Emergency General Surgery

Why Do We Complicate an Uncomplicated Matter?

It’s not about what I want, it’s about what’s fair!

Harvey Dent (aka Two-Face) from the movie Batman – The Dark Knight

As every coin has two faces, every medical story has two viewpoints, the patient’s and the doctor’s…

Head (Patient’s view)

Kenneth McCormick is a 72-year-old man, who’s enjoying his retirement after 45 years working in the local factory. His medical history said hypertension on treatment and appendectomy when he was 6.

One day, after dinner, he started complaining about mild pain in the left lower abdomen… Nothing serious, but quite annoying. He thought it was just intestinal colic and paid no special attention to it.

The day after, when he woke up, the pain was still there, a little bit stronger. Also, he had nausea and fever (37.7°C). He took a tablet of paracetamol 1000 mg and continued doing his usual things. However, after a couple of hours, the pain came back as intense as before. At that point, Kenny decided to go to the hospital.

There, the healthcare personnel drew blood and asked for an abdominal CT scan. The referring doctor said it was probably acute diverticulitis.

Kenny had heard about acute diverticulitis. An old friend of his had it, and he underwent an emergency surgical operation, and when he woke up, he had a stoma.

But his friend had peritonitis, he has just an annoying pain.

After about 2 hours, the doctor announced the lab results showed elevated white blood cell count and CRP (what’s CRP, by the way?!…), and that the CT scan report confirmed the clinical hypothesis of acute diverticulitis.

The doctor told him he should be hospitalized to start IV antibiotics and to be monitored. He said that if Kenny doesn’t improve, it could be necessary to perform a surgical operation.

Kenny doesn’t want to be operated… neither having a stoma…

Kenny started being really worried about that.

Anyway, Kenny was admitted. They inserted an IV line, started giving him antibiotics, and put him on a nil per os diet. He stayed in a 4-bed room, without drinking anything for 2 days and without eating for 3 more days. During his stay, he had difficulties to sleep because of the other patients’ moans and because he was scared as shit to be operated.

Kenny was eventually discharged after 7 days with oral antibiotics.

Tail (Doctor’s report)

Evaluation:

  • Past medical history – hypertension on treatment, previous open appendectomy (6 yo)
  • Clinical history – left iliac fossa pain since yesterday. Nausea, not vomiting. Fever up to 37.7°C. Bowel opened to stool yesterday.
  • Examination – localized left iliac fossa pain, mild rebound tenderness, no guarding. At digital rectal examination no blood. Body temperature 37.5°C on arrival.
  • Lab exam – WBC 12,700/mm3; Hb 14.6 g/dL; CRP 52 mg/L
  • CT scan report – the presence of diverticular pouches along the descending and sigmoid colon. Thickening of the sigmoid wall with increased contrast uptake and pericolic fat stranding. Some enlarged lymph nodes near the sigmoid colon. No free fluid, no intraabdominal fluid collections, no free air.

Diagnosis and Management:

  • Diagnosis – uncomplicated acute diverticulitis
  • Management – admit, IV antibiotics, pain killers, nil per os, fluid therapy, monitoring
Moral of the Story

The doctor was a moron.

The Uncomplicated Acute Diverticulitis

Definition & Classification

Acute diverticulitis is an inflammatory disease involving a colonic tract, mostly the sigmoid colon. It is secondary to a micro-perforation of a diverticulum, which may result in localized inflammation, abscesses, up to diffuse peritonitis.

We talk about uncomplicated diverticulitis when the inflammatory process is localized to the colon and the pericolic fat.

Many classifications exist to define which kind of acute diverticulitis we are dealing with (e.g. Hinchey, modified Hinchey by Sher et al., modified Hinchey by Wasvary et al., Hansen/Stock classification, etc…). All these classifications are based on imaging findings (basically on CT scan findings). The basic principle is the same as that we enounced for acute appendicitis’ scores: choose one, doesn’t matter which. For instance, we are going to use the modified Hinchey classification by Wasvary et al..

GradeFindings
0Mild clinical diverticulitis
IaConfined pericolic inflammation or phlegmon
IbPericolic or mesocolic abscess
IIPelvic, distant intraabdominal, or retroperitoneal abscess
IIIGeneralized purulent peritonitis
IVGeneralized fecal peritonitis
Modified Hinchey Classification by Wasvary et al.

Upon this classification, it appears that uncomplicated diverticulitis corresponds to grade 0 and grade Ia.

Diagnostic Workup

The diagnostic workup for suspected acute diverticulitis consists, as in the case scenario reported above, should include complete clinical history, clinical examination (completed by digital rectal examination), lab test (white blood cell count, and C-reactive protein), and imaging (contrast-enhanced abdominal CT scan). It is possible to use ultrasound as the first-line imaging method, but only a few people are capable of doing it properly. That’s why the CEACT scan is still considered the gold standard for both the diagnosis and the staging of patients with acute diverticulitis.

Conservative Treatment

For what concerns the treatment, patients with uncomplicated acute diverticulitis can be safely discharged home on oral antibiotics, a liquid diet for the first couple of days, and a follow-up visit at the outpatient clinic within 7 days. In the systematic review and meta-analysis published in 2018, Van Dijk et al. reported that only 2 (0.2%) of the 1288 outpatient treated patients needed emergency surgery. Similarly, the percutaneous abscess drainage rate was 0.2% as well. No mortality was recorded considering all the studies analyzed. Moreover, the readmission rate was 7%. However, the studies involved excluded patients with comorbidity, immunosuppression, inability to tolerate oral feeding, or lack of an adequate social network. Despite this, Van Dijk et al. estimated an average healthcare cost savings ranging between 42 and 82%.

The recommended antibiotic regimen is amoxicillin-clavulanic or ciprofloxacin plus metronidazole in patients with penicillin allergy. However, recent studies have demonstrated a non-inferiority of withholding antibiotics in uncomplicated diverticulitis over antibiotics administration, provided that the patients are immunocompetent and there are no signs of systemic inflammation.

If pericolic (within 5 cm) extraluminal gas is identified at CT scan, there is no clear evidence whether these patients need antibiotics or not. In fact, the study by Bolkenstein et al. showed how the failure rate of conservative treatment in patients with pericolic extraluminal gas was 13% in patients treated with antibiotics compared to 4% in those treated without. However, since this study included 109 patients, these results cannot be considered strong enough to make a clear statement upon them. Moreover, the cohort is composed of patients included in the DIABOLO Trial (a multicenter randomized controlled trial) together with those enrolled in a retrospective cohort study.

For what concerns medical treatment, there is no indication in prescribing other medications such as NSAIDs, mesalazine, rifaximin, and probiotics.

Fiber-rich diet or fiber supplementation is recommended in patients with a history of acute diverticulitis. However, there is little evidence that it prevents recurrent episodes of acute diverticulitis. On the contrary, the consumption of seeds, nuts, and popcorn should not be advised against anymore.

Follow-Up

And what about routine follow-up colonoscopy? Is it necessary?
According to recent studies, the prevalence of colorectal cancer in patients who underwent a colonoscopy after an episode of acute diverticulitis was comparable to that of asymptomatic patients. Considering only patients with uncomplicated acute diverticulitis, the prevalence was around 0.5-1%. Therefore, the authors concluded that routine colonoscopy may be avoided in patients with uncomplicated diverticulitis, provided that the CT scan didn’t show anything suspicious. However, in the case of patients with recurrent uncomplicated acute diverticulitis, who have not done any colonoscopy within the last 3 years, an endoscopic examination is recommended at least 6 weeks after the resolution of the acute episode.

Operative Management

Another important query is when to operate a patient with a history of acute diverticulitis. According to the DIRECT-Trial, operated patients who were suffering from recurring episodes of diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode had a higher quality of life compared to those treated conservatively. Moreover, the authors reported how 46% of patients in the conservative group eventually underwent surgery due to severe ongoing abdominal complaints. Laparoscopic sigmoidectomy is the gold standard technique to operate these patients.

Erase / Rewind

In 1999 the Swedish band The Cardigans released the single “Erase/Rewind”…

Let’s do the same thing for our case scenario… Erase what was done, and rewind the decisions made.

How should Kenny be managed?

The doctor came back with the results of the lab exams and of the CT scan. He told Kenny that he had acute diverticulitis, but just a mild one.

He told him there’s no need to worry about it because only a minority of cases develop serious complications. He said to Kenny he can go home with just pain killers and a liquid diet for 2 days. However, in case of worsening of symptoms, Kenny must go back to the hospital right away.

The doctor gave to Kenny an appointment at the outpatient clinic after 5 days.

Kenny went home happy. He followed the doctor’s instructions, and after 5 days he went to the outpatient clinic. The pain has almost vanished, and the follow-up lab exams showed WBC within normal limits and a CRP just above the upper limit.

No need for admission, no need for antibiotics, better patient quality of life, lower hospital costs…

Everybody wins… This time…

References
  1. Sartelli M, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World Journal of Emergency Surgery 2020;15:32.
  2. Schultz JK, et al. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Disease 2020. DOI: 10.1111/codi.15140
  3. van Dijk ST, et al. A systematic review and meta-analysis of outpatient treatment for acute diverticulitis. International Journal of Colorectal Disease 2018;33:505-12.
  4. Emile SH, et al. Management of acute uncomplicated diverticulitis without antibiotics: a systematic review, meta-analysis and meta-regression of predictors of treatment failure. Techniques in Coloproctology 2018;22:499-509.
  5. Bolkenstein HE, et al. Conservative treatment in diverticulitis patients with pericolic extraluminal air and the role of antibiotic treatment. J Gastrointest Surg 2019;23:2269-76.
  6. Stollman N, et al. American Gastroenterological Association Institute Guideline on the management of acute diverticulitis. Gastroenterology 2015;149:1944-9.
  7. Rottier SJ, et al. Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis. BJS 2019; DOI: 10.1002/bjs.11191.
  8. Bolkenstein HE, et al. Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis – 5-year follow-up results of a multicenter randomized trial (DIRECT-Trial). Ann Surg 2019;269:612-20.
How to Cite This Post

Bellio G, Marrano E. Why Do We Complicate an Uncomplicated Matter? Surgical Pizza. Published on August 22, 2020. Accessed on July 28, 2022. Available at [https://surgicalpizza.org/emergency-surgery/why-do-we-complicate-an-uncomplicated-matter/].

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