Diverticular Disease: The Medical and Nonoperative Treatment of Diverticulitis

Clin Colon Rectal Surg. 2009 Aug; 22(3): 156–160.

doi: 10.1055/s-0029-1236159

Diverticular Disease

Guest Editor
David A. Margolin M.D.

, M.D.¹ and , M.D.¹

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The success of medical management for diverticular disease depends on the patient’s presentation and degree of response to treatment. The patient’s presentation can be grouped into categories using classification systems such as the modified Hinchey system. Clinical presentation and diagnostic studies help to group patients. Mild disease can often be managed with oral antibiotics as an outpatient; more severe disease requires hospitalization, bowel rest, and intravenous antibiotics. Interventions such as percutaneous drainage of associated abscesses may allow successful medical management. Probiotics and antiinflammatories may have a supportive role. Indications for elective resections are discussed.

Keywords: Diverticular disease, medical management, antibiotics, percutaneous drainage

Sigmoid diverticulitis is a common disease process that is treated both medically and surgically. Although we may not have good quality prospective outcomes data to support the way we treat diverticulitis, we aren’t completely without a rational approach based on observational studies. The decision about whether a patient needs surgical therapy or can be managed medically is largely based on two factors: the severity of disease at presentation and the rapidity and degree of response to those treatments.

Upon presentation to the clinic or the hospital with signs and symptoms of diverticulitis, a computed tomography (CT) scan should be considered. This imaging modality can be rapidly obtained, is widely available, and yields reproducible results. The CT scan is superior to a contrast enema in its sensitivity (98% vs 92%) and in the evaluation of the severity of the inflammation (26% vs 9%). It can show other complications of the diverticulitis such as an abscess, phlegmon, adjacent organ involvement, or fistula, as well as identify other pathology such as appendicitis, tuboovarian abscess, or Crohn disease. The two most common signs of diverticulitis on CT scan are bowel wall thickening and fat stranding.^1,2,3

With the aid of CT scanning, patients can be grouped into categories at presentation based upon their imaging findings. Hinchey et al⁴ devised a classification system encompassing four clinical stages of perforated diverticulitis, which was later modified. Kaiser et al retrospectively evaluated the management of the patient based on the modified Hinchey classification (stage 0 mild clinical diverticulitis, Ia confined pericolic inflammation, Ib confined pericolic abscess, II pelvic or distant intraabdominal abscess, III generalized purulent peritonitis, IV fecal peritonitis) at presentation based on clinical, CT, or operative findings. Patients who were in the stage 0 and Ia groups did very well with just antibiotics. Only ~6% of these patients required a semiurgent resection because of an inadequate response to conservative therapy. All patients in stages III and IV underwent an urgent surgical resection. The patients in stages Ib and II were managed with a combination of antibiotics, percutaneous image guided drainage, and surgery. The higher the patient’s stage, the less likely they were to avoid resective surgery, both in the short and long term.⁵ Patients with stage III and IV disease should be managed with surgery; patients with stage I or II disease are generally candidates for nonoperative management. See Table .

Table 1

Hinchey Classification System of Diverticulitis

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Once the patient has been diagnosed with diverticulitis, several more questions regarding their treatment need to be answered. First, should they be hospitalized or treated as an outpatient? Next, which antibiotics should be used and for how long should they be given? Last, what sort of bowel rest will be recommended?

The decision to treat a patient as an inpatient or outpatient is based on clinical criteria, such as the severity of the attack (evaluated by physical exam, laboratories, and CT scan), ability to tolerate oral antibiotics and hydration status, and the comorbidities and reliability of the patient. Mizuki et al⁶ studied the outpatient management of 70 patients with acute diverticulitis. The severity was graded by ultrasound, and those with limited inflammation within a diverticulum to an abscess <2 cm in size were included. They all received 10 days of an oral third-generation cephalosporin. They were initially started on a sport drink for the first 3 days then evaluated. If they worsened, they were admitted. If improved, they were allowed a liquid diet then reevaluated on day #7. Once again, if they were worse, they were admitted. If they were improved, they could have a regular diet. Sixty-eight of 70 patients completed the protocol without complications. They found that the cost of this regimen was <20% of the cost of conventional inpatient care of diverticulitis patients.⁶

An interesting but unanswered question in the care of patients with diverticulitis is whether antibiotics are always necessary. Hjern et al⁷ published a retrospective study of 317 patients with CT-confirmed diverticulitis where some were treated with antibiotics and others were not. The decision was left to the attending surgeon. The patients not treated with antibiotics had a lower temperature, C-reactive protein (CRP), white blood cell (WBC) count, and milder CT scan findings as a group. One hundred eighty-six of 193 patients were successfully treated without antibiotics, with 7 crossing over to the antibiotics group. Their results show that there are some cases where antibiotics are not indicated and further prospective studies are needed to clarify this issue. ⁷

What is the best choice of antibiotics and how long should they be given? There have been multiple controlled studies of antibiotics in intraabdominal infections. The most important factors to consider in selecting antibiotics for diverticulitis are their activity against the most common colonic bacteria, gram-negative rods, and anaerobes. Also, adequate tissue levels must be achieved with an absence of toxicity. For an outpatient oral regimen, a fluoroquinolone such as Levaquin^® (Ortho-McNeil-Janssen Pharmaceuticals, Inc., Titusville, NJ) or ciprofloxacin, or Bactrim^® (Roche Pharmaceuticals, Nutley, NJ) plus either Flagyl^® (Pfizer Pharmaceuticals, New York, NY) or clindamycin is a good two-drug combination. Single-agent regimens choices are Augmentin^® (GlaxoSmithKline, Brentford, London, UK), doxycycline, or moxifloxacin. There are many one or two drug choices for intravenous (IV) therapy as well. Possible two-drug regimens consist of an aminoglycoside, third-generation cephalosporin, aztreonam, or a fluoroquinolone plus either Flagyl^® or clindamycin. Single-agent regimen choices are Cefoxitin^® (Merck & Co., Inc., Whitehouse Station, NJ), cefotetan, moxifloxacin, ampicillin-sulbactam, ampicillin-clavulanate, piperacillin-tazobactam, ticarcillin-clavulanate, imipenem-cilastatin, meropenem, or ertapenem. The patient should be switched from IV to oral therapy when the patient can tolerate a diet and oral medicines. Treating for 7 to 10 days is an acceptable period. Unfortunately, there is no good data about the timing of the transition to oral antibiotics or how long the patient should be treated.

Diverticular abscesses are a common complication of acute diverticulitis, occurring in ~15 to 20% of the cases.^8,9,10 The appropriate management of diverticular abscesses is often debated. According to the ASCRS Practice Parameters for Sigmoid Diverticulitis, “Radiologically guided percutaneous drainage is usually the most appropriate treatment for patients with a large diverticular abscess. ” They recommend hospitalization and IV antibiotics for these patients. If the abscess is <2 cm in diameter, it may resolve with antibiotics alone, whereas larger abscesses should be percutaneously drained. By using this approach, most patients can avoid an emergency operation and a colostomy.³ Other studies have found draining abscesses >4 cm to benefit the patient by reducing the abscess size, pain, fever, and leukocytosis. Ambrosetti et al performed a prospective study of diverticular abscesses and found that pelvic abscesses were more likely to require surgery during the initial admission than mesocolic abscesses. Their recommendations were to drain all pelvic abscesses and mesocolic abscesses that were >5 cm in size, or if no improvement after initial antibiotics.¹¹ A retrospective study comparing the management of abscesses <3 cm and ≥ to 3 cm found successful treatment in all 22 patients treated with antibiotics for abscesses <3 cm in size.¹²

Fistulas are another recognized complication from diverticulitis. Both colo-vaginal and colo-vesicle fistulas can occur. The primary treatment for both of these situations is surgical. In a poor-risk patient, nonoperative therapy may be appropriate. Some patients may develop a small bowel obstruction from sigmoid diverticulitis due to a loop of small bowel being involved in the inflammatory process. This may improve with time as the colonic inflammation improves.

A colonic obstruction can also result from diverticulitis, but is more common in the chronic setting than the acute. A relatively new technology in the management of diverticular disease is colonic stents. Self-expanding metal stents (SEMS) have primarily been used to palliate obstructive symptoms in patients with metastatic or inoperable colorectal cancer and as a bridge to surgery in acute, left-sided colonic obstruction.¹³ Their role in management of benign disease is less clear. Complications such as stent migration, perforation, and epithelialization have all been described. The data for SEMS in benign colonic stricture has been limited to multiple small studies looking at the treatment of benign strictures, which have included patients with Crohn disease, radiation, anastomotic, and diverticular strictures.^13,14,15 Forshaw et al found that the greatest benefit for SEMS was for patients with anastomotic strictures that had failed other therapies. They also concluded that SEMS should be avoided in the case of acute diverticulitis due to a high failure rate, but that stenting for acute obstruction to allow delayed elective surgery is usually straightforward and uncomplicated.¹⁴ Small et al concluded that surgical intervention within 7 days after stent insertion would preclude most delayed complications such as stent migration and epithelialization.¹³

Follow-up of patients with diverticulitis is needed. A colonoscope or flexible sigmoidoscopy should be performed several weeks after the resolution of symptoms to confirm the diagnosis and rule out other causes of the colonic inflammation such as cancer, Crohn disease, ulcerative colitis, or ischemia. Once the colon has been imaged, there are some lifestyle modifications that might alter the chance of recurrence of diverticulitis. Some modifiable factors associated with an increased risk of diverticular disease are constipation, smoking, physical inactivity, treatment with nonsteroidal antiinflammatory drugs, and obesity.^16,17 A high-fiber diet might lower the risk. A low fiber diet has long been associated with the development of diverticulosis of the colon.¹⁸ Fiber supplementation has been found to be beneficial in some studies,^{19,20,21,22,23} though not making a significant difference in others.^24,25 Given its relative safety and benefit to overall colorectal health, fiber supplementation to patients with diverticular disease should be recommended. Without any good evidence, certain foodstuffs such as nuts, seeds, popcorn, and corn have long been implicated in the development of diverticulitis and are often advised against by physicians. They were thought to provoke diverticulitis or diverticular bleeding by causing luminal trauma. In a large prospective study of men without known diverticular disease, Strate et al found that nut, corn, and popcorn consumption did not increase the risk of diverticulosis, diverticulitis, or diverticular bleeding.²⁶

The use of probiotics to prevent recurrence has also been studied. Probiotics are thought to work by altering the local microflora in and around the diverticula of the colon and improve immune responses, thus potentially having a beneficial effect on the microscopic colitis associated with the diverticula.²⁷ One study found that the duration of remission was longer after treatment with the probiotic (14.1 months) than without the probiotic (2.43 months).²⁸ In another study, three groups of patients were followed for one year: one group received mesalamine daily, a second received probiotics plus Vitamin B, and a third received mesalamine and probiotics. Significantly more patients remained asymptomatic in the third group than did the other two.²⁹ Though these studies were small and without control groups, they suggest probiotics may have a positive effect on the recurrence of symptomatic diverticular disease. Nonabsorbable antibiotics have also been studied in the setting of symptomatic uncomplicated diverticular disease. These studies have shown a benefit for cyclic rifaximin.^{30,31,32,33,34} Antiinflammatory agents have been studied as well. There have been several studies that evaluated the efficacy of mesalamine alone or mesalamine plus rifaximin. Mesalamine alone has been shown to be useful in the treatment of symptomatic uncomplicated diverticular disease.^35,36,37 Mesalamine in combination with rifaximin has been shown to be superior to mesalamine alone in relief of symptoms and recurrence of diverticulitis. ^38,39

One of the most debated areas in the management of diverticulitis is the timing and necessity of an elective operation for diverticulitis. After an episode of complicated diverticulitis managed nonoperatively, colonic resection should be recommended. The unanswered question is when to operate on patients with uncomplicated diverticulitis. Using a statistical model, Salem et al recommended surgical resection after the fourth attack.⁴⁰ However, Richards and Hammitt in 2002 recommended waiting until after the third attack.⁴¹ We do know that the most severe attack is usually the first as 53 to 78% of patients will present with perforation at their initial presentation.^42,43,44 On the other hand, a recent study showed that of patients having an emergent colon resection, almost one-third of them had prior manifestations of diverticulitis and confirmed that their postsurgical morbidity and mortality, length of stay, hospital charges, and colostomy rate were significantly higher as compared with patients having an elective colon resection. ⁴⁵ Whether younger patients (<50 years old) have more severe disease is not clear. But we do know that because of their longer lifespan compared with the older patient with diverticulitis, younger patients will have a higher risk of recurrence. The take-home point is that this decision should be made on a case-by-case basis taking into account the age of the patient, other medical comorbidities, the frequency and severity of the attacks, and the persistence of symptoms. The number of attacks should not be the main factor in surgical management. Although there are conflicting data, the current recommendations based on ASCRS practice parameters are that “elective resection should typically be advised if an episode of complicated diverticulitis is treated nonoperatively.” Further studies are needed in this area to define the natural history of recurrent diverticulitis.

The management of diverticulitis is multifaceted. Upon the initial presentation, CT scan findings are a good prognosticator. Most Hinchey stage I and II disease can be managed nonoperatively, whereas stage III and IV disease will likely require surgery. Percutaneous catheter drainage is useful for most diverticular abscesses larger than 2 to 3 cm, but not required. After resolution of symptoms, all patients require colonic visualization to confirm the diagnosis and rule out other pathology. Dietary restrictions after resolution of symptoms are no longer needed and fiber supplementation should be recommended. Most patients with uncomplicated diverticulitis can be successfully managed for more than two attacks, whereas most patients with complicated disease should undergo a colonic resection. The decision to operate electively on a patient with recurrent uncomplicated diverticulitis should be made on a case-by-case basis.³

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symptoms, causes, treatment of diverticulosis in Moscow

Intestinal diverticulitis is a disease characterized by inflammation of the diverticula. These are small, herniated “sacs” of the mucosa, most often appearing in the sigmoid and descending colons, but can also affect the entire intestine. Sometimes there is inflammation of the diverticula, and in some cases infection: this condition is diverticulitis. Another name for the disease is diverticular disease.

Benefits of treatment at EMC

Each patient with diverticulitis is treated at all stages by a multidisciplinary team of doctors

Surgeons with vast experience in performing operations of various sizes and any complexity for diverticulitis

Patients in many cases retain natural digestion (the stoma is not removed).

Use of advanced equipment for diagnostics and surgical treatment

Effective rehabilitation programs based on the medical center at Rublevo-Uspenskoe Highway, 187

Classification of diverticulitis

To determine how much the inflammatory process has spread with an acute complication of this disease, the Hinchey E.J. classification is most often used. It was developed by McGill University professor Dr. E. John Hinchey. He pointed out the symptoms associated with each stage of the disease.

Stage I – Pericolic abscess or cellulitis

Stage IIa – Distant abscess that can be drained percutaneously

Stage IIb – Associated abscess with fistulization

Stage III – Generalized purulent peritonitis

Stage IV – Generalized fecal peritonitis

Causes of disease

The exact reasons why diverticular disease develops are still unknown. Diverticula most often form when a person has natural weak spots in the colon that succumb to pressure. This causes the hernia-like “sacs” to protrude through the wall of the colon. When they rupture, the diverticula become inflamed and infected (i.e., bowel diverticulitis develops). Doctors identify several risk factors for the development of this pathology.

1. Older age: The incidence of diverticulitis increases with age.

2. Obesity: Diverticulitis often occurs when people are overweight.

3. Smokers are more likely to develop diverticulitis.

4. Diverticular disease can be triggered by a lack of physical activity. Regular exercise reduces the risk of developing this disease.

5. A diet high in animal fats and low in fiber is associated with the onset of this disease. It is believed that a diet low in fiber, combined with a high intake of animal fats, over a long period of time leads to an increase in pressure in the lumen of the colon, which provokes the formation of hernia-like “sacs”.

6. Diverticulitis provokes the regular use of certain medications (these are steroids, opioids, and non-steroidal anti-inflammatory drugs).

Diverticulitis symptoms

The symptoms of this disease increase over time. When diverticula become inflamed, symptoms such as abdominal pain appear, which can be persistent and persist for several days. Other common symptoms are nausea and vomiting, fever, constipation, and (less commonly) diarrhea.

Complications

In acute diverticulitis, an abscess is possible – diverticula become inflamed and pus accumulates in them. Inflammation leads to intestinal obstruction, which is caused by scarring. Fistulas (abnormal passages) between the intestines and other organs may also occur. Another serious complication in the acute course of the disease is peritonitis, which can occur if an infected or inflamed diverticulum ruptures and the contents of the intestine enter the abdominal cavity. Peritonitis is manifested by acute symptoms (nausea, vomiting, severe abdominal pain) and requires emergency medical attention.

Diagnosis of diverticulitis

If diverticulitis is suspected, the patient is given a colonoscopy. A camera is inserted through the anus, which allows you to visualize the intestines and allows you to assess its condition (the entire large intestine and the final section of the small intestine). With the help of colonoscopy, it is possible to identify the presence of hernia-like “sacs” and determine the size of their gates, the condition of the wall, and the exact localization. If other suspicious changes in the intestine are detected, colonoscopy allows you to take a biopsy to send the material for histological examination.

Another important study for diverticulitis is irrigoscopy. This method allows you to determine the number of hernia-like “sacs”, their exact location, size and shape. The essence of the procedure is the introduction of a radiopaque drug into the colon, after which a series of x-ray images are taken that allow you to assess the condition of the colon. With the help of computed tomography (CT), it is possible to assess the condition of the intestinal walls, to identify the presence of intraluminal neoplasms and the condition of the surrounding tissues. Most often, this study is carried out to determine the exact cause of pain in the abdomen and make a diagnosis of diverticular disease.

Treatment of intestinal diverticulitis

This disease can be treated with medication. Depending on the complexity of the disease, the patient may be offered surgical treatment.

Conservative treatment

If the patient promptly turned to the doctor with this disease and it did not begin to progress, it is optimal to start treatment with medication. Diverticulitis can be treated with antibiotic and anti-inflammatory therapy. Treatment involves hospitalization: during this period, the health and condition of the patient will be monitored by highly qualified clinic staff at the EMC. Treatment consists of the selection of individual antibacterial therapy, anti-inflammatory therapy, correction of water and electrolyte balance. The patient is also on a special diet. After 5-7 days, he is discharged with recommendations for diet and further lifestyle.

With the ineffectiveness of conservative treatment, the destruction of diverticula occurs. The doctor can see this process using any imaging method (ultrasound, CT, MRI). Most often, in this case, planned surgical treatment is recommended.

Surgical treatment of diverticulitis

Surgical treatment is necessary for frequent, recurrent attacks of acute diverticulitis (more than three attacks) or severe attacks. It is also important to carry out surgical treatment in time with the development of complications that are not amenable to conservative treatment. If the patient has developed a single episode of severe bleeding or they are repeated, this is also an indication for surgery. Diverticulitis should be treated surgically with the following indications: age over 50 years, long-term use of non-steroidal anti-inflammatory drugs without a positive effect, the severity of concomitant chronic diseases.

EMC treats this disease:

Operation methods

Diverticulitis requires removal of the affected part of the intestine. Most often it is the sigmoid and descending colon. EMC performs open, laparoscopic and robotic surgeries to resect the affected area of ​​the intestinal tube. Depending on the results of the examination, age and the presence of chronic diseases, a method is selected that is suitable for the patient.

Laparoscopic surgery is a minimally invasive surgical treatment for diverticulitis. It is carried out using thin instruments for resection of the damaged part of the intestine. The surgeon performs a resection through small incisions in the skin (0.5-5 cm). A miniature camera is attached to the laparoscope: it transmits the image to the monitor and allows the doctor to see the operating field in multiple magnification during surgical treatment.

During robotic surgery, the damaged part of the intestine is removed using a high-tech Da Vinci robot, which is controlled by the surgeon. The robot is equipped with miniature instruments and high resolution optics. This method also does not require large incisions and long rehabilitation.

In difficult cases and with a high percentage of bowel involvement, open surgery may be required. Regardless of the complexity of the operation of the chosen method, in EMC, the surgeon will strive for the least possible trauma of the treatment, the shortest possible hospital stay, and a good cosmetic effect.

Possible complications after surgery

After the operation, intra-abdominal bleeding, infectious complications, peritonitis, anastomotic failure, and others are possible. To avoid complications in the EMC allows an individual approach to each patient, who is treated by a multidisciplinary team of doctors. Before the operation, the patient is consulted by doctors of various specialties (surgeons, therapists, cardiologists, anesthesiologists, and others). Before surgical treatment, each patient undergoes a comprehensive examination, doctors collectively assess the risks and make a collegial decision on the surgical intervention and the most appropriate method. Operations in EMC are carried out by doctors with vast experience in the surgical treatment of this disease.

Prevention of diverticulitis

You need to exercise regularly: exercise contributes to the normal functioning of the intestines and reduces the pressure inside the colon. Increase your fiber intake: A diet high in complex carbohydrates reduces the risk of developing this disease. Fiber is rich in foods such as fresh fruits, vegetables, and whole grains. Drink plenty of fluids and stay hydrated: fiber absorbs water and increases the amount of soft, bulky waste in the colon. Constipation can occur if there is not enough fluid.

Ask a question about the operation

Rehabilitation period

1. After the operation, the patient spends about 5-7 days in the hospital.
2. In EMC, rehabilitation is organized using the fast track system, so the patient is verticalized already 1-2 days after the operation, and he can move independently within the ward under the supervision of doctors.
3. After discharge, the patient continues to be observed on an outpatient basis.
4. Intestinal functions after surgery are fully restored in 3-4 weeks.
5. After removing part of the colon, its remaining part adapts to the changes, so during this period the patient may experience such uncomfortable symptoms as spasms, gas formation and other changes in the usual bowel function (diarrhea, frequent stools).
6. Symptoms may continue for several weeks or months after part of the colon is removed.

Prices for the treatment of diverticulitis

You can calculate the cost of treating this disease in EMC after an individual consultation with a doctor.

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X-ray surgery for diverticular disease complicated by abscess formation

X-ray surgery for diverticular disease complicated by abscess formation

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Okhotnikov O.I.

Department of Surgical Diseases, Faculty of Postgraduate Education, Kursk State Medical University, Ministry of Health of the Russian Federation, Kursk, Kursk Regional Clinical Hospital, Kursk, Russia

Yakovleva M.V.

Federal State Budgetary Scientific Institution Russian Scientific Center of Surgery named after A.I. acad. B.V. Petrovsky, Moscow, Russia

Shevchenko N.I.

Department of X-ray Surgical Methods of Diagnosis and Treatment No. 2, Kursk Regional Clinical Hospital, Kursk, Russia

Grigoriev S.N.

Department of Surgical Diseases, Faculty of Postgraduate Education, Kursk State Medical University, Ministry of Health of the Russian Federation, Kursk, Kursk Regional Clinical Hospital, Kursk, Russia

Pakhomov V.I.

Department of X-ray surgical methods of diagnosis and treatment No. 2 of the Kursk Regional Clinical Hospital

X-ray surgery for diverticular disease complicated by abscess formation

Authors:

Okhotnikov O.I., Yakovleva M.V., Shevchenko N .I., Grigoriev S.N. ., Pakhomov V.I.

More about the authors

Journal:

Surgery. Journal them. N.I. Pirogov.

2018;(6): 35‑40

DOI:

10.17116/hirurgia2018635-40

How to quote:

Okhotnikov O.I., Yakovleva M.V., Shevchenko N.I., Grigoriev S.N., Pakhomov V.I. X-ray surgery of diverticular disease complicated by abscess formation. Surgery. Journal them. N.I. Pirogov.
2018;(6):35‑40.
Okhotnikov OI, Yakovleva MV, Shevchenko NI, Grigoriev SN, Pakhomov VI. X-ray-surgery of diverticular disease complicated by abscess formation. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N.I. Pirogova. 2018;(6):35‑40. (In Russ.)
https://doi.org/10.17116/hirurgia2018635-40

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Purpose — to show the possibility of alternative application of interventional radiology techniques in the complex treatment of patients with inflammatory complications of diverticular disease of the colon. Material and methods. In 2012-2016 87 patients with a complicated course of diverticular disease were under our supervision. In 57 (65.5%) patients, infiltrate was diagnosed, in 24 (27.6%) – paracollar abscess (type Ib-II according to Hinchey), in 6 (6.9%)%) — generalized peritonitis (III—IV type according to Hinchey) [5, 9]. Results. According to emergency indications, laparotomy was performed in 13 cases. In 17 patients with paracollar abscesses (type Ib-II according to Hinchey), the diagnosis was established sonographically during the initial examination. In this group of patients, 26 percutaneous drainages of diverticulogenic abscesses of different localizations were performed with self-locking 8Fr pig tail drainage under combined ultrasound and X-ray control. In 13 patients, drainage was single, and the course of diverticular disease was relapse-free during the observation period from 1 to 5 years. Resection of the colon in a planned manner after percutaneous drainage of recurrent paracollar abscess was performed in 4 patients. There were no complications associated with the drainage installation technique, there were no cases of death after drainage. The technical success of percutaneous drainage of the cavity of a diverticulogenic abscess was achieved in all manipulations. Conclusion. Ultrasound examination of patients with suspected inflammatory complications of diverticular disease is a necessary and sufficient method for the primary diagnosis of the disease. Percutaneous drainage of diverticulogenic abscesses (Hinchey Ib-II) seems to be a pragmatic choice of the first line in patients with complicated diverticular disease, which makes it possible to stop the complication in most cases.

Keywords:

diverticular disease

paracolar abscess

percutaneous drainage

X-ray surgery

Authors:

Okhotnikov O.I.

Department of Surgical Diseases, Faculty of Postgraduate Education, Kursk State Medical University, Ministry of Health of the Russian Federation, Kursk, Kursk Regional Clinical Hospital, Kursk, Russia

Yakovleva M. V.

Federal State Budgetary Scientific Institution Russian Scientific Center of Surgery named after A.I. acad. B.V. Petrovsky, Moscow, Russia

Shevchenko N.I.

Department of X-ray Surgical Methods of Diagnosis and Treatment No. 2, BMU “Kursk Regional Clinical Hospital”, Kursk, Russia

Grigoriev S.N.

Department of Surgical Diseases, Faculty of Postgraduate Education, Kursk State Medical University, Ministry of Health of the Russian Federation, Kursk, Kursk Regional Clinical Hospital, Kursk, Russia

Pakhomov V.I.

Department of X-ray surgical methods of diagnostics and treatment No. 2 of the Kursk Regional Clinical Hospital

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Diverticular disease (DD) of the colon is characterized by high rates of both prevalence among the adult population and mortality in complicated forms. In particular, the incidence of colonic diverticulosis in people older than 50 years is 30–50%, in 80-year-olds it is noted in more than 2/3 of the population [1]. Acute diverticulitis occurs in about 4% of patients with colonic diverticula, and in 30–40% of them it becomes recurrent [2, 3]. Mortality in emergency surgical treatment of complicated diverticulosis reaches 978-10.64%, with planned treatment it is significantly lower – 0.5-1.93%, the total number of postoperative complications is 32.64% [4].

Non-surgical treatment (antibacterial therapy and percutaneous drainage) of colonic diverticulosis complicated by abscess [5], according to foreign literature, is strategically the standard first-line method in the treatment of this disease [6, 7].

In our country, the problem of minimally invasive treatment of inflammatory complications of BD is not as widely represented in the literature as it is abroad, but the possibility of using these technologies in the complex treatment of patients is reflected in the clinical recommendations of the Russian Gastroenterological Association and the Russian Association of Coloproctologists for the diagnosis and treatment of adult patients with diverticular disease colon [8].

However, the tactical and technical aspects of the use of interventional radiology techniques in this disease continue to be the subject of discussion.

Material and methods

In 2012-2016 under our supervision there were 87 patients with a complicated course of D.B. At the same time, 57 (65.5%) patients were diagnosed with DB complicated by paracollar infiltrate, 24 (27.6%) patients had colonic diverticulosis complicated by abscess formation (type Ib-II; hereinafter, the type is indicated according to Hinchey), 6 (6.9%) — generalized peritonitis (III—IV type) [5, 9]. According to emergency indications, laparotomy was performed in 13 patients, including 5 patients with localized diverticulogenic abscess, in whom pneumoperitoneum was detected by radiological methods, but widespread peritonitis was absent intraoperatively, and also in 2 patients with paracolar abscess against the background of dolichosigmoid, who were erroneously diagnosed acute destructive appendicitis. In the remaining 17 patients of this group (Ib-II type), the diagnosis was established sonographically during the initial examination. In this group of patients, 26 percutaneous drainages of diverticulogenic abscesses of different localizations were performed. A single self-locking pig tail 8Fr drain was placed into the abscess cavity under sonofluoroscopic control. The abscess cavity was fractionally sanitized with antiseptics, controlling its volume, connection with the intestine, as well as the state of the perifocal tissues according to the results of contrast fistulography and sonographically.

Results

The technical success of percutaneous drainage of the cavity of a diverticulogenic abscess under combined sonofluoroscopic control was achieved in all 26 manipulations. In 13 patients, drainage was single, the course of DB was relapse-free during the follow-up period from 1 to 5 years. The remaining 4 patients underwent 13 consecutive percutaneous drainages during the observation period due to abscess recurrence after removal of the drainage. All recurrences were registered within six months from the moment of primary drainage. Later, in a planned manner, after percutaneous drainage of a recurrent paracolar abscess, these patients underwent resection of the colon. We did not observe any complications associated with the drainage installation technique, and there were no cases of death in this group.

Discussion

DB type Ib-II has traditionally become a subject for the priority use of interventional radiology techniques aimed at minimally invasive sanitation of delimited purulent complications of colonic diverticula with a delayed decision on radical surgical treatment [2, 10—12]. The development of delimited purulent complications of DB has specific features that distinguish this form of abscessing. In particular, a diverticulogenic paracolar abscess is based on perforation of the wall of an inflamed false pulsation diverticulum with extraterritorialization of the contents of the large intestine, which is objectively confirmed by the detection of paracolar gas depots by radiological diagnostics (Fig. 1). Rice. 1. Echogram of a patient with paracolar gas depot (arrow). At the same time, depending on the localization of the perforation zone and the severity of the perifocal infiltrate, gas exterritorialization may have a non-localized character, simulating the widespread nature of inflammatory complications of DB (type III), which happened in 5 patients observed by us.

Diverticulogenic abscesses, apparently, should be treated as a variant of a functioning internal colonic fistula, even if contrast abscessography fails to reliably identify the connection of the abscess cavity with the intestinal lumen. It was noted that such a connection is much more often detected in the paracollar location of the abscess (type Ib) than in its other localizations (type II – retroperitoneal, interintestinal, small pelvic abscess) (Fig. 2). Rice. 2. Fistulogram of a diverticulogenic interintestinal abscess (type II according to Hinchey; lateral view). The abscess cavity (black arrow) was drained percutaneously. Narrow fistulous tract connecting the abscess cavity with the left half of the colon (white arrows). This generalization calls into question the expediency of repeated puncture sanitation of the abscess cavity as a self-sufficient method of treating this disease and forces us to consider them as an exclusively forced measure when it is technically impossible to drain the abscess.

The relationship between the cavity of a drained paracollar abscess and the lumen of the colon that persists during treatment is not a criterion for treatment failure or a predictor of early relapse when the drain is removed. In addition, with significant destruction of the diverticulum, the cavity of the paracollar abscess can acquire a wide fistula with the lumen of the colon, and drainage in this zone becomes a factor supporting the existence of an external colonic fistula.

The absence of a significant discharge of a contrast agent into the lumen of the colon from the cavity of a paracolar diverticulogenic abscess during its primary contrasting may be due to a transient blockade of the neck of the diverticulum against the background of its inflammation. At the same time, it should be noted that it is the violation of the evacuation of the contents from the lumen of the diverticulum that presupposes the development of inflammation in it, followed by destruction of the wall. It can be concluded that the contrasting of the intestinal lumen during primary abscessography indicates a wide communication of the abscess cavity with the lumen of the colon through the diverticulum. The delayed appearance of such a connection after drainage during minimally invasive treatment indicates the restoration of the natural communication of the diverticulum with the intestinal lumen, which should be considered as a symptom of the leveling of inflammation and the associated edema of the diverticulum wall and colon.

Thus, the efficiency factor of minimally invasive debridement of an abscess associated with DB is not so much the presence or absence of a detectable connection between the abscess cavity and the lumen of the colon, but the state of the paracolar infiltrate and the prevalence of concomitant infiltrative changes in the colon, the presence of non-evacuated depots of the contrast agent, and also not zones of paracolar exudation contrasted during abscessography, detected during radiation control (ultrasound, CT) [13]. We are also not inclined to regard the volume of the abscess as a predictor of recurrence, especially since the recurrence of a paracolar abscess against the background of DB with a frequency of up to 35% is localized outside the primary lesion, although the sigmoid colon and the descending colon account for 93% of inflammatory complications of DB [14, 15].

Ultrasound and SCT are the only methods for objective diagnosis of type Ib-II DB, since traditional sigmoidoscopy and fibrocolonoscopy, which are the “gold standard” for instrumental examination of the colon, can provoke generalization of local purulent-inflammatory changes in inflammatory complications of DT [16]. Thus, SCT seems to be the most objective method of radiodiagnosis of inflammatory complications of DT, which makes it possible to stratify the severity of the disease and identify a group of patients in which it is advisable to use non-surgical methods in the treatment of complicated DT, as well as to differentiate a colon tumor [3, 17—21].

At the same time, SCT does not insure against diagnostic errors, especially in types III and IV of complicated DB (common purulent and fecal peritonitis). In particular, M. Gielens et al. [20] report 43% of misverification of type III as type I–II. In this regard, ultrasound examination of the abdominal organs with targeted puncture, visual and laboratory assessment of exudate is of undoubted diagnostic interest. Ultrasound in this case has high sensitivity and specificity, which allows it to be used not only as a screening method for the initial examination of a patient, but also as a sufficient method of radiodiagnosis (Fig. 3). Rice. 3. Echogram of a patient with diverticular disease (type Ia according to Hinchey). Diverticulum (arrow) of the left half of the colon, complicated by paracolar infiltrate with edema and infiltration of the colon wall. In addition, ultrasound, like no other radiation method, implements the principle of real-time examination, which favorably distinguishes sonography as a method of objective monitoring of minimally invasive medical intervention.

It should be borne in mind that with a high diagnostic accuracy of ultrasound in case of suspected infectious complications of DB, including generalized nature (peritonitis), the method has certain limitations in terms of differential diagnosis of the underlying disease, complicated by a paracolar abscess. In complicated DB, sonographically, in most patients, concomitant infiltrative changes in the colon wall in the area of ​​the inflamed diverticulum, especially in the area of ​​the paracollar abscess, are verified. At the same time, ultrasonic changes in the intestinal wall fit into the definition of hollow organ lesion syndrome (HSS), which is primarily characteristic of a tumor lesion of the intestinal tube. In this case, it is difficult to reliably differentiate the etiology of a paracollar abscess, since its formation may be the first clinically clear symptom of a colon tumor complicated by microperforation. In addition, even dynamic sonography against the background of an adequately drained paracolar abscess, which demonstrates positive dynamics in the manifestations of SPSS, does not exclude the tumor genesis of the paracolar abscess, even with confident verification of additional uncomplicated diverticula in the affected intestinal segment in the patient. At the same time, in our opinion, the presence of a paracolar abscess of any etiology suggests its minimally invasive sanation, followed by clarifying radiological and endoscopic diagnostics with a decision on the need and extent of elective surgical intervention. Such treatment and diagnostic tactics increase the requirements for primary ultrasound diagnostics in terms of its etiological component.

In type Ib DB, the drainage trajectory of the paracollar abscess is determined by the principles of the shortest length, non-conflict with the organ and vascular structures of the drainage zone with obligate extraperitoneal access. In the case of distancing the abscess from the zone of the primary defect in the colon, the choice of the drainage trajectory is determined by the general rules of accessibility and safety for an intraperitoneal abscess of any etiology and can be implemented not only transabdominally, but also transrectally, transvaginally, and also through the gluteal muscles [22, 23].

In our observation, after the initial successful percutaneous drainage of an abscess against the background of type Ib-II DB, delayed surgical treatment was undertaken in 4 patients with persistent recurrence of paracolar abscesses. It should be noted that in this group of patients, relapse was observed already during the first year, and not only in the primary lesion zone, which required repeated (from 2 to 5) drainages during the observation period. In patients with a single abscess formation and in the absence of recurrence during the first year, we did not encounter recurrent abscess formation during the subsequent follow-up period (up to 5 years). In this regard, the recommendations of the unconditional need for resection of the colon after relief of inflammatory complications of DT, the authors of which consider percutaneous drainage only a “bridge” to the planned surgical treatment of DT, do not seem indisputable [24]. According to the results of a systematic review and meta-analysis of 22 studies that included 1051 patients with type Ib-II DB, the overall incidence of abscess recurrence did not exceed 28% [6]. Surgical interventions were not performed in 35% of the observed patients, and in 28% of them there was no abscess recurrence during the entire observation period. The data obtained did not allow the authors to speak unambiguously in favor of the need for resection surgery. Recently, an increasing number of authors of publications consider it pragmatic to adhere to expectant management after the initial successful use of percutaneous drainage interventions in type Ib-II DB [7].

Thus, ultrasound examination of patients with suspected inflammatory complications of BD is a necessary and sufficient method both for the primary diagnosis of the disease and for effective real-time monitoring of drainage intervention. Certain differential diagnostic limitations of the method, however, do not reduce its diagnostic value in identifying a paracolar abscess that is subject to external drainage, regardless of the etiology of the process. Percutaneous drainage of diverticulogenic abscesses (type Ib-II) seems to be a pragmatic first-line method of choice in patients with complicated diverticular disease, which allows, in most cases, to stop the acuteness of the lesion.