Current Aspects on the Management of Perforated Acute Diverticulitis: A Narrative Review

Abstract

Unhealthy nutritional habits and the current western lifestyle have led to an increased incidence of acute diverticulitis, which mainly affects older patients. However, the disease course in younger patients might be more severe. It has a continued increase in surgical practice, as it is the most common clinical condition encountered in the emergencies. Diagnosis and management have changed over the past decade. C-reactive protein > 170 mg/L represents the cut-off point between moderate and severe diverticulitis, and a CT scan is mandatory. It demands urgent surgical management and has high morbidity and mortality rate, especially in immunosuppressed patients, reaching up to 25%. According to the contemporary guidelines, there have been certain indications for conservative management and re-evaluation (administration of antibiotics, CT-guided drainage of the abscess, when it is > 4 cm). They include pericolic air bubbles or a small amount of fluid, absence of abscess within a distance of 5 cm from the affected bowel or abscess ≤4 cm. In other cases, Hartmann’s sigmoidectomy is the procedure of choice. An alternative choice, nowadays, is resection and primary anastomosis with or without diverting stoma, especially in younger patients. Laparoscopic lavage only versus primary resection has been performed in severe cases of Hinchey III or IV. Damage control surgery, possible open abdomen, and reoperation are recommended in severe sepsis. Hinchey’s classification may not be absolutely adequate, and several modifications have been proposed. Current classification criteria (CRP, qSOFA score) are more appropriate. The decision-making must be individualized depending on the hemodynamic status (septic shock), age, comorbidity, immune status, intraoperative findings, and MPI (Mannheim peritonitis index).

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

“…High qSOFA score was associated with organ dysfunction and a mortality of more than10% which favored the HP procedure. [ 41 , 42 ]…”

Diverticulite aguda - revisão literária

“…Globalmente, a idade média de admissão hospitalar por diverticulite aguda é de 63 anos. Embora inicialmente a doença fosse mais prevalente em homens, dados recentes indicam que a distribuição da Brazilian Journal of Health Review, Curitiba, v. 7, n. 3, p. 01-10, may/jun., 2024 diverticulite é agora igual entre homens e mulheres (Pavlidis;Pavlidis, 2022;Linzay;Pandit, 2023).…”

“…A diverticulite aguda do lado direito é mais comum em asiáticos e em homens de meia-idade, logo pode ser difícil de diferenciar da apendicite aguda devido aos seus sintomas e sinais semelhantes, especialmente quando localizada no ceco. A taxa de perfuração pode atingir 10%, associada a fatores de risco incluindo elevação da PCR, leucocitose, dor abdominal difusa, parada de Brazilian Journal of Health Review, Curitiba, v. 7, n. 3, p. 01-10, may/jun., 2024 eliminação de fezes e gases, vômitos, comorbidades pré-existentes e idade avançada (Sartelli et al, 2020;Pavlidis;Pavlidis, 2022;Linzay;Pandit, 2023).…”

“…Dos pacientes que apresentam diverticulose dos cólons, aproximadamente 10 a 25% irão apresentar diverticulite aguda durante a vida. As manifestações clínicas da diverticulite aguda são variáveis, a depender da gravidade da doença (Zizzo et al, 2020;Pavlidis;Pavlidis, 2022;Linzay;Pandit, 2023).…”

“…O tratamento da diverticulite é convencionalmente cirúrgico, porém passou a ser uma doença passível de tratamento clínico, mesmo em sua fase mais aguda. Por ser o evento mais frequente de emergências abdominais em pacientes idosos, é de suma importância que seja realizado o diagnóstico correto e tratamento adequado a fim de evitar complicações severas (Zizzo et al, 2020;Pavlidis;Pavlidis, 2022;Linzay;Pandit, 2023).…”