Diverticulitis Debate - Counterpoint

History:

• Disease of the 20th Century - Described by Graser in 1899
• Industrial Revolution and Industrial Nations

Pathophysiology:

• Structural abnormalities of the Colonic wall
• Disordered motility
• Role of dietary fiber

Epidemiology:

Diverticulosis

-Under 30 - 1% to 2%

-Over 60 - 40%

• 10% to 25% - develop diverticulitis

- Severity and even laterality varies geographically

- Economic Impact - 1.5 million days of inpatient care

- Hinchey Classification: I, II, III, IV

- CT classification - Sartelli 2015

• Uncomplicated Diverticulitis - Diverticula, thickening of the wall, Increased density of the pericolic fat
• Complicated: 1A, 1B, 2A, 2B, 3, 4

- Ambrosetti Classification - Mild- localized colonic wall thickening vs Severe - presence of abscess, extraluminal air, contrast

- Modified Neff Criteria

Counterpoint: "Immunocompromised patient who may not mount a normal or significant inflammatory response may have only extraluminal gas on CT without other typical findings of diverticulitis" Baker et. al.

Presentation/Clinical Manifestation (Hwang, et al)

- Abdominal tenderness/Peritonitis - 63% of patients

- Radiological studies - 61% with free air on imaging

- Vast Majority of patient's underwent surgical resection on index hospitalization

Morbidity (Brandl et. al)

- Immunocomptent vs Immunosuppresed

• Higher rate of complicated disease with a higher rate of emergent operations
• Found in Transplant patients emergent surgery showed a overall complication rate of 81%.

The surgery they deserve (Oberkofler et al):

- Primary anastamosis with loop Ileosomy

Diverticulitis Treatment - Superstition to Science

Defining uncomplicated and complicated diverticulitis

Objectives

Acute Diverticulitis in the Immunocompromised

Clinical Scenario

You are asked by the medicine service to consult on a 67-year old obese female with arthritis and polymyositis with limited mobility managed with 10mg prednisone daily, poorly controlled DM, and HTN who has been admitted with acute onset LLQ pain over the past 48-72 hours. Her nutritional status is suboptimal. Chart review indicates that she has had 5 prior episodes of uncomplicated diverticulitis managed at various facilities, both inpatient and outpatient. She is hemodynamically within normal limits, has a mild leukocytosis with left shift, is tender on examination, and has CT findings of a phlegmon without abscess.

Would you offer an operation this admission and what would be your approach?

-From ASCRS(2014) - "Surgeons should maintain a low threshold to recommend operative intervention as definitive treatment during the first hospitalization for acute diverticulitis in these patients"

- From WSES(2016) - "Immunosupression can increase the complication rate in the patients with ALCD. Elective sigmoid resection after an episode of ALCD should be recommended in immunocompromised patients (Recommendation 1 C)"

• Brief review of the history, pathophysiology, and epidemiology of acute diverticulitis.
• Define uncomplicated and complicated diverticulitis.
• Review complications of acute diverticulitis in the immunocompromised patient.
• Recommendation of treatment for Clinical Scenario.

Recommendations

History, Pathophysiology, and Epidemiology

- Optimization: Control diabetes, Optimize nutrition

- Antibiotics: Oral antibiotics x 4 weeks

- Know what you are getting into: Obtain a colonoscopy pre-operatively

- Prep: Stress dose steroids, neomycin and flagyl with full miralax bowel prep.

- Operation: Laparoscopic Coloectomy with primary anastamosis and diverting loop ileostomy with the skin left open

Bibliography

1. Hobson, Kristina G. “Etiology and Pathophysiology of Diverticular Disease.” Clinical Colon Rectal Surgery , 17 Aug. 2004, pp. 147–153.

2. Feingold, Daniel, et al. “Practice Parameters for the Treatment of Sigmoid Diverticulitis.” Practice Parameters for the Treatment of Sigmoid Diverticulitis , 2014, pp. 284–294.

3. Sartelli, Massimo, et al. “WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting.” World Journal of Emergency Surgery , 2016, pp. 11–27.

4. Sartelli, Massimo, et al. “A proposal for a CT driven classification of left colon acute diverticulitis.” World Journal of Emergency Surgery , 2015.

5. Baker ME. "Imaging and interventional techniques in acute left sided diverticulitis" J Gastrointest Surg. 2008; 12:13 14-1317

6. Hwang, Cannnon, et al. "Diverticulitis in transplant patients and patients on chronic corticosteriod therapy: A systematic review" Diseases of the Colon and Rectum. 2010.

7. Brandi, Andreas, et al. “Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?” Can J Surg, vol. 59, 29 Mar. 2016

8. Oberkofler, Christian E, and Andreas Rickenbacher. “A Multicenter Randomized Clinical Trial of Primary Anastomosis or Hartmann's Procedure for Perforated Left Colonic Diverticulitis With Purulent or Fecal Peritonitis.” Annals of Surgery , vol. 256, no. 5, Nov. 2012.