Management of Diverticulitis
MENGDA ZHANG, JMS
Case
HPI: 47 yo female with hx of HTN and diabetes c/o
persistent right abdominal pain that has worsened
since last November.
- diagnosed with diverticulosis in 2005 by colonoscopy.
Also showed small ventral hernia and bilateral ovarian cysts
- 4 hospitalizations with IV antibiotic treatment since
November 2013
- Pain has become more constant, does not radiate. Pain is
worsened after a meal.
Case
Past Surgical Hx
Cesarean section
Hysterectomy
Open cholecystectomy
PMH/Meds
HTN: takes furosemide, beta blockers, olmesartan
Diabetes Mellitus: managed with insulin
Asthma: managed with fluticasone, Tiotropium
Back pain: Percocet
CT Scan 7/25
Diverticulitis
Patient CT
Pre-op Labs
B-hCG pregnancy test: negative
Metabolic Panel: wnl except for elevated glucose
(250mg/dl)
CBC with differential: wnl
WBC count: 7.0
Colonoscopy: confirms diffuse diverticulosis.
Negative for masses or polyps
Physical Exam
Abdomen: Soft, slight right sided tenderness to deep
palpation, non-distended. Well healed right
subcostal and low midline scars.
Diagnosis/Treatment
Recurrent chronic right-sided diverticulitis treated
with IV antibiotics during acute episodes.
After discussing risks and benefits of surgery, patient
underwent elective right hemicolectomy with
primary anastomosis.
Post-Op
No complications
POD2, WBC count elevated to 15.4; Normalized
within next 2 days
d/c home on POD #5 after return of bowel function
and able to tolerate soft diet
Diverticular Disease
Diverticula are small mucosal herniations in the GI
tract, usually occurring where the intestinal wall is
weak like where the vasa recta penetrates the wall
Seen in >65% of patients over 85 years old.
Causes: low fiber diet, constipation, obesity
Sigmoid colon is most common location in caucasians. Right
sided disease more common in Asia
Diverticulitis= inflammation of diverticula. 15% of patients
with diverticulosis develop diverticulitis
Right Sided Diverticulitis
Location: cecum, ascending colon, transverse colon
Common in Asian population (52% vs 49%). Can be
congenital
Patients w R sided disease were younger
Hemicolectomy was more common for right sided
disease, and had lower rate of operative
complications
Symptoms mimic appendicitis
Management of Diverticulitis
Non-surgical: antibiotic therapy, diet changes, OTC
analgesics. Percutaneous drainage of abscess, usually
followed by resection
Surgical: colon resection with primary anastomosis
or Hartmanns procedure
Emergent surgery in complicated diverticulitis=
perforated diverticula
Indications: hemodynamic instability, diffuse peritonitis, or
diverticulitis refractory to conventional therapy
Treating Uncomplicated vs. Complicated
Uncomplicated Diverticulitis:
Colon resection with primary anastomosis with recurrent
disease
Complicated Diverticulitis (rupture/perforation)
For stable patients: IV antibiotics. Schedule surgery
For unstable patients: emergency colon resection followed by
primary anastomosis or Hartmanns procedure
Hinchey Classification
Hinchey Classification
I - localized abscess
II - pelvic abscess
Abscess >5cm should be drained
III - purulent peritonitis
IV - feculent peritonitis
Hinchey I, II can be treated conservatively (abx, soft
diet)
Hinchey III, IV are associated with high mortality, so
surgical intervention is favored
Elective Colectomy for Diverticulitis
2000 ASCRS Practice Parameters: elective
colectomies were performed after 2 episodes of
uncomplicated diverticulitis to prevent future
complications
2014 ASCRS Practice Parameters: individualized
decision for elective resection. recommends against
prophylactic colectomies for uncomplicated
diverticulitis
Addressing the Appropriateness of Elective Colon
Resection for Diverticulitis (2014)
Most emergency colectomies for diverticulitis occur at the
initial hospitalization
<5% patients have to undergo emergent surgery
5-13% chance of recurrent hospitalizations
Recurrence rate 5-11% after resection, 1-5% chance of rescue
colostomy
The incidence of elective colectomy has increased over the
past 20 years, while emergency colectomy rates have stayed
constant
1 in 3 surgeries do not meet the criteria of 3+ hospitalizations or chronic
complication (2010-2013)
Based on complications rates and cost, delay elective
colectomy until at least 4 hospitalizations
Sources
Li D, de Mestral C, Baxter NN, McLeod RS, Moineddin R, Wilton AS,
Nathens AB. Risk of Readmission and Emergency Surgery Following
Nonoperative Management of Colonic Diverticulitis. Annals of Surgery.
2014; 260:3
Simianu VV, Bastawrous AL, Billingham RP, Farrokhi ET, Fichera A,
Herzig DO, Johnson E, Steele SR, Thirlby RC, Flum DR. Addressing the
Appropriateness of Elective Colon Resection for Diverticulitis: A Report
From the SCOAP CERTAIN Collaborative. Annals of Surgery. 2014; 260:3
pg533-9
Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of
sigmoid diverticulitis. Dis Colon Rectum. 2014;57:284294.
Oh HK et al. Surgical management of colonic diverticular disease:
Discrepancy between right- and left-sided diseases.World J
Gastroenterol. 2014 Aug 7;20(29):10115-20
Thank you!
