Large Intestine: Diverticulitis

Diverticulitis

Basics

  • Incidence in Diverticulosis: 4-15%
  • Most Common Source: Left Colon
  • Cause: Perforation (Microscopic or Macroscopic) by Erosion from Increased Intraluminal Pressure
    • Tic Obstruction (Fecalith) & Venous Congestion May Contribute but Now Thought to be Rarer than Previously Thought
  • May be Associated with Colorectal Cancer

Features of Complicated Diverticulitis

  • Hemorrhage
  • Obstruction
  • Stricture
  • Free Perforation
  • Fistula
  • Abscess
  • Purulent or Feculent Peritonitis
  • Unable to Exclude CA

Presentation

  • Abdominal Pain (Classically Constant in LLQ)
  • Fever
  • Nausea & Vomiting
  • Constipation or Diarrhea
  • Urinary Urgency or Frequency

Diagnosis

  • Dx: CT
  • Can Be Made Clinically with Classic Presentation & History of Diverticulitis

Diverticulitis 1

Classification

Hinchey Classification

  • I: Pericolic Abscess or Phlegmon
  • II: Distant Abscess (Intraabdominal/Pelvic/Retroperitoneal)
  • III: Purulent Peritonitis
  • IV: Feculent Peritonitis

Modified Hinchey Classification by Sher

  • I: Pericolic Abscess
  • II: Distant Abscess (Pelvis/Retroperitoneal/Intra-Abdominal)
    • IIa: Amenable to Percutaneous Drainage
    • IIb: Not Amenable to Percutaneous Drainage
  • III: Purulent Peritonitis
  • IV: Feculent Peritonitis

Modified Hinchey Classification by Wasvary

  • 0: Mild Clinical Diverticulitis
  • I: Pericolic Abscess or Phlegmon
    • Ia: Confined Phlegmon
    • Ib: Pericolic Abscess
  • II: Distant Abscess (Pelvis/Retroperitoneal/Intra-Abdominal)
  • III: Purulent Peritonitis
  • IV: Feculent Peritonitis

Other Classification Systems

  • Hughes Classification
  • Kohler Classification
  • Hansen/Stock Classification
  • Siewert Classification
  • Ambrosetti Classification

Modified Hinchey Class 0 2

Diverticulitis Hinchey Class I 3

Diverticulitis Hinchey Class II 2

Diverticulitis Hinchey Class III/IV 4

Treatment

Treatment

  • Uncomplicated (Class 0/Ia): Conservative Management
    • Consider:
      • Bowel Rest with IV Fluid Resuscitation vs Oral Hydration
      • ABX (IV vs Oral) vs None (Controversial)
    • Repeat CT if No Clinical Improvement After 5-7 Days
  • Complicated by Abscess (Class Ib/II)
    • < 3-4 cm: IV ABX
      • Repeat CT if No Clinical Improvement After 5-7 Days
    • > 3-4 cm: IV ABX & Percutaneous Drain
      • If Fails or Unable to Access: Laparoscopic Drain
  • Unstable, Peritonitis or Free Perforation (Class III/IV): Surgical Sigmoidectomy

Surgical Management

  • Surgical Options:
    • Two-Stage Procedures
      • Hartmann’s Procedure with End Colostomy – Traditional Gold Standard
        • Over Half Never Return to the OR for Ostomy Reversal
      • Primary Anastomosis & Diverting Loop Ileostomy
        • Similar Morbidity & Mortality
        • Better Rates of Stoma Reversal
    • One-Stage Procedure
      • Sigmoid Colectomy & Primary Anastomosis without Ostomy
      • May Consider if Stable with Good Nutrition & Minimal Peritonitis
  • Rarely Performed Options:
    • Three-Stage Procedure
      • Proximal Diverting Colostomy
      • Sigmoidectomy
      • Colostomy Takedown
      • Now Largely Replaced by Two-Stage Procedures
    • Laparoscopic Lavage without Resection
      • Generally Not Advised – 3x Increased Risk for Further Invasive Procedures
      • May Consider if No Diffuse Peritonitis with a Contained Abscess or Inflammation Too Severe for a Safe Colectomy

Post-Diverticulitis Management if Managed Nonoperatively

  • Follow Up Colonoscopy in 6-8 Weeks (Evaluate Risk for Cancer)
  • Consider Elective Colectomy
    • Stronger Recommendation After an Episode of Complicated Diverticulitis than Uncomplicated Diverticulitis
    • Statistically Most Likely to Have a Complication with the First Episode than with Later Episodes

Hartmann Procedure 5

References

  1. Anpol42. Wikimedia Commons. (License: CC BY-SA-4.0)
  2. Sartelli M, Moore FA, Ansaloni L, et al. A proposal for a CT driven classification of left colon acute diverticulitis. World J Emerg Surg. 2015 Feb 19;10:3. (License: CC BY-4.0)
  3. Heilman J. Wikimedia Commons. (License: CC BY-SA-3.0)
  4. Naves AA, D’Ippolito G, Souza LRMF, Borges SP, Fernandes GM. What radiologists should know about tomographic evaluation of acute diverticulitis of the colon. Radiol Bras. 2017 Mar-Apr;50(2):126-131. (License: CC BY-4.0)
  5. Terrone DG, Lepanto L, Billiard JS, Olivié D, Murphy-Lavallée J, Vandenbroucke F, Tang A. A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review. Insights Imaging. 2011 Dec;2(6):631-638. (License: CC BY-2.0)