Slovenská chirurgia 4/2015

Current approach to the diagnostics and treatment of acute colonic diverticulitis

Left-sided diverticulosis of the colon is a common condition in Western society. The most frequent complication of diverticular disease is acute diverticulitis. The literature dealing with the diagnosis and treatment of acute diverticulitis has recently discovered some new opinions and recommendations, therefore the purpose of this publication is to highlight the current state of knowledge in this field. The lack of uniformity in terminology results in difficulties interpreting and comparing findings between studies, therefore, it was to simplify the classification stage of diverticulitis by Hinchey first proposed classification system, which was later modified with Wasvary assignment CT correlate. Recurrence rate of acute left-sided colonic diverticulitis (ACD) on the basis of several studies varies between 9 and 29 %, and although the risk for a second recurrence increased to 29 % among those with a first recurrence, the authors concluded, that recurrence overall is rare and therefore does not warrant elective colectomy. Another argument against routine elective resections sigmoid colon implementation after successfully mastered two conservative attacks of acute diverticulitis is that the rate of perforations is highest during the first attack of diverticulitis and perforation risk decreases with each successive attack. CT associated with the use of intravenous and oral contrast and, in ideal conditions, rectal contrast is the diagnostic method of choice. Most patients with uncomplicated diverticulitis (Hinchey 0 or Ia) can be treated conservatively with a success rate of 93 – 100 % and this treatment can be carried out as the outpatient treatment providing for the adequate diagnosis and patient compliance. The Hinchey stage Ib and II abscesses small size, good response to treatment with intravenous antibiotics until abscesses larger than 5 cm in diameter should be drained under CT control. In cases of perforated diverticulitis is resection with primary anastomosis considered for safe performance, which requires experience, whilst respecting the well-known contraindications. Taking rifaximin and fiber in the diet after the attack ACD relieves symptoms in cases of symptomatic diverticular disease, but has not been proved their protective effect against the recurrence of acute diverticulitis. The indication for elective surgical treatment should not be based only on the number of relapses ACD, but the particular complications caused by these attacks, such as stenosis, fistula, bleeding from diverticulas or persistent abdominal pain. In the group of patients operated on electively laparoscopy was reported significantly better quality of life and a lower incidence of postoperative complications.

Keywords: acute diverticulitis, surgical treatment, elective resections, Hartmann’s procedure, laparoscopic treatment