Original Contribution
The American Journal of Gastroenterology (2005) 100, 910–917; doi:10.1111/j.1572-0241.2005.41154.x
The Management of Complicated Diverticulitis and the Role of Computed Tomography
Andreas M Kaiser MD, FACS1, Jeng-Kae Jiang MD1, Jeffrey P Lake MD1, Glenn Ault MD1, Avo Artinyan MD1, Claudia Gonzalez-Ruiz MD1, Rahila Essani MD1 and Robert W Beart Jr. MD, FACS1
1Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and Division of Colorectal Surgery, Department of Surgery, Veterans General Hospital, Taipei, National Yang-Ming University, School of Medicine, Taipei, Taiwan, Republic of China
Correspondence: Andreas M Kaiser, MD, FACS, Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033
Received 13 July 2004; Revised 0000; Accepted 19 October 2004.
Abstract
PURPOSE:
Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis.
METHODS:
We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis.
RESULTS:
In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%.
CONCLUSIONS:
CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.
