Current indications and role of surgery in the management of sigmoid diverticulitis. Luca Stocchi, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 4. United States. Author contributions: Stocchi L performed the research on current literature, analyzed the data and wrote the paper. Correspondence to: Luca Stocchi, MD, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9. Euclid Avenue, Desk A3. Cleveland, OH 4. 41. United States. All rights reserved. This article has been cited by other articles in PMC. Abstract. Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden. Sir John Tusa (born 2 March 1936) is a British arts administrator, and radio and television journalist. He is co-chairman of the European Union Youth Orchestra from 2014. Policy Cross-domain Authenticity/Authentication Definitions and Sources Compiled by Seth Dalby December 2004. Classical music commentary with reviews of new releases of baroque opera & early music CDs & historically-inspired stagings and dance. This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations. Wide- spectrum antibiotics are the standard of care for uncomplicated diverticulitis. Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended.
Rather, a more individualized approach, taking into account frequency, severity of the attacks and their impact on quality of life, should guide the indication for surgery. On the other hand, complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life- threatening condition in the case of free peritoneal perforation. Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis. There is not sufficient evidence supporting any changes in the approach to management in younger patients. Conversely, the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals. Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed. Keywords: Sigmoid diverticulitis, Diverticulitis management, Diverticulitis surgery, Acute diverticulitis, Complicated diverticulitis, Perforated diverticulitis, Laparoscopic colectomy. INTRODUCTIONSigmoid diverticulitis is a common disease of the Western World and results in a significant number of hospital admissions. The prevalence of diverticula in the sigmoid increases proportionally with aging and only rarely results in the inflammation referred to as sigmoid diverticulitis. Sigmoid diverticula may cause significant bleeding which is generally unrelated to diverticular inflammation and is generally referred to as diverticular bleeding or bleeding diverticulosis. Bleeding caused by diverticula will therefore not be included in this review article. The spectrum of sigmoid diverticulitis ranges from a single episode of mild sigmoid inflammation amenable to outpatient treatment to a life- threatening generalized peritonitis caused by acute diverticular perforation which requires urgent surgical intervention. The aim of this review article is to analyze the clinical presentation, treatment modalities for the various forms of sigmoid diverticulitis, the indications for elective and urgent surgery and the postoperative and functional outcomes reported in the literature. RISK FACTORS AND PREVENTIVE STRATEGIESThere are few studies which present evidence of a causal relationship with preventable factors. The data obtained from a prospective cohort of 4. Obesity is significantly associated with an increased incidence of both diverticular bleeding and diverticulitis, which have often been considered together in the studies from this large dataset. The relative risk of diverticulitis was found to be between 1. BMI), waist circumference or waist to hip ratio were considered. Correspondingly, physical activity, particularly if vigorous, is associated with decreased incidence of sigmoid diverticulitis and diverticular bleeding. A diet with an increased fiber intake, particularly cellulose, is also significantly associated with a decreased risk of diverticular disease. On the other hand, the presumed correlation between incidence of sigmoid diverticulitis and the consumption of nut, corn and popcorn has not been confirmed when analyzing this large prospective cohort of men. With respect to the use of medications, the regular and consistent use of nonsteroidal antiinflammatory drugs and acetaminophen is associated with symptoms of severe diverticular disease, particularly bleeding. Localized peritoneal reaction with guarding and rebound tenderness may be noted. Fever and elevation of the white blood cell count can aid in the diagnosis when present. A redundant sigmoid colon may reach the right lower quadrant, and sigmoid diverticulitis under these circumstances may resemble acute appendicitis. In cases of complicated diverticulitis a stricture may lead to obstructive symptoms with nausea and vomiting as the most noticeable symptoms. On the other hand, a history of recurrent urinary tract infection, dysuria with or without urgency, pneumaturia and fecaluria can suggest a colovesical fistula. When a patient reports passing stools per vagina, insertion of a vaginal speculum can reveal a fistulous opening at the vaginal apex, thus confirming a colovaginal fistula. A previous history of hysterectomy is a valuable clinical clue to the correct diagnosis as colovaginal and colovesical fistulas are rare in females with their uterus in place, as the uterus becomes a screen interposed between the inflamed colon and the bladder and vagina. Less commonly, sigmoid diverticulitis can involve other surrounding structures and cause coloenteric, colouterine or colocutaneous fistulas. A full colonoscopy should be typically avoided during an episode of acute diverticulitis because of an increased risk of perforation. In select cases and experienced hands, a gentle flexible sigmoidoscopy can provide additional information and help rule out alternative diagnoses such as cancer, inflammatory bowel disease, or ischemic colitis. Computed tomography (CT) is the most commonly used imaging modality to determine the diagnosis of sigmoid diverticulitis. In this respect, CT has supplanted barium enema and gastrografin enema in the routine evaluation of the sigmoid colon. It can also help establish a differential diagnosis with other conditions which might exhibit similar symptoms such as gynecologic or urinary tract disorders. Irritable bowel syndrome and diverticulitis may present with similar symptoms and physical findings. It is therefore important to confirm the diagnosis of sigmoid diverticulitis by imaging before recommending surgery. CLASSIFICATIONS OF SIGMOID DIVERTICULITIS AND IMPLICATIONS FOR MANAGEMENTIt is appropriate to classify sigmoid diverticulitis into different categories as the morbidity and mortality of this condition are greatly variable. Traditionally, the Hinchey classification has been used to subdivide sigmoid diverticulitis into subgroups based on the degree and extent of the abdominal and pelvic disease identified at the time of surgery and associated with perforated diverticular disease of the colon. Of note, Hinchey credited Hughes for the development of an earlier, similar classification in 1. The Hinchey classification, developed before the advent of routine CT imaging, remains the most widely used classification and a few updated modifications have therefore been proposed in recent years (Table . In fact, the original Hinchey classification might not be the most practical classification to help in the contemporary management of at least some cases of diverticular disease. For example, the Hinchey classification separates a pericolic abscess (Hinchey 1) from a distant abscess (Hinchey 2). However, larger pericolic abscesses and similarly sized distant abscesses might carry similar morbidity and require similar management. In these cases, more important factors in the clinical management of this complication of diverticular disease might instead be the abscess size, location in the pelvis or mesocolon and also the ability to percutaneously drain the abscess regardless of its vicinity to the sigmoid, and therefore maximize the feasibility of a subsequent one- stage operation. In this respect, some proposed modifications of the Hinchey classification specifically include the ability to percutaneously drain the abscess. Furthermore, the Hinchey classification was developed based on the description of surgical findings and was not specifically designed to evaluate cases of sigmoid diverticulitis treated with antibiotics only. More recently, CT scanning has become the imaging modality of choice to diagnose sigmoid diverticulitis and has been proposed as being the imaging modality providing the most important and valuable indication as to the likelihood that medical treatment with antibiotics will fail. In this regard, Ambrosetti et al. On the other hand, the term “severe disease” is used instead in the case of abscess, extraluminal air or extraluminal contrast extravasation (Figure . A: Uncomplicated sigmoid diverticulitis with colonic thickening and straining at CT (arrow), also referred to as “mild” CT diverticulitis. Two diverticula contain contrast medium without evidence of extravasation outside.. UNCOMPLICATED DIVERTICULITISWhen the inflammatory process is limited to the sigmoid it is generally treated with antibiotics. If symptoms are not severe and the patient is otherwise healthy and compliant with medical treatment, wide spectrum antibiotic treatment can be administered orally on an outpatient basis and the patient followed with serial office visits. On the other hand, if the patient is systemically ill, elderly or has significant comorbidities, a hospital admission and treatment with intravenous antibiotics are warranted.
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