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Contrast studies for acute diverticulitis? - Ärzteforum

Post#1 »

What is the feeling of Net members regarding contrast studies for acute diverticulitis? Never? Hardly ever? OK after a few days if pt settling (therefore little help in making the dx)? Routinely in first 24 hrs?


Hans

Re: Contrast studies for acute diverticulitis? - Ärzteforum

Post#2 »

We would go for a CT-scan in the first 24h if diverticulitis (clinically diagnosed!) is not settling well (i.e I do not mean the patient is getting septic or instable etc) under antibiotic treatment. This will guide through further decision making and need for intervention. If there is localized abscess, CT-guided percutaneous drainage is usually adequate and settles with further AB-treatment. If you have a very experienced technician you could of course also go for the same procedure under ultrasound guidance. Before elective surgery after an interval of weeks we would request colonoscopy. For early-elective surgery (after 7-10 days treatment for complicated disease) we perform a water-soluble (Gastrografin) contrast enema to show extent of diverticulae, if unsure about rest of colon: intraoperative colonoscopy. Barium enema has no place in our diagnostic decision making, and would certainly not be recommended early during an episode of inflammation for obvious reasons if you might have to operate.

Regarding therapy:
1. Frank perforation, generalized peritonitis etc etc, I think nobody would treat conservatively, all agree? We would always try to go for resection and anastomosis, intraoperative colonic lavage if necessary . If the surgeon is "unhappy" with the anastomosis and/or cannot perform re-anastomosis during the same procedure: covering double-loop ileostomy as adjunct is performed (closure after anastomosis is checked by water-soluble contrast enema or rectoscopy after 6-8 weeks) This is our policy, after our current chief of department was elected. We have compared our prospective results (with a "historic" earlier group): Anastomotic insufficiency rate 2.5% (vs. 7.1%), mortality 2.7% (vs. 9.5%), general complications 25% (vs. 35%), Hartmann's resection 3% (vs. 16%), ileostomies ~6% (vs. 24%). Published locally in German and updated as poster at our annual meeting of the Swiss Surgical Society.

2. If the patient is 45-50y or younger we would suggest elective therapy after the first major episode of inflammation in a quiescent phase (see literature below) or early, after 7-10 days AB treatment, if diverticulitis was complicated (i.e.drained abscess) and has subsided.

3. If the patient is older and has had several bouts or was admitted for complicated diverticulitis we would suggest resection if general condition permits.

Hartmann's procedure (resection, end colostomy, closed rectum stump) in our hands is reserved for the totally unstable patient (septic, old, bleeding) where you want to get in and out quickly. As stated above this was only necessary in 3% of cases.

Is there anybody still doing routine Hartmann's procedures for perforated diverticulitis/peritonitis? (or even three-staged procedures?)
If and when you do a Hartmann operation, what reasons do you have?

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Surgeon

Re: Contrast studies for acute >diverticulitis? - Ärzteforum

Post#3 »

I'm sure there are many surgeons in your same conditions. I practice in a rural setting but must seem like a university setting to you. We have most of the surgical toys and a CT scan in town. I would not write off laparoscopy because it's here to stay and patients, doctors, and even now the OR staff love it. It took a while to get to a 20 min lap chole but it's such a common procedure now that the open chole is remarkable. Young surgeons will not be well trained in routine open choles in the United States due to it's rarity. I would suspect the absence of many voices on this forum may be due to the more intense amount of time involved in formulating the most intelligent answers like Klaus's example. With a wife, three teenage kids at home, local internet access seems busy all the time, and a busy practice most of the time it's a struggle just to get the list read. However, it's one of the more pleasurable and worthwhile pastimes.

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Re: Contrast studies for acute diverticulitis? - Ärzteforum

Post#4 »

Thanks for the refreshing note on the management of acute diverticulitis which reflects modern approach with which I agree totally.

The use of Barium in any surgical emergency or potential emergency should be only condemned for obvious reasons.

CT has been proved as an excellent method to stage acute diverticulitis-prognisticate and plan therapy.

When emergency operation is indicated sigmoidectomy is considered sin qua non. I agree with primary anastomosis -in favorable circumstances. I would still go for a Hartmann's in established diffuse fecal peritonitis and/or a very compromised patient.

It appears that the policy practiced in your hospital is very advanced -most US surgeons are still committed to Hartmann's.

The series you described should be published in a "normal" surgical journal- rather wasteful publishing this fantastic results in an obscure German journal.

And finally, do you have any evidence that antibiotics are necessary at all in "simple"-non perforated acute diverticulitis- but where is the evidence?

Grandpa Phil

Re: Contrast studies for acute diverticulitis? - Ärzteforum

Post#5 »

I agree with all that you say about diverticulitis except the need for a ROUTINE CT for "staging and therapy"... interesting how my results are the same as everyone else's without the use of CT, and how in this age of CT the emdical management has no better results than in the 1960's before CT--no lesser incidence of requiring surgery. In most cases, the diagnosis is clinical, and treatment with bowel rest and antibiotics is instituted on that basis alone--if the patient gets better, that confirms your diagnosis, without the need for any imaging. If the patient does not improve or worsens, then image--the latter happens in only a small minority of cases--CT up front does not change this. Since you are the one advocating the use of an expensive test, surgeon, where is YOUR evidence that it has benefit?? Not that it was used and seemed to work, but evidence that it has better results than the clinical approach alone? After all, the burden is on you to prove the benefit.

Proctologist

Re: Contrast studies for acute diverticulitis? - Ärzteforum

Post#6 »

I have studied the Ambrosetti papers which are a must for every surgeon who is treating acute diverticulitis. Jurg gave the references in his post.

Diverticulitis is a problem of the next decade. It was very fashionable for a period followed by a long period of no advances. Now it is haute coture again. Ambrosettis work is one major reason. The other is laparoscopic resection for diverticulitis which a mess much in need of being sorted out. We need much better classification and much better diagnosis to support a better classification. With respect to laparoscopy you migth consider the simple distinction between acute attacks and elective resection. Most lap resections have been elective but they are usually described with the term "diverticulitis".

I have seen video-taped lap resections for diverticulitis which, in my mind, had no disease at all. There is a lot of data around to suggest that lap resections for diverticulitis is easy and produce 2-3 days shorter hospital stay. I am just anxious that a lot of patients will have unnecessary operations or even used to make money.

The problem is this: Many patients have an episode of LLQ pain with or without some signs of systemic inflammation. Most will never require an operation but many will be treated with antibiotics. Many patients have diverticula on barium enema. Post hoc it provides a diagnosis of diverticulitis. Even more patients have simply colorectal dysmotility disorder. I am concerned that too many patients will have a signmoid resection electively for symptomatic dysmotility disorder without a correct diagnosis of sigmoiditis/diverticulitis, and it will not benefit the patients.

Let us have a good diagnosis. CT scan for the acute attack is good (90% accuracy), slightly worse than gastrografin enema.

Surrgeon

Re: Contrast studies for acute diverticulitis? - Ärzteforum

Post#7 »

As usual, you raise good points. Here is a recent case which illustrates the misdiagnosis possibility. 55ish patient of mine has not felt well since he had severe (but not necrotizing just profound hypovolemia, profoundly critically ill) pancreatitis about 1 year ago. Goes to Mayos for second opinion and they do decide helpfully they he probably has sleep apnea. However, they also do a colonoscopy (who knows why) and find some diverticula (actually a normal finding for someone his age).

He returns home and within 1 week of the colonoscopy is admitted with new lower abdominal pain, a little more pronounced on the right which then localizes to the right lower quadrant. My colleagues treat him for 48 hours for presumed diverticulitis because of the colonoscopy report which they interpreted as a significant finding. Not too surprisingly, he had appendicitis, luckily not yet ruptured.

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Resident

Re: Contrast studies for acute diverticulitis? - Ärzteforum

Post#8 »

You forgot to answer about antibiotics. Are they necessary? is "bowel rest" necessary?

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