Practice Parameters for

SigmoidDiverticulitis

Janice F. Rafferty, M.D.

Professor, University of Cincinnati

Department of Surgery

Chief, Division of Colon and Rectal Surgery

Cincinnati, Ohio, USA

Practice Parameters for Sigmoid

Diverticulitis Paul Shellito, M.D. Neil H. Hyman, M.D. W. Donald Buie, M.D. Standards Committee of The American

Society of Colon and Rectal Surgeons

Dis Colon Rectum 2006; 49: 939–944

Practice Parameters for Sigmoid

Diverticulitis Published literature from January 2000 to

August 2005 was retrieved and reviewed. Searches of MEDLINE were performed by

using keywords: diverticulitis, diverticulosis, peridiverticulitis, and fistula.

Levels of Evidence I Meta-analysis of multiple well-designed, controlled studies,

randomized trials with low-false positive and low-false negative errors (high power)

II At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)

III Well-designed, quasi experimental studies, such as nonrandomized, controlled, single-group, preoperative-postoperative comparison, cohort, time, or matched case-control series

IV Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies

V Case reports and clinical examples

Adapted from Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of evidence and clinical recommendations on theuse of antithrombotic agents. Chest 1992;102(4 Suppl):305S–11S

Grade of Recommendation

A Evidence of type I or consistent findings from multiple studies of Type II, III, or IV

B Evidence of Type II, III, or IV and generally consistent findings

C Evidence of Type II, III, or IV but inconsistent findings

D Little or no systematic empirical evidence

Statement of the Problem

Acquired colonic diverticular disease affects the sigmoid colon in 95 percent of cases.

Thirty-five percent of patients with sigmoid diverticulosis also have more proximal diverticuli

Diverticula are rare below the pelvic peritoneal reflection. Prevalence correlates with age:

* 30 percent by age 60 years

* 60 percent of those 80 years and older

10-25 % of those with diverticulosis -> diverticulitis

Diverticular Disease

2.2 million cases

(2 billion dollars) Sandler Gastroenterology

2002

Health care costs-

$1.7 trillion www.cms.hhs.gov/statistics

(accessed 4/1/2005)

Diverticular Disease-Etiology

Deficiency of dietary fiber (Burkitt and Painter Lancet 1972, Backo BJS 2001:88:1595, Aldoori AM J Clin Nutr 1994)

Segmentation and high intra-colonic pressures

Aging (decreased tensile strength of collagen and muscle fibers)

Hereditary disorders (Marfan’s and Ehler’s Danlos syndrome)

Initial Diagnosis

History and physical exam Helpful tests: KUB, CBC, urinalysis (V,D) Alternative diagnoses: *irritable bowel syndrome * gastroenteritis

* bowel obstruction * IBD

* appendicitis *ischemic colitis

* colorectal cancer *urinary tract infection

*kidney stone *gynecologic disorder

Acute DiverticulitisMaking the Diagnosis

Signs and SymptomsFeverLeukocytosisleft lower quadrant pain with

or without mass

Initial Diagnosis: CT Scan

Accuracy enhanced by enteral contrast Highly sensitive and specific High PPV for inflammation and wall thickness Can identify complications “Severity staging” possible III, A

CT Scan: Severity Staging

More severe inflammation predictive of

* Failure of medical management

* Future complications

Detry R, James J, Kartheuser A, et al. Acute localized diverticulitis: optimum management requires accurate staging.

Int J Colorectal Dis 1992;7:38–42

Chautems RC, Ambrosetti P, Ludwig A, Mermillod B,Morel P, Soravia C.Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgerymandatory? A prospective study of 118 patients. Dis Colon Rectum 2002;45:962–6

CT Criteria to assess severity of

DiverticulitisMild

Localized sigmoid wall thickening (>5 mm) Inflammation of pericolic fat

Severe

Abscess Extraluminal air Extraluminal contrast

Ambrosetti et al Dis Colon Rectum 2000:43:1363-7

Acute DiverticulitisHinchey Classification

Stage I Pericolic Abscess Stage II Pelvic,

Retroperitoneal or intra-abdominal abscess

Stage III Purulent Peritonitis

Stage IV Fecal Peritonitis Hinchey et al Adv Surg 1978:12:85-105.

Phlegmon

Phlegmon

Free Air

Diagnosis: Other modalities

Ultrasound Barium enema Flexible sigmoidoscopy Cystoscopy III, B

Acute Diverticulitis

Contrast enema findings “Deformed diverticula” Extravasation of contrast Intramural fistulization Spasm Stricture Diverticulosis

Fistula

Medical treatment of acute diverticulitis

Nonoperative treatment typically includes dietary modification and oral or intravenous antibiotics (III, B)

Successful in 70-100 % of patients. OUTPATIENT MANAGEMENT: appropriate IF NO

* fever

* excessive vomiting

* marked peritonitis Must have opportunity for follow-up Patient should be able to take liquids and antibiotics PO

CT guided drainage

15% will have pelvic or mesenteric abscess >2cm abscess: in patient care plus drainage <2cm: may resolve without drainage May allow multi-staged approach Stoma avoidance III, B

Role of Percutaneous Drainage

Well Defined Abscess “Radiologic Window” Contraindicated in

patients with generalized peritonitis or pneumoperitoneum

Generally NOT necessary for patients with small pericolic abscesses

Emergency surgery for acute diverticulitis (III,

B) Severe or diffuse peritonitis (Hinchey 3,4) Failure of medical management Surgical options:

* Hartman’s procedure

* primary anastomosis (Hinchey 2-3)

* anastomosis with proximal diversion

Hartmann Resection

Elective surgery after uncomplicated diverticulitis

Evaluate on case by case basis 1/3 will have episode within one year Additional 1/3 will have a third attack Elective resection may not decrease

likelihood of complications Worst episode=first episode III, B

Elective surgery after uncomplicated diverticulitis

CT graded severity predictive of natural history: more sever= worse outcome

Inability to exclude carcinoma Immunosuppression

Natural history of diverticulitis

Age/Severity on CT n Poor Outcome Probability

at 5 yrs

<50/Mild 14 6 36<50/Severe 14 9 54%>50/Mild 74 16 19>50/Severe 16 7 44%

Chautems et al Dis Colon Rectum 2002;45:962-966

Diverticulitis and Renal Disease

184 renal failure patients • 59 PKD• 125 ESRD

12 pts with PKD had acute diverticulitis versus 4 of non-PKD (20% v. 3%)

50% required surgery Suggested diverticular disease may be an

extrarenal manifestation of PKDLederman AM Surg 2000;66:200-3

Young patients with diverticulitis

Virulence appears to be no different Male predominance Longer life=increased cumulative risk? Younger patients more likely to present

with severe disease

Diverticulitis in Young Patients

40 patients - < 50 years old

25% - surgery on first admission

Two- thirds did not require surgery during

the follow-up period of 4-9 years

Vignati et al Dis Colon Rectum 1995;38:627-629.

Diverticulitis in Young Patients:

retrospecive review: 5,499 patients 962 <50 years; 411 had CT with 1st episode of disease

335 (81%) uncomplicated diverticultitis- 234 were followed nonoperatively.

28% recurrent uncomplicated episode,

4% recurrent complicated episode

2% required emergent operation and colostomy.

76 (19%) complicated diverticultitis

23 emergent surgery, 38 elective surgery, 15 non-operative management

7/15 recurrent uncomplicated episode

None required emergent operation or colostomy.

Nelson RS, Velasco A, Mukesh BN.Dis Colon Rectum. 2006 Sep;49(9):1341-5

Young patients with diverticulitis

< 40 years >40 years

Severe 72% 35% p<.02

Emergent Op 40% 13% p<.04

*Pautrat K, Bretagnol F, Huten N, de Calan L. Department of Digestive Surgery, Trousseau Hospital, Tours, France.Dis Colon Rectum. 2007 Apr;50(4):472-7

Complicated diverticulitis

Abscess Stricture Fistula Bleeding

Stricture

Diverticular fistulas

Complicated diverticulitis

41% will develop severe recurrent sepsis Elective resection following abscess

drainage recommended III, B

Kaiser AM, Jiang JK, Lake JP, Atrinvan A, Gonzalez-Ruiz C, Beart RW Jr. Am J Gastroenterol. 2005 Apr;100(4):910-7

Non-operative management of

Complicated diverticulitis Retrospective study- 256 patients with complicated

diverticulitis on CT; 99 managed non-operatively Patient outcomes were reviewed. 46% had a recurrent episode 20 underwent a sigmoid colon resection, 1 required stoma No recurrence resulted in emergency resection

Nelson RS, Ewing BM, Wengert TJ, Thorson AG. Am J Surg. 2008 Dec;196(6):969-72

Extent of resection

Proximal margin: pliable colon without hypertrophy or inflammation

Distal margin: splay of taenia Risk of recurrence higher with colosigmoid

anastomosis III, B

Level of Anastomosis and Recurrent Diverticulitis

Anastomosis Number Recurrence

# (%)

Colocolostomy 321 40(12.5)

Coloproctostomy 180 12(6.7) Total501 52

Benn et al Am J Surg 1986;151:269-71

Laparoscopy for diverticulitis

Appropriate in selected patients No increase in complications Cost and outcomes comparable III, A

Conclusions

Timing and need for surgical treatment of sigmoid diverticular disease remains a topic of controversy.

Elective surgery for diverticulitis can be avoided in patients with uncomplicated disease, regardless of the number of recurrent episodes.

Age of the patient should not influence need for elective surgery

Clinical exam, and radiologic severity index, help determine which patients need operation

Thank youJanice Rafferty, MD

University of Cincinnati

Division of Colorectal Surgery

2123 Auburn AvenueSuite 524

Cincinnati, Ohio 45219(513) 929-0104