guided percutaneous drainage (PCD) is popular (14,15). In the UK and the Continent even abscesses are treated selectively as discussed below.
CT-guided percutaneous drainage (PCD)
Technical aspects of this are discussed in details in another chapter in this book on intra-abdominal abscesses.
Stabile et al. (15) performed PCD in 19 patients with ‘diverticular abscess’. All had large paracolic or pelvic abscesses, with a mean size of 8.9 cm. There were no complications related to catheter placement, and 15 required drainage for less than 3 weeks. Inflammation resolved rapidly, and only two patients had persistent fever or leukocytosis beyond the third day of drainage. In these authors experience (15) 74% of patients undergoing the PCD completed the treatment plan of preoperative catheter drainage followed by single-stage sigmoid colectomy and primary anastomosis without complications. Routine sinography (e.g. the injection of contrast material through he PCD catheter) revealed fistulous communications to the colon in nine patients (47%), but only three (16%) had grossly feculent drainage. The latter had inadequate control of infection, suggesting the need for early operation and fecal diversion in such cases. The authors concluded that that preoperative PCD obviates the need for colostomy and multiple-stage surgery in approximately three-fourths of patients with large diverticular abscesses.
Conservative treatment of diverticular abscesses
Ambresetti's updated prospective experience includes 61 diverticular abscesses diagnosed by CT (9). Fifty-seven mesocolic and pelvic abscesses were treated conservatively and only underwent PCD in the absence of clinical improvement within 48 hours. The majority of mesocolic abscesses (82%) and pelvic abscesses (70%) settled without any invasive procedure. The size of the abscess is a predictor; most abscesses which are smaller than 5 cm' respond to conservative treatment (16).
Thus, do not get “excited” when radiologists reports a ‘small’ peri-colic, diverticular abscess on CT. Do not rush for PCD even if the radiologists “recommends” it. Most of this abscesses, especially if mesocolic, pelvic and “small” will resolve, probably by spontaneously draining back into the lumen of the bowel.
Emergency surgery for acute diverticulitis
Should you choose to follow the approach hitherto presented, between 15% to 25% of your acute diverticulitis patients will need an emergency laparotomy. A few- those presenting with diffuse peritonitis, free air and toxicity will be rushed to the operating room after a brief period of optimization. Others will be operated a day or two after admission, because they failed, or deteriorated on, conservative treatment or PCD.
When discussing emergency surgery for acute diverticulitis two issues stand out:
- a.
Should the affected segment of colon be resected;
- b.
Should intestinal continuity be restored after resection; e.g. to do or not to do an anastomosis? In simple terms the surgeon has the following options:
- Divert only -do a diverting proximal colostomy.
- Resect the affected segment of colon-do a sigmoidectomy without an anastomosis (e.g. Hartmann's procedure).
- Resect the affected segment of colon-do a sigmoidectomy with a colorectal anastomosis.
Diverting colostomy
This was the procedure of choice since the early years of 20th century, and for many decades until as late as the 1980's.
It consists of a laparotomy with an appropriate ‘peritoneal toilet’, after which the inflamed or perforated sigmoid colon is drained and a proximal, ‘diverting colostomy’-usually a loop, transverse one- is performed. Subsequently, after the patient “improves”, the sigmoid is resected – the “second stage”. The colostomy is closed during yet another operation-the “third stage”. The problem with this approach was that it left in situ a diseased, perforated organ, with a column of feces proximal to it (distal to the colostomy) – continuously perpetuating the local and systemic infection. Gradually surgeons realized that:
- a.
The mortality and morbidity of an immediate resection of the sigmoid was lower than that of diverting colostomy (17).
- b.
Each of the subsequent stages carried additional morbidity and mortality (18).
- c.
Only about half of the patients had eventually their colostomies closed (19).
The only high level study which deals with this issue – by Kronborg defends the “orthodox-conservative” approach (20). A prospective randomized trial was carried out on 62 patients with diffuse peritonitis from perforated diverticulitis of the left colon, comparing acute transverse colostomy, suture and omental covering of a visible perforation with acute resection without primary anastomosis. For purulent peritonitis the postoperative mortality rate was significantly higher after acute resection (six of 25) than after colostomy (none of 21). Significantly, however, stomas became permanent in four of 25 patients with diverticulitis surviving acute colostomy and in seven of 22 surviving acute resection. Kronborg concluded that suture and transverse colostomy is superior to resection for purulent peritonitis because of the lower postoperative mortality rate and in spite of the shorter hospital stay in those surviving acute resection.
The “current consensus”, however, is that diverting colostomy in acute diverticulitis should be almost totally discarded. It may be indicated in extremely rare situations such as a moribund patient who is judged not to be able to withstand any “greater” procedure (may happen) or when an inexperienced surgeon has difficulties in resecting the diseased colon (should not happen). In 99% of patients undergoing an emergency operation for acute diverticulitis the sigmoid should and can be safely resected.
Hartmann's procedure
In the USA, since the 1970's, sigmoidectomy has become the procedure of choice in the operative management of acute diverticulitis. A colorectal anastomosis was considered unsafe following the emergency resection in an unprepared bowel and amidst the inflamed peritoneum. The term Hartmann's procedure as used today refers to the resection of the entire diverticula-bearing sigmoid colon, down to the colorectal junction at the peritoneal reflection. Proximal diverticula in the descending colon must not be “chased” after since recurrent diverticulitis is extremely rare after the entire sigmoid has been resected (21). After the resection, the rectal stump is closed manually, or with linear stapling device. The proximal colon is exteriorized as an end colostomy.
Resection of the inflamed sigmoid may be “difficult”, endangering adjacent structures such as the ureter. Severely “plastered” diverticulitis has been referred to by some as “malignant diverticulitis” (22) and claimed to be a contra-indication to resection. Using an appropriate technique and staying “near the bowel” an experienced surgeon should be able to resect any sigmoid (23). Pre-operative placement of ureteral stents may offer some protection. A specific complication is a leakage from the closed rectal stump, leading to postoperative pelvic abscess or peritonitis. This complication may be more common than suspected (24). Preventive measures include the closure of the stump at a level of healthy rectal tissue, away from the inflamed sigmoid. Our bias is for a stapled closure.
The two main problems with the Hartmann's procedure are:
- a.
It requires another major operation to re-establish intestinal continuity- an operation with a relatively high morbidity and even fatality rate.
- b.
In at least one third of the patients the colostomy is never reversed (25).
Sigmoidectomy with a colorectal anastomosis
A one-stage sigmoid resection plus an immediate anastomosis could be the ideal operation for perforated diverticulitis, but is it safe? Madden and Tan championed one-stage approach already in 1961 (26) but remained its almost lonely advocates for many years; primary anastomosis in the face of an unprepared colon and adverse local circumstances was considered unsafe by mainstream American Surgery. Since the late 1980's the paradigm has begun to change and primary colorectal anastomosis is being gradually accepted.
The issue of unprepared colon is solved by some surgeons using intra-operative, antegrade colonic lavage (27). Others do not bother with bowel preparation at all (28). Notably, the obsession of surgeons with the need to mechanically prepare the colon prior to an anastomosis is based on more dogma than science. There is ample evidence to suggest that anastomosis can be as safely performed in an unprepared colon as in the well-prepared one (29, 30, 31). Other variables than bowel preparation may be pertinent in the proper selection of patients in whom a primary anastomosis would be advisable. Common sense dictates that the additional time required constructing the anastomosis should not be spent in unstable or critically ill patients. Poor nutritional status (e.g. low serum albumin) or steroid dependence is an adverse prognostic factor, which would deter most surgeons away from the creation of an emergency primary anastomosis. Traditionally, the presence of diffuse, or localized peritonitis, or an abscess represents for surgeons a contra-indication to anastomosis. It appears however that an anastomosis may be safely attempted in selected patients suffering from localized peritonitis or suppuration-as opposed to those with diffuse forms of established peritonitis (28, 32, 33, 34). Avoiding a Hartmann's procedure obviates the costs, risks and morbidity of the additional operation needed to reverse the colostomy.
Current practice
In a recent audit 500 US Gastrointestinal Surgeons were asked: “What is your procedure of choice in a hemodynamically “stable” 72 year old patient suffering from diverticular perforation of sigmoid with localized purulent peritonitis?
Only one third of the responders recommended a one stage procedure in a “good-risk” patient with perforated diverticulitis associated with local peritonitis-most would do it without an ‘on table’ colonic lavage. In “high-risk” patients most surgeons (88%) would opt for a Hartmann's procedure. [Unpublished data]
Emerging therapies
Enthusiastic laparoscopists continue to test their “novel” methods anywhere, including acute diverticulitis. This consists of conventional laparoscopic techniques using “as many ports as deemed necessary”. The procedure may include the “staging” of the process, resection of the sigmoid, and “peritoneal toilet”. Published experience on laparoscopy for acute diverticulitis consists of limited retrospective studies. Authors who attempted sigmoid resection reported a conversion rate of 50% and a morbidity rate of 33% when operating on patients with “advanced” diverticulitis. The results were better in patients with “less advanced disease”-but those are the patents, which may not need an operation at all. As expected, when laparoscopic resection was successfully accomplished-hospital stay was shortened (35). More revolutionary was the laparoscopic approach by Irish (36) and French (37) surgeons. The Irish (37) laparoscopically operated on eight patients with generalized peritonitis, performing “peritoneal toilet” but leaving the involved sigmoid in situ. All their patients recovered uneventfully and remained well during 12 to 24 months of follow-up. The French (37) laparoscopically explored ten consecutive patients for generalized purulent and fecal peritonitis secondary to perforated diverticula. After peritoneal lavage the contaminating sigmoid lesion was covered with biological glue and a drain inserted at the site of the lesion. All patients recovered with low morbidity; nine patients underwent an elective a sigmoid resection (laparoscopic in eight cases) 3 to 4 months later. It appears that laparoscopic resection of the severely inflamed sigmoid represents a formidable procedure and should be attempted by “experts” only and selectively. The novel approach using laparoscopy to treat the peritoneal infection without removing its source-the sigmoid- is potentially exciting but needs further supportive evidence. Looking at the results of O'sullivan et al. (36) a devil's advocate may ask: “Who said that sigmoidectomy is needed in all patients after recovery from complicated diverticulitis?
After the emergency
What to do with the vast majority of acute diverticulitis patients, who recover on conservative management, occasionally aided by percutaneous drainage? Who needs an elective sigmoidectomy, and when-if at all- is controversial. Obviously, the aged, infirm patient who has recovered from a mild attack needs nothing further to be done. The prevailing dogma asserts that any patient admitted twice with documented acute diverticulitis should be considered for operation after taking into considerations his surgical risk. But can we be not more specific?
- Age: it was claimed that acute diverticulitis in the young (< 40 years) is more severe. Out of 67 young patients who responded to conservative management, 55% required a re-admission during follow-up, 23% having a serious complication. Overall half of the 67 underwent eventually sigmoidectomy. The authors concluded that that these results justifies an early elective operation in young patients (38). Others (39), following for 5 to 9 years 30 patients aged less than 50, who recovered for acute diverticulitis, concluded than only one third of them eventually needed an operation-justifying an expectant approach.
- Severity of initial attack: based on their above shown data, Ambrosetti et al. claim that “severe attack” as defined on CT, together with age of less than fifty, predict an operation during the current admission or subsequent to it in about half of the patients (11).
It all depends on your own philosophy. If “aggressive”, you may take a 50% risk of recurrence as an indication for elective sigmoidectomy. If “conservative”, you may consider this risk as an indication for follow-up. The “truth” – as always-probably lies in between these two extremes.
Special note: It is important to exclude colonic cancer after the acute attack has subsided. The cancer may co-exist with, contribute to, or be masked by acute diverticulitis (40). The underlying cancer can be suggested on CT (41) but is usually detected and confirmed on elective colonoscopy-in the aftermath of the acute episode.
Conclusions
Acute diverticulitis of the sigmoid colon is an inflammatory complication, affecting 1–3% of individuals who harbor diverticula. The spectrum of this condition is wide, ranging from simple phlegmonous diverticulitis, which almost always responds to conservative management, to diffuse fecal peritonitis, which mandates an emergency laparotomy. As high level evidence concerning this condition is lacking, we must rely on the multiple available retrospective studies. We advocate a practical diagnostic and therapeutic approach, emphasizing that the treatment should be tailored to the severity of the disease. The diagnosis of acute diverticulitis is clinical. A minority of patients present with diffuses peritonitis and need an emergency laparotomy; the majority present with clinically localized disease and should be treated with wide spectrum antibiotics, effective against E. Coliand B. Fragilis. A CT scan is indicated, selectively, in patients who fail to improve within 24–48 hours, in order to stage the process and document abscess formation. Small peri-colic diverticular abscesses should respond to a prolong course of antimicrobials. Larger abscesses are best managed by percutaneous drainage. At least 75% of patients should resolve on conservative treatment. Failure to improve, or deterioration, mandates a laparotomy, which usually entails a sigmoid resection. When local and systemic circumstances are favorable, a primary colorectal anastomosis is indicated and safe; otherwise a Hartmann's procedure should be performed. In patients who have responded to conservative management a “one stage” elective sigmoidectomy may be indicated: after the second attack, after a first attack which was staged on CT as severe, in “young” patients, or following a successful percutaneous drainage of an abscess. These indications are relative and controversial as up to half of such patients may never suffers a recurrent attack of diverticulitis. Therefore, the decision to operate or not should be carefully individualized. Further evidence is necessary to substantiate early claims that emergency laparoscopic surgery, without sigmoid resection, is an effective treatment of acute diverticulitis. A critical look at the currently-prevalent practices around suggest that probably: we operate too aggressively and too early in acute diverticulitis, we perform too many CT's and carry out too many percutaneous drainage procedures, we remove too many colons, we exteriorize too many colostomies, we re-operate electively on too many patients, and perform too few randomized controlled trials in order to know what is right and what is wrong.
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