Advances in the Management of Uncomplicated Sigmoid Diverticulitis
James A. Harris, M.D., FACS
Diverticulitis is the most common complication of sigmoid diverticulosis. The process by which a sigmoid diverticulum becomes inflamed is similar to that causing appendicitis, in which the diverticulum becomes obstructed at its neck by inspissated stool. This leads to distention and ischemia of the diverticulum and finally perforation and infection of the peridiverticular tissues.
Uncomplicated diverticulitis occurs when the infection is localized to the pericolonic fat and mesentery. Complications of diverticulitis include free perforation and peritonitis, abscess formation, sepsis, intractable signs and symptoms and colon obstruction.
The extent and location of the perforation determines its clinical behavior and treatment. Acute uncomplicated sigmoid diverticulitis typically causes left lower quadrant and/or suprapubic pain and tenderness, change in bowel habits, fever and leukocytosis. The diagnosis can usually be ensured by history and physical exam. Because diverticulitis is a predominantly extraluminal disease, barium enema and colonoscopy can be inaccurate and possibly unsafe. Computed tomography has the ability to assess transmural and extraluminal disease and is the diagnostic modality of choice. It can be used when the diagnosis is in question or to look for complications of diverticulitis. Colonoscopy or barium enema is typically delayed for several weeks after recovery.
The treatment of diverticulitis depends on its severity. A patient with mild symptoms can be treated as an outpatient with a clear liquid diet and a 7-10 day course of broad-spectrum oral antibiotics with activity against anaerobes and gram-negative rods. Appropriate antibiotic choices are amoxicillin with clavulanic acid, a quinilone plus metronidazole or sulfamethoxazole/trimethaprim plus metronidazole. Patients with significant signs of inflammation, high fever, marked leukocytosis, elderly patients, immunocompromised patients or those with significant comorbid conditions should be admitted to the hospital for bowel rest, IV fluids and IV antibiotics. There are several appropriate antibiotic combinations including metronidazole or clindamycin with an aminoglycoside or third generation cephalosporin. Alternatively, single agent coverage might include a second generation cephalosporin or a B-lactamase inhibitor combination. Noticeable improvement should occur within 2-3 days.
Surgery is usually not necessary after one episode of uncomplicated sigmoid diverticulitis, as the recurrence rate is only 30%. However, the recurrence rate after two episodes is greater than 50%, and surgical treatment should be strongly considered. Elective resection is best scheduled 4 to 6 weeks after recovery. Special consideration should be given to younger patients (< 50 years). The recurrence and complication rate are much higher in younger patients and elective resection should be considered after one episode. Similar recommendations apply to immunocompromised patients, as their complication rate from diverticulitis is increased.
A major advance in the surgical management of uncomplicated sigmoid diverticulitis is the advent of laparoscopic colorectal resections. Similar to other operations in the abdomen, the laparoscopic approach has been shown to have clear advantages over the traditional open approach (see Table). Less bowel manipulation causes less postoperative ileus and earlier return of bowel function. Patients are begun on a diet the first postoperative day and are discharged after 2 to 4 days. Postoperative pain is less which decreases narcotic use. This allows earlier ambulation and fewer complications such as venous thrombosis and pneumonia. The laparoscopic approach has become the standard of care in many hospitals for diverticulitis, particularly in patients undergoing elective resections for uncomplicated disease.
References
Stollman NH, Raskin J. Diverticular Disease of the Colon. J Clin Gastroenterol 1999;29(3):241-252.
Hong D, Lewis M, Tabet J, et al. Prospective Comparison of Laparoscopic versus Open Resection for Benign Colorectal Disease. Surg Laparosc Endosc Percutan Tech 2002;12(4):238-242.
Schwenk W, Bohm B, Muller JM. Postoperative Pain and Fatique after Laparoscopic or Conventional Colorectal Resections. A prospective randomized trial. Surg Endosc 1998;383(1):49-55.
