A couple of cases of acute diverticulitis
I have had a couple of cases of acute diverticulitis over the past several weeks and am interested in how everyone approaches this subject:
First, a reasonably healthy 65 year old presents with LLQ pain, fever and mass exam. Abdominal CT show an abscess next to the sigmoid colon, presumable diverticular in origin. This is percutaneously drained by the radiologist and then surgeons are consulted. After drainage, the patient feels well and his white count normalizes. When should sigmoid resection be performed?
Options:
- 1) prep bowel and operate during index admission,
- 2) wait about 6 weeks,
- 3) not operate.
Second, when operating for acute, complicated diverticulitis, who does what operation? To keep things standard, I understand the Hinchey classification as follows:
- Stage I = pericolic phlegmon or abscess;
- Stage II = contained pelvic, abdominal, retroperitoneal abscess;
- Stage III = purulent peritonitis;
- Stage IV = fecal peritonitis.
Surgical options include resection with anastomosis, resection with anastomosis and protecting/diverting ostomy, resection with colostomy (Hartmann), drainage with delayed resection and anastomosis. Of course, the laparoscopic approach could be used for any of these. Who would do on-table colonic lavage?
Another case. 86 year old lady who is confined to a nursing home. She has Alzheimer’s dementia, though she recognizes family and can feed herself. Remote history of coronary disease, but no other medical co-morbidities. Well nourished. Presents with abdominal pain, distension, vomiting that the nursing home staff thought was small bowel obstruction. Seen by the internists in the ER who agree and place her in the hospital with NG suction and antibiotics. The following morning, the radiologist calls to report free air on the abdominal X-rays from the prior night (had been missed by the ER staff and the internist, despite being easily seen by a third year medical student to whom I showed the films). Surgical consult is then obtained. At this point the patient is hemodynamically normal, febrile (38.5), WBC elevated to 13.5 with left shift, and abdomen is obviously surgical. The family desires that surgery be performed but refuse to give permission for a colostomy. At surgery, perforated sigmoid diverticulitis is present with diffuse purulent peritonitis, but no fecal soilage. Stool in the proximal bowel is soft. Where should we go from here?
Regarding your question about diverticulitis– The initial approach of choice to diverticulitis is medical management with bowel rest, IV hydration and antibiotics and NO imaging with CT–why? Because that is all you need in better than 90% of cases! Your first case most likely would never have needed percutaneous drainage if you had just not done the CT–what a surprise that you found peri-sigmoid fluid! You always will–only role for CT is in that small minority of cases which do not respond to medical management. In your last case, I would agree that free air is a good indication to operate usually, but only because you do not know where it is coming from. But this patient’s stable status and the family’s restraint of your options would still have made this a good candidate for medical management with a good chance of success–nothing to lose here since the patient is not sick. Even perforated duodenal ulcer will respond to this under such conditions, as the British have clearly shown us. Also, there is nothing wrong with primary anastomosis after resecting the sigmoid,, REGARDLESS of the degree of surrounding contamination. We surgeons need to be a little more honest with ourselves, at least–isn’t it interesting how ready we are to blast in with operating when we’re not sure of what to do? Your first case is a clear example of operating on an X-ray rather than a patient, as is your last case of the elderly woman with Alzheiner’s.
the first Case:
I would wait 4 weeks before sigmoidectomy to avoid an anastomosis near a previously drained abscess cavity.
In stageIII purelent peritonitis with no grass perforation the patients do well with laparoscopy sucking out all the pus and wash with saline of peritoneal cavity and continue with cephalosporin -Flagyl IV.
In Stage IV faeculent only do Hartmann procedure.
the second case: If no consent for Colostomy , if microperforation than only abdominal toilet if macro than sigmoidectomy and hope for the best.
This is an excellent question covering a wide spectrum of acute diverticular disease!
The CT was helpful in that it showed you a complication of diverticulitis (abscess) which I would consider an indication for surgery. I would prep the bowel and do it this admission with primary anastamosis.
In the emergent cases: I would anastamose the bowel if the abdomen cleaned up well with irrigation and the anastamosis was not laying bathed in purulent exudate AND this was a stable patient (Not some old hypotensive on steroids). I would do on table lavage if proximal bowel packed with stool.
A CT does not show an “abscess”–it shows fluid! Again, you do not see my point, and do not realize that you are advocating operating on an X-ray rather than the patient–the patient is doing fine, so nothing is lost by going with non-op management. If it does not work, well then do what you would have anyway, with no harm to the patient. But this way you offer the opportunity to avoid operating, something the evidence is very clear from the past several decades of literature can be accomplished in over 90% of cases! It is well documented how often this CT picture resolves without operation in this setting. This, of course, is the reason to avoid getting unnecessary imaging against all reason, rather than basing treatment on the patient–even welleducated and well-reasoned surgeons like yourself end up going off the deep end when those pictures appear! If, however, you have evidence showing any correlation whatsoever between the CT and patient outcome in this setting–that is, in patients with a new diagnosis of diverticulitis not yet treated–or of any benefit whatsoever to the ROUTINE use of CT in improving patient outcome over and above the tried and true clinical approach now recognized as standard, please share it with us–without such evidence, you have no justification in operating on an X-ray–since you are the one advocating the invasive intervention, you are the one with the burden of proving it to be of benefit.
I have been amazed at the success of non- operative initial management in patients with complicated diverticulitis (Sigmoid), even when their CT scans look terrible. We all need to redirect our judgments to our patient’s clinical course rather than the X-rays. Am I wrong in my impression that younger surgeons are much more likely to operate because of an abnormal X-ray? I hope I’m wrong, but it is my very strong impression that the wonderful advances in technology have created a new generation of surgeons a step removed from all we used to be taught about the importance of a history and physical exam, and the clinical course.
The older generation of surgeons perhaps did not take advantage of the new technology and relied too much on clinical impressions. That’s the other mistake.
New technology, like the CT, which is no longer new, allows an earlier and more exact understanding of the pathology. What one does with the information is entirely up to the surgeon. It certainly takes some experience not to operate when significant pathology is there to be seen from the pictures. The problem, really, is not to operate or not operate but to choose the course of action that gives the patient the simplest and smoothest recovery. The operation is, at times, no more than the means of obtaining that goal.
And, how do you teach young surgeons the sort of knowledge which allows them to choose wisely all the time. One obviously needs to provide them with some other sort of structured information besides the X-ray pictures to guide them. Clinical impression is marvellous but what is it? Can it be structured and measured such that it can be taught and relied upon as objective evidence of good clinical practice? Or must it remain an art which surgeons possess or fail.
Just moving the focus from pathology, however one reveals it, to pathophysiology is a very big thing. I think what you are suggesting is something like this: Don’t look too much at the pathology but concentrate on how the patient responds to the pathology. Look at the patient=B4s physiology. Quantitate it and understand it. We are no longer explaining disease with pathology but with physiology. Patients do not die from their disease but from the physiological consequences of the disease, as William Osler put it a long time ago.
We have APACHE and we have SIRS. These are about physiology. And we have the understanding that pathophysiology is the intrinsic responses to the pathology which is the trigger. We need to reverse the trigger which at times is best done with an operation. But then the operation is in itself a trigger of pathophysiology. It takes a lot of experience to learn when the trigger is better reversed with an operation. And it may take even more experince to learn that if it is not done today then tomorrow the situation may be so complicated that surgery cannot help. Disease is about pathophysiology – medicine and surgery is about reversing and controlling that pathophysiology.
An interesting observation–but I’ve also seen this tendency among older surgeons who have less understanding of this high tech gimmickry, and somehow feel they have to jump on this bandwagon to keep up with advances– I would hope that ultimately reason will prevail, otherwise the field of medicine is liable to go the way of the Roman Empire, which collapsed under the propagation of decadent excess, forgetting the basic values on which civilization is built.
It’s not that these imaging modalities don’t serve somevery important purposes, and have definite roles, but when they are used in settings such as this which are not supported by any evidence of benefit, and in which simpler approaches are well established in benefit, the tragedy begins for our patients.
From the description of the patient my clinical diagnosis would be a complication of diverticulitis. Not a fluid collection but a true abscess with pain, fever, leukocytosis, and a palpable mass. This patient was not doing “fine”. If I hear hoofbeats in Minnesota I think of horses and not zebras. The CT just confirms the clinical impression, makes sure that it’s not some huge perforating carcinoma, and guides your drain into the abscess cavity. I suppose you could accomplish the same thing with ultrasound. Pus needs to be drained. I think it’s preferrable to drain it percutaneously so the patient can be stabilized and operated with a prepped bowel in a more elective setting. Most patients can be managed nonoperatively with diverticulitis (the primary care guys don’t even call me) but few with the above signs, symptoms, and physical exam findings.
This is simply not true–try it sometime and you’ll see you and your patient will like it. ALL diverticulitis initially presents with fever, leukocytosis and peritonitis–that’s how you make the diagnosis–and it is THAT presentation that responds–not “a lot of the time”, but over 90% of the time to non-op management. It’s evident you have not been approaching it this way, and so you are speaking more from your imagination than experience–as you can see from all the other posts, the non-op way really does work–give it a try and see for yourself. Also, once again. a CT scan can not distinguish “pus” from simple phlegmonous fluid–you are reading too much into it, all the more reason to simply not see it to begin with–if the patient resolves nonoperatively, that is the best indication that in fact it was not pus–if not, then operate and you may find pus. The CT does not help in making this distinction, a distinction you shouldn’t get so hung up on.
In the practice here, a lot of patients present in this way, and only the ones who deteriorate by becoming septic, while under treatment, are drained, or operated upon emergently. Currently, I have a 56 y/o nurse with LLQ pain, guarding, tenderness, elevated WBC=17,000, and a CT ordered thru the ER that showed a phlegmon and contained abscess (urgent call from the radiologist). The patient just did not look that bad, and after 3 days of IV antibiotics, she is much improved in all respects. I can endorse what Eric is recommending based upon my experiences, as illustrated by this example.
Perhaps the original person that posted this case can enlighten us. Did pus with bacteria roll out of the drain or was it just a sterile fluid collection? I was not advocating operating on the palpable mass that was fluid on the CT; I AM advocating that in a febrile patient with pain, mass and leukocytosis, a CT is an appropiate step, and if the mass is fluid ( it would seem most likely to be “real” pus in my book with bacteria and WBC’s) a percutaneous drain is very appropiate.
I and the others who have replied to you understand perfectly what it is you advocate–the problem is you can not support your stance, but the literature and obviously our experience (since we do it this way routinely and you do not) support ours–we haven’t yet heard any evidence from you to refute our non-op approach, which, again, remains the standard. As logical as your conjectures may sound to you, reality says otherwise. How do you explain the fact that most of us (at least me) do not get CT for your indication at initial diagnosis, yet have perfectly acceptable results, apparently with much less surgery? All you have to do in a case like this is give it a go with non-op management, and you will see for yourself how successful it is–nothing is lost in the very unlikely event that it fails. It’s kind of like learning to walk–at some point you’ve got to just let go of your crutches and go it alone. Don’t believe us–read any chapter in any text of your choosing.
Just a question for my edification on this topic regarding the patient with an episode of acute diverticulitis which settles completely on conservative management and returns to normal – i.e. no pain and no obstructive symptoms, normal bowel habit. How often will such a patient get a recurrent episode of diverticulitis. I don’t know the answer to this. If I did then I would make a better decision as to whether to operate or just leave the patient alone.
“The CT just confirms the clinical impression, makes sure that it’s not some huge perforating carcinoma ”
how does CT tell you that?
If I read and remember the work by Ambrosetti correct a rough estimate is this. If the patient is 50 years or younger at the attack, and if it is a severe attack by CT diagnosis (abscess or leak) then the chance that the patient will have a later operation is 25%. To such a figure one must, of course, add those who were operated during the first attack.
In my mind it does not help a lot, even if it was as much as the chance of tossing a coin (50/50). And the course you describe seems more likely a mild attack where the chance of later operation is closer to 5%.
Using the surgeon’s decision to operate as a surrogate measure for the recurrence rate is questionable and certainly many more patients have recurrent symptoms.
I apologize for this long posting but I feel a need to stand up for CT evaluation of complicated diverticulitis (fever,leukocytosis, tender abdominal mass) and percutaneous drainage of abscesses. Eric, per your suggestion I opened my trusty Schwartz, Principles of Surgery textbook and I quote “a tender mass in the LLQ is suggestive of a localized phlegmon or, more likely, an abscess.” “The CT is usually the test of choice to confirm the suspected Dx of diverticulitis. It reliably detects the location of the inflammation and provides valuable accessory information such as the presence of an abscess, ureteral obstruction, or a fistula between the colon and urinary bladder (by demonstrating air in the bladder). If an abscess is present, percutaneous drainage under CT guidance is a valuable therapeutic procedure.
Last summer at the U of Minnesota annual surgery course Stanley Goldberg gave a great lecture on “Complicated diverticular disease: An american approach” He does not advocate a CT for every patient with the diagnosis of diverticulitis but advises it when the patient deteriorates, does not improve clinically, or if abscess is suspected. He advocates percutaneous drainage of abscesses. “The only contraindications to percutaneous drainage are an abscess which is inaccessible, pathology which is inappropriate (primarily phlegmonous), a patient who is too high-risk (coagulopathy), and cases which require emergent surgical intervention irrespective of the presence of the abscess (peritonitis)”. Perhaps I would add no one around to put the percutanous drain under CT or US guidance in a rural setting. As pertains to the topic of resection after abscess drainage, his colorectal group evaluates the patients and makes the following recommendation for patients who resolve their abscess with drainage and antibiotics “If the involved segment is long, stenotic, or otherwise severely diseased, we recommend elective resection. If, however, the diseased segment is short and pliable, we do not recommend elective resection after the patient’s first attack.”
I think it’s sometimes difficult to treat these virtual patients without being there and giving the patient the most important test : Eyeball and Hand Scan (very cheap and readily available around the world). I interpreted the patient presented as more than the usual diverticulitis that gets better with a course of IV antibiotics because he had a palpable tender mass which can frequently turn out to be an abscess. For these complicated patients a CT scan does have a role in the management.
Thank you for your posting on the role of CT in diverticulitis–your analysis of the book chapters is what I also found–at least in Schwarz, but not in Fromm’s–but you suddenly change the topic–you advocated operation for nothing more than the prsence of fever, peritonitis and leukocytosis, which is how ALL diverticulitis typically presents, and you failed to note in the Schwarz chapter, as well as in Sabistyon and Fromm’s text, that the only indication to OPERATE (which is what our debate was about) is FAILURE of MEDICAL MANAGEMENT following the diagnosis of diverticulitis ( which an only be diagnosed by noting fever leukocytosis and peritonitis)! In other words, medical management is tha STANDARD approach to diverticulitis, unless an exceptional indication exists. That was my major point of contention with which you disagreed. Also, your description of what Stanley Goldberg recommends is EXACTLY what I posted originally–which you also disagreed with! Interesting you quote him as supporting you–I guess you change your mind quickly! I specifically said there certainly is a role for CT, but only in the exceptional case when the patient does not respond to STANDARD medical management–then it certainly does have value–and as you note, he specifically says CT should NOT be used routinely, and for the best of reasons–it isn’t necessary, as all decisions can be made on the clinical picture of the patient. And all these articles you failed to quote probably basically say the same thing–and I agree–there IS a role for CT–that was never the issue–What that role is was the point of contention–so don’t confuse the issue–you were very selective in your quoting of Schwarz, conveniently leaving out the major point of operative indication, and once again my challenge stands–you have not yet provided any evidence that the ROUTINE use of CT in EVERY CASE has any benefit, nor that the mere appearance of diverticulitis with its typical manifestations is in itself an indication to operate–and saying merely that someone else does it is no proof. If you can not provide such evidence, that says scads about the strength and rationale of your stance.
I didn’t advocate operating or CT on all diverticulitis, just for the complicated abscess which was appropriately drained. I will continue to get a CT when I palpate a mass in a patient with diverticulitis. I don’t think we are in disagreement on managing these patients. We are at a disadvantage by not having the patient before us on rounds so we can both examine him/her and discuss the management “live”. Pus is a recurring topic on this list but the diverticular kind seems exhausted. Let’s let it drain away.
The CT was helpful in that it showed you a complication of diverticulitis (abscess) which I would consider an indication for surgery.