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Acute Colonic Diverticulitis
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Complicated Inflammatory Bowel
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Disease andColonic Non-diverticular
Emergencies
FrancescoMariaCarrano, AntoninoSpinelli,
andHayatoKurihara
1 Introduction
Inammatory bowel disease (IBD) are non-infectious chronic inammatory disorders of the gastrointestinal tract with a relapsing-remitting course that primarily
include Crohn’s disease (CD), ulcerative colitis (UC), and indeterminate colitis.
Currently, approximately nearly seven million individuals are living with IBD
worldwide and the number of prevalent cases is on the rise, especially in newly
industrialized countries [1]. The highest incidence of IBD is among adolescents and
young adults (ages 18–35 years) with an almost 1:1 female to male ratio [2].
Although their pathogenesis is still to be uncovered, it is thought to be driven by
genetics and environment, such that dysregulated mucosal immune function is associated with a dysbiotic commensal microbiome that coordinately drives a pathological inammatory cycle [3]. CD is characterized by transmural inammation that can
occur in the entire gastrointestinal tract, and complications of poorly controlled
disease include strictures, stulae, obstruction, and perforation. The most common
localizations include the terminal ileum and caecum. On the contrary, the inammation in UC is conned to the mucosa and submucosa, usually beginning in the distal
rectum and progressing to the more proximal colon. In about 25% of patients with
UC, terminal ileum is also involved (backwash ileitis) [4]. Due to the nature of the
disease, IBD can often manifest as acute surgical emergencies in the form of acute
F. M. Carrano · A. Spinelli
Department of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
e-mail: antonino.spinelli@hunimed.eu
H. Kurihara (*)
Emergency Surgery and Trauma Section, Department of Surgery, IRCCS Humanitas
Research Hospital, Milan, Italy
e-mail: hayato.kurihara@humanitas.it
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. Coccolini et al. (eds.), Mini-invasive Approach in Acute Care Surgery,
Hot Topics in Acute Care Surgery and Trauma,
https://doi.org/10.1007/978-3-031-39001-2_8
87
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severe colitis, toxic megacolon and fulminant colitis, uncontrolled bleeding, free
perforation, intra-abdominal masses or abscesses with sepsis, and intestinal obstruction. In 47% of patients with CD and 16% of patients with UC, those emergent
presentations lead to surgery within 10 years of diagnosis [5] with a signicant
morbidity and impact on the quality of life.
This chapter will discuss the main presentations of IBD in the acute setting and
the relative treatment approaches.
F. M. Carrano et al.
2 Initial Assessment andDiagnosis
When a patient is admitted to the Emergency Department (ED) with abdominal
pain, fever, diarrhea, bloody stools, and weight loss, the possibility of an IBD
should be suspected. In case of a positive history of IBD, it is important to investigate whether patient’s symptoms are related to a are of IBD or the insurgence
of a complication (i.e., C. difcile infection, cytomegalovirus infection, enteric
stulae formation) or if it’s an unrelated event (i.e., acute diverticulitis, appendicitis, etc.). To achieve a proper differential diagnosis, it is important to obtain a
thorough patient’s medical and surgical history, physical examination, laboratory
test results (including a complete blood count, electrolytes, serum albumin,
C-reactive protein, and fecal calprotectin), and imaging studies. In case of
Crohn’s disease patients, it is important to evaluate the disease phenotype, which
is usually classied following the Montreal classication [6] according to age at
diagnosis (early or late onset), predominant disease location (small bowel, large
bowel, or perianal), and behavior (penetrating, brostenotic, or inammatory)
[7, 8]. Disease severity in CD can be measured with The Crohn’s disease activity
index (CDAI), the International Organization for the study of IBD (IOIBD)
index, and the Harvey–Bradshaw index, although their use may not be very practical in the ED setting. In case of UC, it can be divided in the active stage, with
active mucosal lesions and symptoms, and in the remission stage, with resolution
of symptoms and lack of active mucosal lesions at endoscopy. According to disease extent, UC can be divided into proctitis, distal colitis (up to the sigmoid
colon), left-sided colitis (up to the splenic exure), and pancolitis. The severity
of UC can be graded according to Truelove-Witts criteria into mild, moderate,
and severe [8, 9]. More recently, the American College of Gastroenterology proposed an updated UC activity index [10] (Table1).
In the emergent setting, however, a complete investigation of the disease may not
always be possible. Thus, of primary importance is to correctly stratify patients, in
order to decide if the patient can be discharged home safely or if further studies are
needed, if patients require hospitalization or emergency surgery. A series of criteria
that can be used as practical guidance for this task is listed in Table2.
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Table 1 UC activity index grading proposed by the American College of Gastroenterology
Moderate to
Remission Mild
Stools/day (n) Formed stools <4 >6 >10
Blood in stools None Intermittent Frequent Continuous
Urgency None Mild, occasional Often Continuous
Hemoglobin Normal Normal <75% of normal Transfusion
ESR <30 <30 >30 >30
CRP (mg/L) Normal Increased Increased Increased
FC (μg/g)
Endoscopy
(Mayo subscore)
UCEIS 0–1 2–4 5–8 7–8
ESR erythrocyte sedimentation rate, CRP C-reactive protein, FC fecal calprotectin, UCEIS
Ulcerative Colitis Endoscopic Index of Severity
Adapted from Rubin DT etal. [10]
Table 2 Practical criteria for the management of IBD patients in the ED
Clinical
criteria
Laboratory
criteria
<150–200 >150–200 >150–200 >150–200
0–1 1 2–3 3
When to request a CT-scan
Abdominal signs or symptoms
suggestive of IBD complications
Bowel obstruction Bowel obstruction
Surgical bowel resection in the
past 30days
Very high CRP
severe
When to hospitalize
Abdominal signs or symptoms suggestive
of IBD complications
Fever
Surgical bowel resection in the past 30days
Vomiting
Ano-perineal abscess
Hemodynamic instability
Laboratory-conrmed signs of dehydration
Acute kidney failure
Hemoglobin <9g/dL or decrease of ≥2g/dL
Fulminant
required
89
Modied from Hebuterne etal. [11]
3 Acute Severe Colitis
Acute severe colitis (ASC) is a life-threating condition that can occur in both CD
and UC patients. In this paragraph, we will focus mainly on acute severe ulcerative
colitis (ASUC) for clarity of exposition; however, the management of ASC in CD
patients is similar. ASUC requires hospital admission in up to 25% of UC patients,
it is burdened by high morbidity, requires colectomy in 40% of cases [12, 13], and
carries a 1% mortality [14]. In the ED, patients with a clinical suspect of ASUC
should receive extensive laboratory testing, including complete blood cell counts,
basic metabolic panels, liver function tests, serum albumin, and prealbumin. An
abdominal radiograph should be obtained to assess the degree of bowel dilation and
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F. M. Carrano et al.
rule out the presence of toxic megacolon or free air. In case of recent history of
bowel resection, or if abdominal signs or symptoms are suggestive of IBD complications (bowel obstruction, perforation, abscess, bleeding), patients should be studied with an abdominal CT scan with contrast. Those patients who meet admission
criteria should be hospitalized with the aim of further investigating the disease
activity and initiate the most appropriate treatment. At admission, stool cultures and
Clostridium difcile test are fundamental to rule out enteric infection, though this
should not delay initial treatment. Additionally, Hepatitis B serology and
Quantiferon-y test, cytomegalovirus (CMV), human immune deciency virus
(HIV), Epstein–Barr virus (EBV) serology, and tuberculosis exposure should be
considered once the emergent need for surgery is excluded to rule out latent infections, in preparation for possible rescue therapy with biologic agents. Patients
should receive early endoscopy, within 24 h from the admission, without bowel
preparation and using minimal air insufation, to conrm or exclude CMV colitis,
which is essential for optimal treatment [13]. After a proper diagnosis is achieved
and an initial risk stratication performed, it is of upmost importance to determine
which patients are at higher risk of requiring rescue therapy or emergent colectomy;
several disease scores are used for this purpose. The most used criteria to predict
outcomes in ASUC are those from Truelove and Witts, although they were not originally conceived for this task. In fact, it has been demonstrated that, if used alone,
they may under classify those patients who have active UC without the markers of
systemic disturbance, possibly leading to the undertreatment of an important subset
of patients [14]. Another commonly used tool is the Oxford (or Travis) index, developed in 1996, that predicts the need for colectomy to be 85% in patients with a CRP
level greater than 45mg/L and 3–8 bowel movements a day after 3days of intravenous corticosteroid treatment. Recent studies have shown a potential advantage of
using the Ulcerative Colitis Endoscopic Index of Severity (UCEIS). A UCEIS score
of 5 or more was associated with a 50% chance of requiring rescue therapy and 33%
rate of colectomy compared with 27% and 9% for those with a score of less than or
equal to 4 [12]. The rst-line treatment for ASUC patients is high-dose intravenous
steroids in both anti-TNFα-naïve and previously exposed patients, instead, iniximab and cyclosporine are the recommended drugs in case of steroid therapy failure
in anti-TNFα-naïve patients [15]. The surgical option should be evaluated early in a
multidisciplinary setting and not only considered when medical treatment fails, to
reduce the risk of postoperative complications. The primary goal of this multimodal
treatment is to avoid the onset of complications requiring an emergency operation,
which is fundamental to reduce mortality (Table3).
Urgent colectomy is required for medical treatment failure or in case of toxic
megacolon with imminent perforation [13]. The goal of the operation is to restore
patient’s health status and create the conditions for future restorative procedures.
There should be no room for single staged ileal pouch-anal anastomosis (IPAA)
procedures in the urgent setting. Two- or three-stage procedures should be the primary choice. Only the rst stage is performed in the urgent setting; a total abdominal colectomy with an end ileostomy is completed leaving behind the rectal stump.
The operation should be ideally performed in a minimally invasive fashion whether
Complicated Inammatory Bowel Disease andColonic Non-diverticular Emergencies
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Table 3 ASUC treatment algorithm
Initial
Timing
Admission
(day 0)
Day 3 Reevaluate Identify high-risk
Days 3–7 IV
Adapted from Carvello etal. [13]
investigations Additional tests Initial treatment
Full blood count,
urea, creatinine,
electrolytes, liver
function tests,
CRP, ESR,
magnesium, lipid
prole
• C. difcile
toxin
• Abdominal
X-ray
• Stool
frequency
• Nutritional
status
assessment
Full blood cell
count, CRP,
stool frequency
Additional tests:
• CT
• Colonoscopy
hydrocortisone
responder
Full blood cell
count, CRP
• Stool
frequency
• Convert to oral
prednisolone
CMV, hepatitis B
and C serology,
HIV, EBV serology,
and TB exposure
• CT
• Early
colonoscopy
patients
Stool frequency>8/
day
• CRP>45mg/L
• Require rescue
therapy
(ciclosporin or
iniximab)
Rescue therapy
responder
Ciclosporin (convert
to oral after
5–7days)
• Iniximab,
assess on day 7
for response
(if non-responder
MTD
consultation)
IV hydrocortisone
(100mg 3–4× daily)
• Prophylactic
LMWH
• IV uids, consider
potassium
replacement
• Early nutritional
support
Management
decisions
• MTD consultation
• Continue IV
hydrocortisone
• Start rescue
therapy in
high-risk patients
(ciclosporin,
iniximab)
Rescue therapy
non-responder
MTD consultation
• Colorectal surgeon
• Stoma nurse
(education and
necessary support)
• Dietitian
• Gastroenterologist
• Multidisciplinary
input (planning
surgery and further
treatment)
Daily clinical
assessment
• Stool
frequency
• Temperature
• Heart rate
• Clinical
abdominal
examination
• Full blood
cell count,
urea,
electrolytes,
CRP
91
conventional laparoscopy, hand-assisted laparoscopic surgery (HALS), or roboticassisted HALS colectomy may be particularly useful to help surgeons overcome the
laparoscopic learning curve, as well as in complex cases, that would otherwise
require an open approach. In a recent case series, conventional laparoscopy compared to HALS total colectomy was associated with a reduced postoperative pain,
lower complications and readmissions rate, and shorter length of stay, with only
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F. M. Carrano et al.
ab c
Fig. 1 Single port approach for total colectomy. (a) Single port platform placed at the future
stoma-site; (b) operator positioning during surgery; (c) nal “no-scar” result
marginal differences in operation length [16]. A possible rule of thumb of which
approach to choose may be the following: if there is suspect of free perforation or
the patient is hemodynamically unstable→open approach; in case of slim patients
with no previous history of surgery, in good overall conditions, and with milder
acute presentations→single port surgery (Fig.1); for all the remaining→laparo-
scopic multi-port surgery.
Whichever the approach, this rst operation provides a relatively rapid and safe
resolution of the emergency while preserving intact pelvic planes for the future
steps, avoiding the risk of pelvic bleeding and injury to the pelvic nerves and bladder, that may easily occur in the emergent setting. A restorative operation can then
be performed at a later stage when the patient has fully recovered and is in optimal
conditions. The remaining rectal stump can be managed in different ways, according to the individual patient characteristics and institutional experience, as there is
no consensus in the literature on the optimal management. According to recent
metanalyses, subcutaneous placement of the closed rectal stump is the least morbid
[17, 18], with a pelvic sepsis rate of 2 and 0% mortality [18]. Another option is the
intraperitoneal placement of the rectal stump, which is associated with the lowest
wound infection rate (7.9%); however, higher rates of pelvic sepsis (5.3%), overall
complications (25%), and mortality (1.5%) are reported with this technique [18].
In our opinion, mucous stula may represent the best option in case the patient is
highly compromised, with poor nutritional and performance status, and in case tissues are extremely inamed and would not guarantee a secure management with a
stapling device. Medical management after total colectomy includes topical therapy
with either 5-aminosalicylic acid preparations and/or steroids or systemic therapy
with thiopurines, methotrexate, iniximab, cyclosporine, and/or steroids, although
there is no consensus on the best strategy [18]. The development of proctitis of the
Complicated Inammatory Bowel Disease andColonic Non-diverticular Emergencies
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rectal stump after total colectomy occurs in most UC patients (almost 80%) and is a
predictor for the development of pouchitis and therapy-refractory pouchitis [19].
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4 Fulminant Colitis or Toxic Megacolon
Toxic megacolon is a more severe presentation of ASC carrying high mortality rates
in case of perforation, ranging between 27 and 57%. It is identied by the same
criteria as for ASC plus a radiographic evidence of total or segmental colonic distention greater than 6cm. Unlike the typical colonic obstruction, in which cecal
dilation is the area most likely to undergo perforation, in toxic megacolon the area
of greatest attention is the transverse colon. Medical treatment should be started
immediately and aggressively, following the same guiding principles of ASC treatment. However, toxic megacolon patients should be re-evaluated more frequently to
evaluate response to therapy in the rst 24–48h, as a delay in surgery has a high risk
of colonic perforation and onset of abdominal compartment syndrome that would
greatly increase mortality. Colectomy should be performed when the response to the
initial medical treatment is poor, and immediately in case of complicated presentations with free perforation, massive hemorrhage, toxic shock, and progression of
colonic dilatation. If the patient is hemodynamically unstable, an open approach is
recommended [20].
5 Bowel Perforation
Bowel perforation is another serious and potentially life-threatening complications
in IBD patients and, although it occurs only in 1–3% of CD patients and 2% of UC
patients, it is one of the main indications for emergency surgical intervention [21,
22]. In case of free perforation suspect, a contrast-enhanced CT-scan should be
promptly obtained, and uid resuscitation started with broad-spectrum antibiotics.
In cases of a perforation blocked by omentum or neighboring structures, the rst
option is image-guided drainage (ultrasound or computed tomography) followed by
operative or non-operative management. Positioning a drain gives the opportunity
to avoid an operation in emergency conditions leading to lower morbidity and mortality rates [23]. This strategy cannot be followed in case of a diffuse peritonitis,
where the only option is surgery. In CD patients, this complication occurs more
frequently in the terminal ileum, often as a result of a complete small bowel obstruction due to an inammatory stricture [22, 23].
In this case, a small bowel or ileocolic resection with primary anastomosis should
be undertaken (Fig.2). The construction of a mucous stula should be considered in
heavily contaminated elds, very inamed tissues, poor nutritional status, and in
case of multiple previous surgeries. If evidence of severe sepsis/septic shock, damage control surgery may be considered, with resection, stapled off bowel ends, and
temporary abdominal closure with return to theater in 24–48h for a second look,
washout, and consideration of stoma vs anastomosis [21]. In case of perforation due
to a colonic stricture causing large bowel obstruction, a subtotal colectomy
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F. M. Carrano et al.
a b
Fig. 2 Dividing the mesentery during a small bowel resection could be tricky in CD patients, and
choosing the right approach is fundamental to reduce risks. In case of a mesentery that is moderately inamed and thickened, a laparoscopic resection can be safely undertaken (a); when inammation is severe and tissues are thickened and edematous, it is safer to divide the mesentery in an
open fashion (b)
including the stricture site with the construction of an end ileostomy should be performed. A segmental colonic resection with primary anastomosis and proximal
diversion or a Hartmann procedure may also be considered, however, they are associated with earlier disease recurrence [22, 23]. In UC patients, perforation typically
occurs in the setting of toxic megacolon or, not rarely, due to iatrogenic injury during surveillance colonoscopy [24]. In both cases, the operation of choice would be
a total abdominal colectomy with end ileostomy. Only in case of rectal perforation
a proctectomy should be undertaken. Both open and laparoscopic approaches are
appropriate in the emergency setting, if the patient is hemodynamically stable, otherwise an open approach is recommended [21].
6 Acute Abscess
The formation of an acute abscess is a typical manifestation of CD, with different
clinical presentations, from asymptomatic to septic shock. We hereby discuss its
diagnosis and management according to the site of occurrence.
6.1 Intra-abdominal
The typical presentation of intra-abdominal abscesses is characterized by fever, often
associated with shivers, abdominal pain, and rebound tenderness. Alterations in
blood tests show an increase in white blood cells count and increased CRP.Many
times, clinical presentation may mimic that of acute appendicitis. Abscess formation
is often associated with a diseased bowel tract stulizing into another bowel segment
Complicated Inammatory Bowel Disease andColonic Non-diverticular Emergencies
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95
ab
Fig. 3 An ileal stula with sigmoid colon (a) can be safely managed laparoscopically with a sta-
pled wedge resection (b)
(usually cecum or sigmoid colon), abdominal wall, or bladder (Fig.3). A contrastenhanced CT-scan or MRI should be obtained and early broad-spectrum antibiotic
therapy initiated. If an abscess greater than 5cm is demonstrated at imaging, initial
management would be the placement of a percutaneous drainage with the help of
interventional radiologists [23]. If patients do not respond to conservative treatment
and become septic, patients should undergo a staged procedure, consisting in surgical exploration, resection of the diseased bowel segment, abscess drainage, lavage,
and stoma formation. The anastomosis would be left for a secondary stage procedure
when out of harm’s way [25]. After bowel resection, attention should be paid to the
prevention of recurrence, and a personalized therapy should be discussed in a multidisciplinary setting, see Fig.4 for an example of possible management strategies.
Despite the increased technical demand, the presence of abscesses or inammatory masses should not discourage from the adoption of the laparoscopic approach,
which is the current treatment of choice for non-penetrating CD due to the proven
reduced surgical trauma and postoperative pain, earlier bowel function, and shorter
hospital stay compared to open procedures [27]. Despite the more aggressive clinical behavior of emergent cases compared to elective, often requiring more complex
resections and longer hospital stays, morbidity is not higher in these patients [27].
With this approach, surgeons should clearly have in mind that chances of a conversion to open surgery are higher than usual [27].
6.2 Perianal Sepsis
Perianal disease can occur in 1in 3 patients with CD and, sometimes, may be present at the time of diagnosis or even precede other intestinal symptoms. The most
common presentation is perianal sepsis caused by an acute perianal or ischiorectal
abscess, which is often associated with one or more perianal stulae [28]. The
majority of abscesses in CD develop at the level of the dentate line or may be the
result of an obstructed stula tract. In case of severe perianal pain without local
clinical ndings at inspection, an ischiorectal, intersphincteric, or supralevator
abscess should be suspected [29]. For this reason, early diagnosis is important and
an urgent MRI scan with contrast should be requested. Once precisely located,
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