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280 Per-Olof Nyström
Complicated Diverticulitis
In the minority of diverticulitis patients, local and systemic signs of inflammation will persist or increase over the next couple of days. This is when you should
start considering the presence of complicated forms of diverticulitis. Now it is time
to order abdominal computed tomography (CT; > Chap. 5) to better define the
pathological anatomy. Ambrosetti in Geneva has devised criteria to grade acute
diverticulitis on CT in a clinically meaningful way (Ambrosetti et al. 1997):
Simple attack: bowel wall thickness of more than 5 mm with signs of in-
flammation of the pericolic fat
Severe attack: in addition, abscess, extraluminal gas, or leakage of contrast
About half of the patients found on CT to have a severe attack required an
operation during the current admission or subsequent to it. Significantly, however,
half of such patients did not require an operation, suggesting that CT findings are
to be used together with the clinical picture in tailoring the proper management.
Should you order a routine CT of all patients suspected of suffering from
acute diverticulitis? This is surely unnecessary overkill as most patients respond
to conservative treatment. In addition, in some instances of clinically mild diverticulitis, the CT is negative.
Approach to Complicated Diverticulitis
A small number of patients present from the start with diffuse peritonitis,
with free intraperitoneal gas on abdominal X-ray or CT (> Chaps. 3–5). Here, of
course, a CT scan is part of the modern standard of care. The CT scan will define
the pathology so there is no question about the diverticulitis as the source of the
peritonitis. The exception is the even smaller group with frank generalized peritonitis with increasing systemic inflammation accompanied by tachycardia, tachypnea, hypovolemia, oliguria, hypoxia, or acidosis for whom time is better spent in
the intensive care unit for resuscitation and preoperative preparation (> Chap. 6).
The final diagnosis will then be established at the operation.
The CT manifestations of a severe attack (e.g., extraluminal gas, leakage of con-
trast, or abscess) in a patient who failed to resolve after a few days of antibiotics are
not necessarily an immediate indication for an operation. Minor free intra-abdominal
gas is also not an immediate indication for surgery if the patient is “stable.” Instead,
in the absence of spreading abdominal signs or systemic deterioration, even small
(<5 cm) pericolic abscesses usually resolve without an operation (probably spontaneously draining back into the bowel). In such cases, we would therefore advise the
continuation of conservative treatment under close clinical surveillance.
Larger pericolic abscesses (>5 cm) should be drained; this is best done percutaneously under CT guidance. After successful drainage, a semielective
26 Acute Diverticulitis 281
resection of the sigmoid is recommended by some. We do not know, however,
whether this is absolutely necessary since an unknown percentage of such patients would probably never develop another attack of acute diverticulitis.
The Operation for Acute Diverticulitis
When you are forced to operate for acute diverticulitis, the procedure of
choice is sigmoidectomy. It is usually best to open the abdomen with a lower mid-
line incision, which should extend above the umbilicus to allow access to the descending colon and be extended further to reach the left flexure should it be
necessary to mobilize it. The inflamed sigmoid has frequently folded itself into the
pelvis, adherent to the left pelvic brim, and may rest against the bladder or uterus.
At times, it will descend further into the pelvis between the rectum and bladder in
the man and behind the uterus and upper vagina in the woman, depending on how
deep the fossa is. The differential diagnosis of a perforated cancer easily comes to
mind. A clue is to remember that the inflammation is always at the summit of the
sigmoid loop. The rectum and the rectosigmoid junction anterior to the promontory are always unaffected. It is usually possible to reach the anterior rectum from
the right side of the pelvis to identify the folding of the sigmoid. Try not to use
sharp dissection in this inflammatory and adherent situation; using finger dissection is your best bet. Gentle finger pinching of the planes will separate the inflamed
sigmoid from its attachments to the surrounding viscera.
This is not a cancer operation, and your aim is simply to remove the sigmoid
colon, which is the source of the problem. Staying near the bowel wall helps you
to stay out of danger, away from the left ureter and ovarian and spermatic vessels,
which may be part of the inflammatory mass. It is best to start dividing the mesentery away from the inflammatory process below and above the sigmoid. After
dividing and clamping (or using a linear stapler) the sigmoid at both ends, deal
with the rest of the sigmoid mesentery. It is prudent to suture-ligate vessels within
the thick, edematous mesentery rather then use simple ligatures that may slip.
Using a vascular cartridge in a linear stapler to control the mesentery is another,
albeit more expensive, alternative. Remove any residual blood, pus, or intestinal
contents (> Chap. 12) and consider the next step. (This contributor believes that
the inflamed mesentery of the sigmoid should be removed as well.)
To Anastomose or Not?
Should the two bowel ends be joined together, or is a Hartmann procedure
with an end sigmoid colostomy to be preferred? An anastomosis is justified in the
majority of patients, but there are a number of factors to consider. Localized peri-
tonitis or an abscess is certainly not a contraindication to an anastomosis.
282 Per-Olof Nyström
Generalized peritonitis is also not a contraindication in itself, but the surgeon
needs to give it special consideration. Whether purulent or feculent, the generalized peritonitis signifies a greater insult to the patient, as reflected by the corresponding APACHE II (Acute Physiological and Chronic Health Evaluation II)
score and the higher risk of dying (> Chap. 6). Operative trauma adds to the
postoperative SIRS (systemic inflammatory response syndrome) and MODS
(multiorgan dysfunction syndrome) (> Chap. 54). Most patients with general-
ized peritonitis due to perforated diverticulitis have an immunological defect
that prevents localization of the process. Typically, they suffer from chronic obstructive lung disease or chronic arthritis with use of anti-inflammatory drugs or
steroid dependence for years. Occasionally, they have received chemotherapy or
are just recovering from major surgery, such as a coronary bypass. On the other
hand, it seems that patients without such immunologic defects are capable of
containing the inflammation and rarely have free peritonitis. Patients with free
peritonitis will certainly not tolerate an anastomotic failure, and it is therefore all
the better if there is no need to worry about the integrity of an anastomosis during the postoperative course. Therefore, in such patients we choose a Hartmann’s
procedure: sigmoidectomy, end colostomy, and closure of the rectal stump.
It is our impression that surgeons pay little attention to the consequences of
the operative trauma added to the acute inflammation. We find surgeons blaming the unfavorable course of some of these patients on the diverticulitis and
peritonitis, believing that residual infection is the problem. They should instead
think about the operative trauma and postoperative SIRS. Consider this: if a sick
patient is thrown out of the window (inadvertently, of course) and the surgeon
then blames the subsequent course on the original illness, we would all say it
is a misconception of the situation. The height the patient falls is the operative
trauma. The longer the operation takes, the more dissection that is necessary,
and the more bleeding it causes, the greater the operative trauma. This metaphor
encapsulates the modern concept of damage control, and surgeons need to have
a firm understanding of when enough is enough.
Fecology
Reasonable amounts of feces in the colon are not a contraindication for an
anastomosis. You can evacuate most of the fecal material from the left colon by milking it into a dish. Occasionally, however, the colon may contain large amounts of fecal
material because the sigmoiditis has caused a relative obstruction in the days preceding the acute attack. Massive fecal loading is a factor against an anastomosis. To
overcome this, it has been proposed that on-table antegrade bowel irrigation
(through the cecum or appendiceal stump) be added to clean the colon before the
anastomosis. Unless such irrigation is common practice in your hospital, with all the
26 Acute Diverticulitis 283
equipment available, the irrigation will take at least half an hour and often much
longer to accomplish. The subsequent anastomosis will add another 20–30 min to
the operation. If this is the case, a stoma is quicker and gives better damage control.
In summary, consider an anastomosis in patients who are in reasonable
health and without diffuse peritonitis. There should be no technical problems in
making the anastomosis if the bowel ends are healthy and without tension. [For
how to do it, see > Chap. 13.]
A Few Controversies
Some surgeons believe that the inflamed mesentery should be anatomi-
cally resected together with the sigmoid, claiming that it usually provides for a
better source control and anastomosis when there is no intervening mesentery
left. Although the sigmoiditis affects the apex of the sigmoid colon, the mesentery is often shortened by the inflammation. The distal transection of the bowel
should always be at the rectosigmoid junction because leaving a part of the distal
sigmoid is the cause of recurrent diverticulitis. For these several reasons, some
think that it is often better to resect the sigmoid in much the same way as one
does a resection for cancer, and this is obviously the way to do it if one suspects
the presence of cancer.
Should the left flexure always be mobilized? No. This is indicated only in
the minority of patients in whom the proximal colon fails to reach the rectum for
a good anastomosis without tension or in patients in whom the blood flow in the
marginal artery is uncertain. Diverticula of the descending colon are common,
but we do not hesitate to anastomose diverticula-containing descending colon to
the rectum. Recurrent diverticulitis proximal to the sigmoid is extremely rare.
What should you do with phlegmonous diverticulitis accidentally discov-
ered during operation with no frank perforation or suppuration present? Probably, you should do nothing at all, just close and treat with antibiotics. Most such
patients will never return.
Very rarely, the source of the perforation would be a huge diverticular mass
densely adherent to, and obliterating, adjacent structures. (e.g., bladder, ureter,
small bowel). A proximal diversion (with transverse colostomy or jejunostomy) and
drainage of the perforation may be a safer management plan than resection, particularly when cancer is suspected or cannot be excluded. Definitive resection would
become a much easier task later, when inflammation and infection have subsided.
Newer Concepts
There were early reports of successful laparoscopic management with peritoneal lavage of perforated diverticulitis and generalized peritonitis—without the resection of the involved bowel. All patients recovered uneventfully and were well
284 Per-Olof Nyström
during 12–24 months of follow-up. The concept that emerges is that the disease pro-
cess can be reversed without a bowel resection, which can be postponed or not be
performed at all. Larger experience has recently validated such an approach. This is
so interesting that it calls for some details: in a prospective multicenter study (Myers
et al. 2008), 100 patients with peritonitis from diverticulitis (the large majority had
radiographic or CT evidence of free gas or fluid) underwent laparoscopy, during
which they were found to have purulent peritonitis. Peritoneal lavage with 4 L of saline reversed the peritonitis without resection of bowel. Patients recovered and were
discharged with only two instances of acute diverticulitis in the following 3 years.
With such results, we may be seeing the introduction of a new treatment principle with several advantages. It will also avoid the colostomy associated with the
Hartmann procedure and the problems associated with its reversal. Only fecal peritonitis, which perhaps represents the true perforated diverticulitis, will require a
Hartmann resection. All other forms, which respond well to resuscitation followed
by laparoscopic lavage, seem to have a better prognosis than after a resection.
[This nonresective approach seems so exciting that it calls for another
opinion, which is offered by Dr. Jonathan Efron.—The Editors]
Dr. Nyström raises the very exciting prospect of minimal intervention for
perforated diverticulitis, which is indeed justified from recently published reports of great success with laparoscopic lavage for general peritonitis—without
sigmoid resection. As greater than a third of stomas created emergently (when
performing a Hartmann procedure) are not reversed, any procedure that reduces
the morbidity of colostomy formation is to be applauded. I think, however, that
several cautionary points need to be emphasized as our own very early experience with this technique has not been as successful as the reported data.
Laparoscopic lavage has not been performed in any of the published series
for feculent peritonitis. Indeed, when identified, this was an immediate indica-
tion to proceed to sigmoid resection with Hartmann’s pouch formation. Feculent
peritonitis is commonly associated with an ongoing colonic perforation, with
poor tissue quality making effective primary closure of the perforation difficult. With 30% mortality occurring in these patients, sigmoid resection with
Hartmann’s pouch formation is still the operation of choice. Similarly, patients
with purulent peritonitis and significant signs of sepsis (hypotension, renal dysfunction, acute respiratory distress syndrome [ARDS], or pressor requirements)
require removal of all potential sources of continued sepsis and therefore should
undergo sigmoid resection. This same line of reasoning is applied to patients who
have multiple comorbidities for whom persistent sepsis from ongoing diverticulitis may lead to further medical complications, and serious consideration should
be given to sigmoid resection.
26 Acute Diverticulitis 285
Stable patients who are suspected of having perforated diverticulitis are
potential candidates for a laparoscopic exploration with lavage and drainage.
On entering the abdomen laparoscopically, if the patient has minimal adhesions,
exploration with four-quadrant irrigation should be performed. If there is a colonic defect or obvious perforation, an attempt should be made to laparoscopically close it; however, in most cases of purulent peritonitis no obvious “hole”
in the colon is identified. Drains should be left in areas of an obvious abscess or
near any suture repair; usually a 10F Jackson Pratt or Blake drain can be passed
through one of the trocar sites.
Not all cases of diverticulitis are alike, and some simply do not respond
to prolonged therapy with intravenous and oral antibiotics, and these cases will
require surgical resection. This same rationale should be applied to patients for
whom sepsis continues to progress after laparoscopic washout; in this case, sigmoid resection is required. Finally, thought should be given to resection with
primary anastomosis and proximal diversion as opposed to Hartmann’s pouch
formation in many of these patients. As long as patients are stable at the time
of surgical resection and the tissue quality of the proximal colon and rectum is
sound, many feel it is safe to proceed with primary anastomosis and proximal diversion (or even without it). In the end, this may significantly decrease the number
of patients who currently have to live with their “temporary stomas” forever.
[As a visible perforation is absent in most patients treated by laparoscopic
lavage and postoperative fecal fistulas are not seen, it is clear that in most such
patients control of the source of the purulent peritonitis has been achieved
spontaneously—before the operation. We doubt, therefore, whether the lavage
in these cases achieves more than what a course of antibiotics would achieve.
We suspect that many of these patients who improve so rapidly with laparoscopic lavage and do not need any further surgery on follow-up did not need the
laparoscopic lavage at all.—The Editors]
After the Attack
Most patients with acute diverticulitis respond to conservative therapy; it is
estimated that around one-fourth will experience a recurrence. Somewhat confusingly, this is variably interpreted as either confirming the need for elective surgery
or indicating that the majority of patients do not require an operation. According
to tradition, the second attack has been considered an indication for an elective
sigmoidectomy, this being particularly true in the younger patient. Also, this approach has been recently questioned. Patients undergoing such elective sigmoid
resections are not faring symptomatically better compared to patients who had no
286 Per-Olof Nyström
surgery. In general, it is the initial attack that tends to complicate with “free” perforation, abscess formation, or fistula. Recurrent attacks tend to be relatively benign and to respond to medical treatment. The reasonable approach is to
individualize the management. There will be a few in need of a sigmoid resection
for persisting symptoms of fibrotic stenosis or complicating fistula, but the large
majority would not benefit from elective surgery.
Looking at the “whole picture,” it appears that we operate too early in acute
diverticulitis, perform too many CTs, carry out too many percutaneous drainage
procedures, remove too many colons, raise too many colostomies, reoperate electively on too many patients, treat too many with antibiotics, and perform too few
randomized controlled trials in order to know what is right and what is wrong.
Editorial Comment: Other Forms of Acute Diverticulitis
Although sigmoid diverticulitis is so common in our daily practice, other
forms of diverticulitis should be kept in mind.
With the horrendous amount of junk food consumed by “Western societ-
ies,” we see a growing number of younger patients with colonic pandiverticu-
losis extending from the rectosigmoid junction to the ileocecal valve. Some of
these present with acute diverticulitis in the right or transverse colon, which may
mimic acute cholecystitis or acute appendicitis. The key to diagnosis here is an
abdominal CT scan finding of a localized colonic phlegmon. This avoids unnecessary laparotomy and the temptation to proceed with colonic resection when the
vast majority would respond to conservative treatment with antibiotics.
“Solitary” cecal diverticulitis. This is a different entity: young, mostly male,
patients present with one or two diverticula in the cecum—in the absence of diverticula distally. Once or twice a year, you will see a patient presenting with what you
think to be “classical” acute appendicitis, but at operation you will find a cecal inflammatory mass or phlegmon of variable size. Free perforation and localized peritonitis are uncommon. On CT scan, a good radiologist should be able to distinguish
cecal diverticulitis from acute appendicitis; if this is the case, you can treat conservatively as these patients would respond to antibiotics exactly like those with sigmoid diverticulitis. And, of course, recurrent cecal diverticulitis has been reported
in conservatively treated patients. Most patients, however, come to operation either
because CT is not done or its findings are mistaken for acute appendicitis. What to
do at operation depends on the size of the process, ranging from diverticulectomy
(place a liner stapler across the base of the diverticulum—including healthy cecal
wall—and fire) to partial cecectomy (again, fire a stapler across and be careful not
to narrow the ileocecal junction). Occasionally, when the diverticulum is situated
just off the ileocecal valve, it is safer to excise and close the cecal hole by hand. Surgeons who are not aware of this condition or cannot recognize it are often carried
26 Acute Diverticulitis 287
Fig. 26.1. “Which of these do we have to remove?”
away and perform right hemicolectomy. But, now you know that this is unnecessary.
Surgeons who discover the process at laparoscopic appendectomy usually do not
know what they see (one has to palpate it) and have to convert.
For the sake of completeness, let us mention here that acute diverticulitis
very rarely affects patients with jejunal diverticulosis. These patients present
with systemic signs of inf lammation as well as with local peritoneal signs in the
center of the abdomen. The key to diagnosis and subsequent nonoperative management and treatment with antibiotics (usually successful) is a CT scan, which
shows an inflammatory mass affecting a segment of the jejunum and its mesentery. If forced to operate, all you have to do is a segmental small bowel resection
and anastomosis.
>
Figure 26.1 will remind you that intestinal diverticula affect all of us;
they may produce complications, but most can be treated without an operation.
In the heart of Africa, you will rarely see a case of acute diverticulitis; people
there do not yet eat the junk that we do.
References
Ambrosetti P, Grossholz M, Becker C, Terrier F, Morel P. (1997). Computed tomography in
acute left colonic diverticulitis. Br J Surg 84:532–534.
Myers E, Hurley M, O’Sullivan GC, et al. (2008). Laparoscopic peritoneal lavage for genera-
lised peritonitis due to perforated diverticulitis. Br J Surg 95:97–101.
Massive Lower Gastrointestinal
Bleeding
Per-Olof Nyström
Whenever you encounter massive bleeding, the first thing to remember is that it is
not your blood.
Massive bleeding is defined as exsanguinating or hemodynamically sig-
nificant bleeding that persists and requires at least four units of blood over a
period of 24 hrs. Fortunately, truly massive bleeding from the colon and rectum
is unusual. The vast majority of episodes of lower gastrointestinal bleeding
(LGIB) are self-limiting and not hemodynamically significant. However, as with
all types of gastrointestinal bleeding, never neglect it or think it is trivial until a
period of vigilant observation tells you whether the bleeding is minor or major,
whether it is likely to have ceased or is protracted.
Sources of Bleeding
Most episodes of overt colonic bleeding never have the precise site and
cause established. This is true even if colonoscopy is performed on the day of
admission. Often, the bleeding is assumed to originate from an already-known
pathology. Later, when the bleeding episode is over, a diagnostic workup may
reveal previously unknown pathology as the cause or suggest, in retrospect, a
lesion that may have been the source. > Table 27.1 shows the most common
causes.
A short comment about the causes mentioned in the table may help you to
choose the most likely cause in your next patient with colonic bleeding.
Neoplasms, whether cancer or benign polyp, rarely bleed massively but often
have occult bleeding that can produce significant anemia. Rectal cancer commonly bleeds overtly and if associated with anemia can at first suggest a massive
bleed until rectoscopy is performed. The patient with rectal cancer may give a
history of tenesmus, and usually there will have been episodic minor bleeding
with the stools for some time. Bleeding in inflammatory bowel disease (IBD) is
27
Per-Olof Nyström
Department of Surgical Gastroenterology, Karolinska University Hospital, Huddinge, 141 86 Stockholm,
Sweden
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_27, © Springer-Verlag Berlin Heidelberg 2010
289
290 Per-Olof Nyström
Table 27.1. Causes of colorectal bleeding (not listed in order of frequency)
Neoplasm
Inflammatory bowel disease
Diverticulosis—diverticulitis
Ischemic colitis
Vascular malformation—angiodysplasia
Hemorrhoids
Postoperative—anastomotic
Meckel’s diverticulum
Infectious
almost never the first symptom of the disease and is rarely massive (> Chap. 24).
The diagnosis will be known in most such patients, and the bleeding is associated with an exacerbation, for which diarrhea precedes the bleeding by several
days. The exception is proctitis, which may present with bleeding, again easily
identified at rectoscopy. The differential diagnosis of proctitis includes infec-
tions such as Campylobacter or amebiasis. The onset is then more sudden, with
diarrhea and bleeding beginning together. Radiation proctitis may bleed significantly, but here the history is obvious.
Diverticula of the sigmoid colon are assumed to be the most common cause
of acute major LGIB. Naturally, this occurs more often in elderly patients, particu-
larly in those taking nonsteroidal anti-inflammatory drugs (NSAIDs) or anticoagulants. In middle-aged patients and also elderly patients with no other reason
for hemorrhage, you must consider mucosal angiodysplasia as the possible
explanation. The bleeding can be massive and recurrent. In elderly patients,
ischemic colitis can rarely present with massive bleeding. Postoperative bleeding from colonic anastomosis, polypectomy, or after anal surgery should be easily identified. And finally, do not forget that internal hemorrhoids may bleed
copiously; you do not want to diagnose an anal source only after laparotomy.
Diagnosis
We find it very annoying to consult on bleeding patients for whom the referral note simply states: “Patient has melena.” Anything can hide behind such a note.
It tells us that not a lot of thought was invested in this request. There are two very
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