Uncomplicated Diverticulitis nonsurgical treatment

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Uncomplicated Diverticulitisnon-surgical
treatment

• Sanjay Munireddy
• Sinai Hospital of Baltimore

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DIVERTICULOSIS

• Small outpouchings of colonic mucosa and
  submucosa through muscularis externa
• Emanate from weak points in the wall where
  mesenteric blood vessels penetrate the circular
  muscle layer
• Incidence of diverticulosis is about 10 in pts.
  over 40 yrs of age and 50 over the age of 60.
• Sigmoid colon is involved in 90 of the pts.
• Increased intraluminal pressure thought to be the
  cause (constipation, colonic spasms etc.)

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DIVERTICULITIS

• Complication of diverticulosis
• Causes
• Impaction of feces or hardened mucus within the
  diverticulum
• Increased intraluminal pressure
• Symptoms fever, lower abd pain, nausea,
  vomiting, irregular bowel habits
• Complicated diverticulitis obstruction, abscess
  or fistula formation, perforation

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Diverticulitis

• 15-20 pts. with diverticulosis develop
  symptomatic diverticulitis
• 15-20 of those with diverticulitis develop
  complications
• As many as 20 of pts with diverticulitis are lt50
  yrs of age

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DIVERTICULITIS

• Initial episode of uncomplicated diverticulitis
  is managed conservatively with admission, IV
  fluids, IV antibiotics
• If symptoms/signs persist gt48 hrs despite
  antibiotic therapy, consider CT scan to r/o
  abscess
• Small abscesses lt5 cm respond to abx and larger
  ones require percutaneous drainage

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Recurrent Uncomplicated Diverticulitis

• Uncomplicated cases should be managed
  conservatively
• Risk of recurrent diverticulitis after initial
  non-op management is lower and hence do NOT
  mandate elective colectomy1
• Overall recurrence rate 13.3 and annual
  recurrence rate is 2 per year 1
• Controversial regarding mgt. of young pts. (lt50
  yrs of age)
• 1 Broderick-Villa et. al Archives of Surgery
  140(6), June 2005 576-583

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Uncomplicated Diverticulitis

• Some have suggested that diverticulitis is more
  virulent and hence more complications occur in
  young pts.
• However, others have suggested NO significant
  difference b/w younger and older patients 2
• At least 4 out of 5 young pts. would NOT be
  expected to have recurrence and it would be
  difficult to recommend operative intervention
  based solely on age1
• 2 Ambrosetti et. Al J Am Col Surg 1994 179
  156-160
• 1 Broderick-Villa et. al Archives of Surgery
  140(6), June 2005 576-583

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Uncomplicated Diverticulitis

• Mortality rate after elective resection increases
  from 0 to 15 with increasing age 3
• Elective resection was associated with higher
  rates of MM than elective resection for
  colorectal carcinoma 3
• 3 Bokey et. al Dis Colon Rectum 1981 24 181-182

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Uncomplicated Diverticulitis

• Surgery is often NOT the end of these patients
  problems
• 1 to 10.4 develop recurrent diverticulitis after
  resection of whom 0 to 3.1 require a further
  resection 4
• Persisting symptoms are found in 27-33 of
  patients who undergo resection 5
• 4 Benn et. al Am J Sur 1986 151 269-171
• 5 Munson et. Al Dis Colon Rectum 1996 39 318-322

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Uncomplicated Diverticulitis

• Ambrosetti 6 et. al attempted to randomize pts.
  to elective colectomy or conservative treatment
  after 1st attack.
• After a mean f/u of 19 months, only 4/52 pts.
  (8) had recurrence
• 6 Ambrosetti et. Al Br J Sur 1992 79 117-119

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Uncomplicated Diverticulitis

• No role for prophylactic resection as only 26
  had a history of diverticular disease before
  presenting with complications 7
• Once a pt. definitely recovers from an episode of
  diverticulitis, his risk of suffering
  diverticulitis approximates that of the general
  population with diverticulosis 8
• 7 Somsekar et. al J R Col Sur Edin 2002 47
  481-484
• 8 Haglund et. al Ann Chir Gyn 1979 68 41-46

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• Inadequate evidence to suggest that complications
  are more likely to occur with each successive
  hospital admission 9
• Well designed prospective trials are required if
  specific recommendations are to be made.
• 9 Janes, S et. Al Br J Surg 2005 92(2) 133-142