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C
I K
S HIV/AIDS
INTR
ODUCTION
A
n unusual outbreak of Kaposi sarcoma (KS) and Pneumocystis cari-
nii pneumonia among young homosexual men was rst reported
by the Centers for Disease Control and Prevention (CDC) in 1981.
By the end of 1982, the term acquired immune deciency syndrome
(AIDS) was born. In 1983, two research groups published their ndings of the retrovirus thought to be responsible for AIDS. Initially
referred to as human T-lymphotrophic virus III and lymphadenopathy-associated virus, it turned out both researchers were dealing with
the same virus, renamed human immunodeciency virus (HIV) in
1986.
AIDS and HIV are global pandemics. By the end of 2011, the
World Health Organization estimated that 34 million people were
living with HIV. is number varies from country to country, with
African nations being the most severely aected; 4.9% of the African population is living with HIV. More than 2.5 million new cases
of HIV were diagnosed in 2011, and the World Health Organization
estimates that 1.7 million people worldwide succumbed to AIDSrelated illnesses in 2011. Heterosexual spread is the most common
mode of transmission, although in the Western world, homosexual
men are still the most frequently aected.
HIV infections and the syndrome of AIDS are big public health
problems in the United States. e CDC estimated that in the United
States in 2010 there were 47,500 new HIV infections and that 872,990
people were living with HIV. e CDC also reported that in the United
States in 2010, a total of 32,052 people were diagnosed with AIDS and
487,692 people were living with AIDS. e number of AIDS-related
deaths in the United States in 2010 was 15,529, and the estimated
total AIDS-related deaths through 2010 was more than 636,048. Gay
and bisexual persons and men who have sex with men are the most
frequently aected individuals in the United States. White men having sex with men account for 11,200 of the new infections, followed
by black men having sex with men at 10,600.
HIV is spread through exposure to infected blood (transfusions,
needle sticks, or needle sharing), sexual contact (including oral,
vaginal, and anal sex), and transmission from pregnant mothers to
fetuses. e risk varies depending on the type of exposure and the
surrounding circumstances. Direct exposures to infected blood or
needle sticks still carry the highest risk. Varying sexual acts carry
diering risks of infection, with receptive anal intercourse having
the highest risk. e rectum is a well vascularized organ with fragile
mucosa, allowing for easier transmission of the virus. Multiple publications have shown that the presence of other sexually transmitted
diseases increases the risk of HIV transmission.
Primary HIV infection oen presents with a short u-like illness
that lasts around 14 days. is illness is accompanied by fever, malaise,
and lymphadenopathy. Seroconversion, the period when antibodies
are produced by the body’s immune system, occurs in 4 to 10 weeks
in most patients but can take up to 6 months. In this “window” period,
antibody tests may give false-negative responses. Rapid antibody tests
Henr
y R. Govekar and Dana R. Sands
re available and used for point of care tests to aid in the diagnosis
a
of HIV infection. e Food and Drug Administration has recently
approved the use of a rapid in-home test for this purpose. Further
testing is required to conrm the diagnosis, and a negative result may
not be reliable in the “window” period. e enzyme-linked immunosorbent assay tests the patient’s serum against a plate of HIV antigens.
If antibodies are present, the test is conrmed via Western blot. e
current immunoassay for detection of HIV is in its fourth generation. It uses a synthetic peptide or recombinant protein antigens that
are designed to detect immunoglobulin (Ig)M and IgG antibodies and
p24 antigen. A positive result is tested to dierentiate HIV-1 antibodies
from HIV-2 antibodies. Patients with a positive result from this second
test should be considered positive to either HIV-1 or HIV-2 and should
seek medical care for further testing for viral load and resistance assays.
e introduction of antiretroviral therapy, more commonly
referred to as highly active antiretroviral therapy (HAART), has
helped improve the outcomes of patients infected with HIV. HAART
medication is made up of three categories of drugs: protease inhibitors, non-nucleoside reverse transcriptase inhibitors, and nucleoside
reverse transcriptase inhibitors. e combination of these drugs
has allowed patients to live longer, increasing life expectancy from
months to decades. A recent study from the HIV Prevention Trials
Network conrmed that HAART therapy can reduce the risk of sexual transmission of HIV from one partner who is infected with HIV
to his or her noninfected partner by 96%.
CYTOMEGALOVIRUS COLITIS
ytomegalovirus (CMV) is a double-stranded DNA virus rst iso-
C
lated in 1956. It is a member of the herpes virus family, oen establishing a latent infection aer the initial exposure. Recent statistics
suggest that at least 60% of the U.S. population has been exposed to
CMV. CMV infection is thought to occur most frequently in immunosuppressed patients. e risk of exposure increases with the age
of the patient and varies according to geographic location. CMV,
the most common colonic infection in patients with HIV, is found
in up to 10% of cases. Clinical disease oen occurs when the CD4
counts have fallen below 100 cells/mm
HAART medication, the incidence of CMV end organ dysfunction
was greater than 20% per year among patients with HIV and AIDS.
According to reports from recent AIDS literature, the proportion is
now 3.2% to 5% per year.
e role of CMV in the development of colitis remains unclear.
e question is whether the virus itself is the source or acts as a promoter or cofactor for other infections. Infection oen produces a vasculitis aecting the capillaries and arterioles, leading to thrombosis
and subsequent ischemia, thrombosis, or ulceration. One study of
the mechanism of CMV colitis suggested that the CMV virus helped
block the macrophage inhibition of the HIV-1 infection, enhancing
inammation and tumor necrosis factor-α release.
3
rior to the introduction of
. P
231
232
e most common symptoms of CMV colitis are bloody diarrhea
Cyt
omegalovirus
ileoColitis
and Kaposi
and abdominal pain. Patients may present with hemorrhage but also
can have fever, weight loss, and anorexia. Diarrhea is a symptom of
other opportunistic infections in the AIDS population, such as cryptosporidium, Giardia, and shigella. Stool cultures are important. Perianal ulceration may occur and must be distinguished from herpes
simplex.
Patients presenting with suggestive symptoms will oen undergo
extensive workup including radiographs, computed tomography
scan, and colonoscopy. e computed tomography ndings may
include colonic wall thickening, localized edema, and fat stranding. ese ndings are suggestive of colitis, but the diagnosis cannot
be conrmed without endoscopic evaluation. A barium enema was
oen performed in the past, with ndings including diuse mucosal
ulceration, skip areas, and thumbprinting.
e gold standard for diagnosis for CMV colitis is colonoscopy
with biopsy. Endoscopic ndings include submucosal hemorrhage
and diuse ulcerations that measure 3 to 5 mm. Random biopsies
are recommended to distinguish CMV from other causes of colitis.
e ulcers may be seen throughout the colon but can also be patchy,
commonly clustering in the right colon. In one study, in 13% of
patients, disease was only found in the right colon. For that reason,
a full colonoscopy rather than a exible sigmoidoscopy is important.
CMV lesions can resemble those of ulcerative colitis and occasionally
have ndings of a whitish membrane similar to pseudomembranous
colitis.
Diagnosis of CMV colitis is conrmed via biopsy. e pathognomonic nding on histology, oen described as “owl eyes,” is the
presence of large basophilic intranuclear cytomegalic viral inclusion
bodies. As the cells infected with the virus necrose, the inclusion
bodies become less clear and take on a blue-red appearance, which
is highly suggestive of CMV colitis. CMV can be detected by antigen
pp65 testing and polymerase chain reaction assays. However, viremia
may be present in the absence of colitis, suggesting latent infection.
Treatment of patients with CMV but without evidence of colitis is not
recommended. Treatment should start with the initiation of HAART
therapy by HIV specialists.
e treatment of choice for CMV colitis is ganciclovir, and
improvement is oen seen in the rst week. Ganciclovir is a competitive inhibitor of deoxyguanosine triphosphate incorporation
into DNA. Treatment dose is 5 mg/kg by intravenous (IV) administration every 12 hours for 14 to 21 days. Adverse eects include
neutropenia, anemia, thrombocytopenia, fever, diarrhea, and liver
dysfunction.
In pre-HAART studies, maintenance therapy was frequently
required for patients with evidence of CMV colitis. is maintenance
therapy was oen given as an oral preparation of valganciclovir or an
IV maintenance dose of ganciclovir every 4 to 6 weeks. More recent
studies from the National Institutes of Health challenge those recommendations. Current literature does not support the use of lifelong
maintenance therapy, although it should be considered if relapse
occurs.
Foscarnet is a DNA chain inhibitor of phosphorylation that is
active against herpes simplex virus and CMV virus. It is oen used
against ganciclovir-resistant strains of the CMV virus. Foscarnet is
given at a dose of 90 mg/kg by IV administration every 12 hours for
14 to 21 days. Foscarnet is nephrotoxic, so the patient must stay well
hydrated during treatment to avoid renal impairment. Adverse eects
include anemia, headache, nausea, and neurologic toxicities.
Other drugs, including oral valganciclovir, can be used when
symptoms are less severe. No evidence exists that preemptive therapy with antiviremic medications is necessary in high-risk patients.
CMV disease is best prevented by utilization of HAART to keep CD4
counts above 100 cells/mm
3
e treatment of CMV retinitis includes
.
newer medications such as cidofovir that have not been adopted for
the treatment of CMV colitis. Since the advent of HAART in 1996,
the incidence of opportunistic infections, including CMV, has signicantly decreased.
sarComa in Hiv/aids
SURGER
A
lthough most patients will respond to medical therapy, emergency
Y
surgery may be needed. An initial study from 1988 that examined
patients with AIDS who were undergoing intra-abdominal surgery
found that CMV colitis was the indication in two thirds of these
patients. Mortality was 86% at 6 months. e most common symptoms in these patients were diuse uncontrolled hemorrhage and
perforation, oen leading to a subtotal colectomy. In 1994, Soderlund et al reported their ndings on elective resection of patients
with CMV colitis for whom medical therapy failed. Within 30 days
of surgery, only two minor complications occurred among the eight
patients, along with one death. Mean survival was 13 months, and
four patients had recurrent or persistent symptoms of CMV enterocolitis within 1 year.
Indications for surgery include diuse hemorrhage, perforation,
or toxic megacolon. If emergency surgery is needed, a subtotal colectomy with an end ileostomy is the procedure of choice.
KAPOSI SARCOMA
KS i
s the most common malignant tumor in patients with AIDS. It is
now known to be a vascular tumor caused by the human herpes virus
type 8. KS was originally described by Hungarian dermatologist Dr.
Mortiz Kaposis in 1872. Prior to the AIDS epidemic, KS was seen in
elderly men of Mediterranean descent as a bluish-red skin lesion with
a benign course. In the mid 1980s the incidence began increasing in
the homosexual community.
e AIDS-associated (epidemic) form of KS is the fourth variant
of the disease. e disease can be found aecting skin, lymph nodes,
and the intestinal tract. Oen asymptomatic, gastrointestinal disease
can be found in up to 40% of patient with AIDS. e transmission of
KS in the AIDS population is thought to be related to anal receptive
intercourse because the incidence is 50% higher in homosexual males
with AIDS compared with heterosexual males with AIDS.
KS commonly appears as a pink to purple skin lesion. ese cutaneous lesions can be found in up to 50% of patients with AIDS. e
gastrointestinal tract is rarely the sole site aected; most patients
present with raised nodular skin lesions on the foot. e most common presenting symptoms of colonic KS are abdominal pain, nausea,
obstruction, and gastrointestinal bleeding.
Endoscopic ndings in patients with KS of the colon vary from
small patchy hemorrhagic lesions to papules and nodular lesions projecting into the lumen. Biopsy can reveal spindle-shaped cells and
hemosiderin-laden macrophages.
Treatment is palliative, aimed at improving symptoms as disease
progresses. First and foremost, HAART therapy should be initiated
if it is not already in use. Studies have shown a decrease in cases of
AIDS-related KS and regression in the size and burden of disease in
patients with KS lesions. Publications in the early 1990s showed that
the use of radiation therapy can help treat rectal lesions but is of no
use for disseminated disease.
Topical and local therapies have been used for supercial lesions,
which oen is not the case in colonic disease. A 0.1% alitretinoin is
a topical agent approved for local therapy, but skin irritation may be
limiting. Local therapy includes intralesional chemotherapy, cryotherapy, and photodynamic treatment. Vinblastine has shown a
response rate of 70% on intralesional injections.
Systemic chemotherapy is used for cases of widespread disease.
Liposomal anthracyclines (doxorubicin) have become rst-line treatment for disseminated KS. e treatment dose for doxorubicin is 20
2
mg/m
and neuropathies. A trial looking at 54 patients with AIDS-related
KS showed that 82% of patients had a complete or partial response in
6 weeks with a combination of HAART and liposomal doxorubicin.
Taxanes, specically paclitaxel, showed response rates up to 71% in
patients with AIDS who had KS. Standard doses are 135 to 175 mg/m
very 3 weeks. Adverse eects can be mild, including alopecia
e
2
COLON
233
iven every 3 weeks. Adverse eects were one of the limiting factors,
g
with arthralgias, alopecia, and myelosuppression being the main
eects. Low-dose paclitaxel (100 mg/m
2
very 2 weeks) produced
e
tumor regression in patients who did not respond to chemotherapy.
A complete or partial response was seen in 56% of the patients.
Patients were shown to have improved quality of life and tolerated
the adverse eects; neutropenia was the most dramatic adverse eect
with an incidence of 35%.
Interferon alpha, a biologic response modier, has been available
for treatment of KS, especially residual cutaneous lesions. One study
showed that high-dose interferon alpha along with zidovudine had a
31% response rate compared with 8% in the low-dose group. Another
study showed that liposomal doxorubicin was better tolerated and
had less toxic eects than the low-dose treatment of interferon alpha.
Surgery is only recommended for uncontrolled hemorrhage, perforation, or obstruction. Surgery should be limited to the diseased
segment and may require fecal diversion.
u
S
A
Centers for Disease Control and Prevention. Diagnoses of HIV infection in the
Centers for Disease Control and Prevention. Monitoring selected national HIV
Cohen MS, Makhema J, Elharrar V, etal. Prevention of HIV-1 infection with
Dezube BJ. Management of AIDS-related Kaposi sarcoma: advances in target
Erice A, Tierney C, Hirsch M, et al. Cytomegalovirus (CMV) and human
S t
g g e
rora M, Goldberg E. Kaposi sarcoma involving the gastrointestinal tract.
United State and dependent areas, 2011; July 24, 2013. < http://www.cdc.gov/
hiv/library/reports/surveillance/2011/surveillance_Report_vol_23.html >.
prevention and care objectives by using HIV surveillance data—United States
and 6 U.S. Dependent Areas—2010; July 24, 2013. < http://www.cdc.gov/hiv/
surveillance/resources/reports/2010supp_vol17no3/index.htm >.
early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.
discovery and treatment. Exp Rev Anticancer er. 2002;2(2):193–200.
immunodeciency virus (HIV) burden, CMV end organ disease, and sur-
vival in subjects with advanced HIV infection (AIDS Clinical Trials Group
Protocol 360). Clin Infect Dis. 2003;37(4):567–578.
e d
R
e
a d i n g
Kaplan JE, Benson CA, Holmes KK, etal. Guidelines for prevention and treat-
ment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV
Medicine Association of the Infectious Diseases Society of America. Atlanta,
GA: Department of Health and Human Services, Centers for Disease Control and Prevention; 2009.
Karakozis S, Gongora E, Caceres M, et al. Life-threatening cytomeg-
alovirus colitis in the immunocompetent patient. Dis Colon Rectum.
2001;44(11):1716–1720.
Lichterfeld M, Qurishi N, Homann C, etal. Treatment of HIV-1-associated
Kaposi sarcoma with pegylated liposomal doxorubicin and HAART simultaneously induces eective tumor remission and CD4+ T cell recovery. Infection. 2005;33(3):140–147.
Maheshwari A, Smythies LE, Wu X, etal. Cytomegalovirus blocks intestinal
stroma-induced down-regulation of macrophage HIV-1 infection. J Leu-
kocyte Biol. 2006;80(5):1111–1117.
Marques Jr O, Averbach M, Zanoni EC, et al. Cytomegaloviral colitis in
HIV positive patients: endoscopic ndings. Arquivos Gastroenterologia.
2007;44(4):315–319.
Soderlund C, Bratt GA, Engstrom L, etal. Surgical treatment of cytomegalovi-
rus enterocolitis in severe human immunodeciency virus infection. Dis
Colon Rectum. 1994;37(1):63–72.
Tulpule A, Scadden DT, Gill PS, et al. Multicenter trial of low-dose pacli-
taxel in patients with advanced AIDS-related Kaposi sarcoma. Cancer.
2002;95(1):147–154.
Welles L, Saville MW, Lietzau J. Phase II trial with dose titration of paclitaxel
for the therapy of human immunodeciency virus-associated Kaposi’s sarcoma. J Clin Oncol. 1998;16(3):1112–1121.
Wexner SD, Smithy WB, Trillo C, etal. Emergency colectomy for cytomeg-
alovirus ileocolitis in patients with the acquired immune deciency syndrome. Dis Colon Rectum. 1988;31(10):755–761.
Wilcox C, Chalasani N, Lazenby A, Schwartz D. Cytomegalovirus colitis in
acquired immunodeciency syndrome: a clinical and endoscopic study.
Gastrointest Endosc. 1998;48(1):39–43.
World Health Organization. HIV/AIDS; 2016. < http://www.who.int/gho/hiv/en/ >.
D
M A
C D
Daniel L.
INTR
ODUCTION
C
olonic diverticula are false diverticula—that is, pockets composed
of mucosa and submucosa that have herniated through weaknesses in
the colon wall at the points where intramural vasa recta penetrate the
inner circular muscle of the bowel (Fig. 48-1, A and B). e generally
accepted pathophysiology of diverticulitis centers on a diverticular
microperforation causing a bacterial infection. A possible alternative
mechanism suggesting that diverticulitis may be a primary inammatory process has been proposed. When the inammation resolves
uneventfully, the diverticulitis is described as uncomplicated. In
contrast, patients who experience clinical sequelae as a result of
diverticulitis are described as having complicated diverticulitis
(Box 48-1). e presence of a phlegmon or simple extraluminal gas
demonstrated on cross-sectional imaging is not considered complicated disease. is chapter will focus on specic aspects of sigmoid
diverticulitis, including presentation, diagnostic evaluation, and clinical management.
PRESENT
e severity of presentation of diverticulitis ranges from mild to life
threatening, depending on the extent and duration of inammation
and peritoneal contamination. Patients with sigmoid diverticulitis
typically describe worsening le lower quadrant abdominal pain.
According to the lay of the sigmoid loop, some patients may experience right-sided or suprapubic pain, and nonspecic symptoms
such as anorexia, nausea, vomiting, constipation, fever, or diarrhea may be present. Dysuria may be reported in cases in which
the inamed colon abuts the bladder, and small bowel obstruction
may occur when a loop of small bowel is kinked by an inammatory attachment to the colon. Patients with stulizing disease may
describe pneumaturia, fecaluria, abnormal vaginal discharge, or a
draining skin sinus.
Physical examination typically reveals a febrile patient distressed
by pain with tenderness in the lower abdomen. Signs of localized
peritoneal inammation, such as rebound tenderness and guarding,
oen can be elicited. A phlegmon may be appreciated upon palpation.
Psoas or obturator signs also may be present because of the inammatory process. Patients with severe diverticulitis can be hemodynamically unstable with signs of diuse peritonitis, whereas at the
other end of the spectrum, patients with recurrent episodes may recognize an attack early and present when signs are still minimal.
DIA
GNOSTIC EVALUATION
A
lthough the constellation of le lower quadrant tenderness, fever,
and leukocytosis is suggestive of sigmoid diverticulitis (especially
in patients with recurrent diverticulitis whose diagnosis has been
234
Feingold and Ravi P. Kiran
ATION
previously conrmed), other possible diagnoses should be considered (Box 48-2). Urinalysis and plain abdominal radiographs are
helpful in excluding urinary tract infection, kidney stones, and bowel
obstruction. Because of the superiority of cross-sectional imaging
compared with other types of evaluation, a computerized tomography (CT) scan of the abdomen and pelvis is the most appropriate
initial imaging in patients with suspected diverticulitis. Multislice
CT imaging with intravenous and intraluminal contrast material has
excellent sensitivity and specicity that is reported to be as high as
98% and 99%, respectively. CT ndings consistent with diverticulitis
may include colon wall thickening, mesenteric fat stranding, phlegmon, extraluminal gas, abscess, stricture, and stula (Fig. 48-2, A-D).
Patients who have early or mild diverticulitis and immunocompromised patients whose ability to mount an appropriate inammatory
response is limited may not demonstrate these typical inammatory
changes. A major benet of CT imaging is its ability to diagnose other
disease processes that may mimic the presentation of diverticulitis.
An additional unique benet provided by CT scanning is the ability
to grade the severity of diverticulitis, which has been shown to correlate with risk of failure of nonoperative management, recurrence of
infection, persistence of symptoms, and the long-term development
of strictures and stulas.
Transabdominal, high-resolution ultrasound can be a useful
alternative to CT imaging in patients with relative contraindications
to CT scanning such as pregnancy, renal insuciency, or allergy to
contrast material. Although the diagnostic accuracy may be as high
as 97%, ultrasound is a more subjective test and is less eective in
evaluating alternative diagnoses compared with CT imaging. e
utility of ultrasound also can be limited in patients with abdominal tenderness because the use of the transducer probe requires
compression. e quality of ultrasound imaging may be reduced in
obese patients, as well.
Magnetic resonance imaging (MRI) is potentially a better alternative to CT than ultrasound, with a sensitivity and specicity as high as
94% and 92%, respectively, in the setting of diverticulitis. e use and
popularity of MRI colonography in this setting may increase, especially in patients requiring serial imaging, because its use does not
involve exposure to ionizing radiation.
A water-soluble contrast enema, which has been largely supplanted by cross-sectional imaging, may still be useful in evaluating
select patients (Fig. 48-3). Use of barium is contraindicated in the
acute setting and in patients with a suspected leak because barium
extravasation may lead to chemical peritonitis. Although a water-soluble contrast enema can expedite surgery by detecting an occult colon
cancer, physicians tend to be reluctant to utilize contrast enemas early
in the course of diverticulitis because of fear that a contained perforation will convert into a free perforation. A contrast enema is particularly useful when evaluating certain diverticular stulas, in cases with
equivocal CT ndings, when colonoscopy is incomplete because of
a rigid tortuous colon, and when a stricture of the sigmoid colon is
suspected (Fig. 48-4,
A an
d B).
COLON
235
X 48-1:
BO
ree perforation
F
Abscess
Sepsis
Intestinal obstruction
Ureteral obstruction
Colon stricture
Fistula
Lower gastrointestinal bleeding
X 48-2:
BO
olon cancer
C
Appendicitis
Irritable bowel syndrome
Inammatory bowel disease
Ischemic colitis
Bowel obstruction
Gynecologic disease
Urologic disease
di
agnosis cannot be overstated. A diagnostic colonoscopy is usually
performed within 6 to 8 weeks of resolution of the acute episode in
patients who have not had a recent colon evaluation. CT colonography may be considered as an alternative.
Complications of Div
erticulitis: Differential Diagnosis
Div
erticulitis
A
B
FIGURE 48-1
mucosa/submucosa protruding through openings in the muscular bowel
wall where vasa recta penetrate. B, Numerous diverticula seen on
colonoscopy.
lthough exible endoscopy is not usually performed in a patient
A
with acute diverticulitis because of concern about the possibility of
disrupting a contained perforation, it may be helpful in patients with
unresolved questions regarding diagnosis. e main role of colonoscopy in managing patients who have recovered from an episode of
presumed diverticulitis is to evaluate the colon to exclude neoplasia, conrm the diagnosis, and rule out any coexisting conditions
that may inuence management. Although the chance of nding
colonic neoplasia in this setting is low, the importance of an accurate
A, Colonic diverticulosis seen in cross-section shows
MEDIC
I
n general, patients with uncomplicated disease who tolerate oral antibiotics can be treated initially as outpatients, and the vast majority of
patients who are treated in this manner recover. e need for antibiotics
in this treatment paradigm has recently been called into question by randomized controlled studies that have demonstrated no signicant dierences in clinical outcomes between groups of patients treated with and
without antibiotics. Patients who do not respond to outpatient management or who have complicated presentations or signicant comorbidities
are hospitalized and treated with bowel rest and intravenous antibiotics
covering gram-negative and anaerobic colonic ora. Nonoperative inpatient treatment is successful in as many as 91% of patients.
Once a patient recovers from a bout of diverticulitis, a variety
of agents have been suggested to help decrease the risk of recurrent
diverticulitis. Although the use of supplemental ber, rifaximin, antispasmodic agents, mesalamine, and probiotics have been studied in
this setting, the ecacy of these types of products remains questionable, and their role in prevention remains to be dened.
Patients with diverticulitis and an associated abscess resulting
from a contained perforation are usually rst treated nonoperatively.
Most small abscesses up to about 3 to 4 cm will resolve with standard
medical therapy without requiring drainage. Patients who do not
improve clinically without drainage and those with large abscesses
should undergo placement of percutaneous drains, which allows
most patients to avoid urgent surgery. An interval, elective, one-stage
colectomy can be considered. Predictors of failed medical therapy
without drainage include fever higher than 101.2° F on presentation,
location of an abscess in the pelvis, and an abscess size larger than
about 5 cm. Patients without an adequate window for percutaneous
access may be candidates for laparoscopic drainage.
SURGIC
atients with generalized peritonitis need emergency surgery. On the
P
way to the operating room, intravenous hydration and antibiotics
are administered. Although many of the less urgent indications for
AL MANAGEMENT
AL MANAGEMENT
236
Dia
gnosis an
D ManageMent of acute colonic Diver
ticulitis
AB
CD
FIGURE 48-2
and small bowel obstruction with dilated proximal bowel and decompressed distal bowel. C, A CT scan with thickening of the colon wall with a
diverticulum. D, A CT scan with mesenteric abscess and fat stranding.
s
urgery listed in Box 48-3 are self-evident, some remain controversial
and deserve specic mention.
e recommendation to proceed with an elective colectomy aer
two or three attacks of uncomplicated diverticulitis has been called
into question, and the decision to recommend sigmoidectomy in
this setting should be individualized. is practice recommendation
is based on a modern understanding of the clinical outcomes from
diverticulitis. e recurrence rate aer recovering from an episode
of diverticulitis is low, and the likelihood of requiring emergency
surgery with stoma creation as a result of recurrent diverticulitis is
1 in 2000 patient-years of follow-up. e practice of recommending
an elective colectomy to prevent a future recurrence requiring emergency surgery with stoma creation should be discouraged. Nonetheless, patients in certain situations with recurrent, uncomplicated
disease may choose to undergo elective resection. Such instances
include patients with multiple repeat attacks clustered over a short
time interval, patients with chronic symptoms related to prior bouts
of diverticulitis (“smoldering” disease), and patients with certain
socioeconomic inuences. Transplant patients and those whose
immunity is otherwise compromised have a signicantly greater risk
of recurrent diverticulitis that requires emergency surgery compared
with the remainder of the population, and it is commonly recommended that these patients undergo denitive, semielective resection
aer an episode of diverticulitis.
It is generally recommended that patients who experience an
episode of complicated diverticulitis have an elective resection.
Although patients with a stula or stricture most commonly require
a colectomy for symptom resolution, patients who recover aer having an abscess are oen asymptomatic, and the recommendation
A computerized tomography (CT) scan with mesenteric fat stranding and extraluminal gas. B, A CT scan with pelvic abscess
A,
FIGURE 48-3
Multiple div
erticula seen with use of an air-contrast enema.
for surgery in this setting remains controversial. Although low-level
evidence suggests that the diverticulitis recurrence rate aer having
an abscess treated to resolution may be as high as 40%, expectant,
nonoperative management in this group of patients has been supported by other reports. Large-scale prospective research is needed
COLON
237
AB
FIGURE 48-4
t
o better determine the criteria for resection in this setting. However,
A contrast enema demonstrating a diverticular stricture. B, A contrast enema demonstrating a colovesical fistula.
A,
in patients who are poor operative candidates, nonoperative management even in the setting of complicated diverticular disease should
be considered.
Young patients (typically considered younger than 50 years at
the time of their initial episode of diverticulitis) deserve special
mention. Historically, young age has been associated with more
severe disease and worse clinical outcomes, and young patients
have been counseled to undergo resection after a single bout of
uncomplicated diverticulitis. More recent literature demonstrates
similar disease severity across age groups in terms of the need for
resection at the initial hospitalization and emergency surgery or
stoma creation during subsequent attacks. For these reasons, routine elective resection based entirely on young age is no longer
recommended.
Surger
A l
y
aparoscopic approach to an elective colectomy is preferred because
the short-term outcomes and hernia rates are superior to those of
open surgery. However, given the degree of technical diculty of laparoscopic colectomy, the open approach to surgery for diverticulitis
should be performed at the discretion of the surgeon.
Regardless of the operative approach, the extent of elective
resection involves removing the entire sigmoid colon, leaving margins of healthy colon and rectum. It is important that the distal
line of transection, and hence the anastomosis, be at the level of
the proximal rectum because recurrent diverticulitis may develop
in a segment of retained distal sigmoid colon. During the operation, the main sigmoidal artery is usually ligated, or the vessels can
be taken at the mid mesentery, sparing the superior hemorrhoidal
artery. Preserving the blood supply to the rectum may reduce the
risk of anastomotic failure but may not be feasible depending on
the postinammatory anatomy. Patients for whom neoplasia has
not been excluded preoperatively should undergo a cancer-type
resection.
In the setting of urgent surgery in patients with diverticulitis,
the surgeon has several options once the inamed segment has
been resected. ese options include primary colorectal anastomosis with or without a proximal stoma and end colostomy with
BO
X 48-3:
On
e episode of complicated diverticulitis
Div
erticulitis: Current Indications for Surgery
*
Lack of improvement with inpatient medical management
Chronic symptoms related to diverticulitis (“smoldering diver-
ticulitis”)
Recurrent attacks of uncomplicated diverticulitis
Inability to exclude cancer
Fistula formation
Generalized peritonitis
Colon obstruction as a result of a stricture
Secondary small bowel obstruction
* e decision about whether to perform surgery needs to be individualized.
versewing of the rectum (the Hartmann procedure). e risk of an
o
anastomotic leak is weighed against the recognition that end colostomy reversal is typically a technically challenging operation with
its own risk of morbidity and that many end colostomies are never
reversed. e decision to perform a colorectal anastomosis with
or without proximal diversion or to create an end colostomy must
incorporate patient characteristics (e.g., body mass index, severity of peritonitis, immunosuppression, and the condition of the
patient), intraoperative factors (e.g., Hinchey grade, acidosis, and
hemodynamic instability), and surgeon preference. Because of the
risk of stoma creation and morbidity from an urgent colectomy for
diverticulitis, laparoscopic lavage has been suggested as a possible
alternative to resection. Until randomized clinical trials determine
the utility of lavage, it is not appropriate for patients with purulent
or feculent peritonitis to be treated in this way, because the septic
focus remains and risks ongoing and recurrent infection.
g g e
u
S
mbrosetti P. Acute diverticulitis of the le colon: value of the initial CT and
A
timing of elective colectomy. J Gastrointest Surg. 2008;12:1318–1320.
Chabok A, Påhlman L, Hjern F, etal. Randomized clinical trial of antibiotics
in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539.
Dharmarajan S, Hunt SR, Birnbaum EH, et al. e ecacy of non-opera-
tive management of acute complicated diverticulitis. Dis Colon Rectum.
2011;54:663–671.
S t
e d
R
a d i n g
e
238
Dia
gnosis an
D ManageMent of acute colonic Diver
ticulitis
Elagili F, Stocchi L, Ozuner G, et al. Outcomes of percutaneous drainage
without surgery for patients with diverticular abscess. Dis Colon Rectum.
2014;57(3):331–336.
Feingold DL. Laparoscopic lavage for Hinchey grade III sigmoid diverticulitis.
Semin Colon Rectal Surg. 2011;22:173–179.
Feingold D, Steele SR, Lee S, etal. Practice parameters for the treatment of
sigmoid diverticulitis. Dis Colon Rectum. 2014;57:284–294.
Janes S, Meagher A, Frizelle FA. Elective surgery aer acute diverticulitis. Br
J Surg. 2005;92:133–142.
Maconi G, Barbara G, Bosetti C, etal. Treatment of diverticular disease of the
colon and prevention of acute diverticulitis: a systematic review. Dis Colon
Rectum. 2011;54:1326–1338.
Rogers AC, Collins D, O’Sullivan GC, Winter DC. Laparoscopic lavage
for perforated diverticulitis: a population analysis. Dis Colon Rectum.
2012;55:932–938.
Schwenk W, Haase O, Neudecker JJ, Müller JM. Short term benets for laparo-
scopic colorectal resection. Cochrane Database Syst Rev. 2005;2:CD003145.
S
T
D
C
ODUCTION
INTR
urgical management of patients presenting with complications of
S
diverticular disease can be elective, semi-elective, or an emergency,
depending on the severity of the disease and patient comorbidities.
A laparoscopic sigmoid resection is the preferred procedure in the
elective setting, whereas two-stage procedures (e.g., the Hartmann
procedure [HP] and primary resection with anastomosis and diversion [PRA]) are better choices in the semi-elective and emergency
setting. Performing either the HP or PRA laparoscopically results in
decreased morbidity and mortality rates, as well as a shorter length
of hospital stay. However, a signicant shi in the surgeon’s mindset
is required because data suggest that minimally invasive techniques
are rarely used in emergencies—in as few as 6% of cases. Although
patient characteristics may preclude use of minimally invasive procedures, it is fair to say that the primary limiting factor is usually a
lack of familiarity with these techniques. Laparoscopic peritoneal
lavage (LPL) may be an alternative option to resection in the emergency setting, especially for Hinchey stage III patients. Although this
procedure has been associated with lower morbidity and mortality
rates than either laparoscopic or open HP and PRA, further studies
are required to determine its role in the treatment algorithm of this
disease.
e objective of the present chapter is to provide a clear and concise surgical algorithm for the management of diverticulitis, including both elective and emergency operations. Surgical management of
patients presenting with recurrent episodes of diverticulitis or those
who show inadequate response to optimal medical management will
be discussed. Complicated diverticulitis will be reviewed separately.
UNDERST
DISEASE AND ITS MANAGEMENT
F
rom a practical treatment standpoint, acute diverticulitis can be
classied into uncomplicated and complicated disease. Generally
speaking, uncomplicated disease includes patients who become
asymptomatic with medical treatment. Despite being at risk of recurrent episodes, elective surgery is not indicated unless quality of life is
signicantly aected by the frequency or severity of these episodes.
In contrast, complicated diverticulitis is usually an indication for
surgery. Complicated diverticulitis includes patients presenting with
an associated abscess, stula (colovesical, colovaginal, or colocutaneous, among others), acute colonic obstruction, or diuse purulent
or feculent peritonitis. Treatment ranges from semi-elective to emergency procedures. In some cases, emergency situations can be temporized by placement of a percutaneous drain or stent.
Patients who have persistent symptoms aer an acute episode of
uncomplicated diverticulitis and those in whom symptoms of partial
obstruction develop will require an elective operation. Management
of diverticular disease is summarized in Table 49-1.
ANDING DIVERTICULAR
Raul M. Bosio and Conor P
A
CUTE UNCOMPLICATED
DIVERTICULITIS
e prevalence of diverticular disease ranges from 5% to 45% and
increases with age. Eighty percent of patients respond to outpatient
medical management. Treatment consists of broad-spectrum antibiotics and dietary changes once the acute event is resolved. Although
the role of antibiotics during acute episodes of diverticulitis has been
questioned on the basis of some recent data, antibiotics remain the
primary treatment for this disease. e percentage of patients requiring hospitalization is small (20%), but this still means approximately
300,000 admissions per year at an annual cost of $1.8 billion (direct
medical cost). Up to 30% of these patients will subsequently experience recurrent episodes or progress to complicated disease requiring
surgery.
Who Requir
Diverticulitis?
A
s previously discussed, elective resection is indicated for patients
with recurrent episodes of diverticulitis that signicantly aect their
quality of life. Previous practice guidelines recommended surgery
aer a rst episode of diverticulitis in patients 50 years or younger
and aer two episodes of diverticulitis at any age. Current practice
parameters for the treatment of sigmoid diverticulitis published by
the American Society of Colon and Rectal Surgeons in 2014 are more
conservative. ese recommendations are now aligned with a large
body of literature that has demonstrated that age at the time of the
rst episode of diverticulitis is not a predictor of more aggressive disease. Recommendations based on the number of prior episodes of
uncomplicated diverticulitis have also come under scrutiny, and the
number of prior episodes is no longer a major indicator of the need
for surgery. Whereas a total of four attacks was set as a threshold at
which the risk of surgery would be acceptable to reduce the number
of ostomies or mortalities caused by the disease, in practice, the absolute number may not be so important. For example, four attacks over
four decades is a very dierent situation to three attacks in 6 months.
us indications for elective surgery in persons with uncomplicated
disease should be individualized based on the severity, frequency, and
the impact of these recurrences. Patients with persistent symptoms of
acute diverticulitis or chronic obstruction despite adequate medical
management would benet from elective surgery. Immunocompromised patients (e.g., transplant patients, patients with collagen-vascular diseases, or patients with chronic use of steroids) constitute
a separate subgroup; in this population, surgery should be considered during the rst episode of diverticulitis, although surgery is not
always necessary in our experience.
Laparoscopic sigmoid resection is the preferred technique for elective sigmoid colectomy because an abundance of data have shown signicant dierences in morbidity, mortality, length of hospital stay, and
es Elective Surgery after Uncomplicated
. Delaney
239
240
Surgic
al Trea
TmenT of DiverTiculiTiS anD iTS complicaTionS
TABLE 49-1: Diverticular Disease: Management Algorithm
Disease Classification Pr
ncomplicated diverticulitis First episode
U
esentation Initial Management
Antibiotics and dietary changes
Recurrent episode
Colonoscopy or BE aer resolution of
symptoms
Surgical
Management
Not indicated
Recurrent episodes aecting
quality of life
Nonresolving episode
Immunocompromised patients
Complicated diverticulitis With abscess formation Antibiotics and percutaneous drain-
With stula formation Antibiotics and dietary changes
With purulent peritonitis
(Hinchey stage III)
With feculent peritonitis
(Hinchey stage I-V)
Chronic partial obstruction Evaluation of colon: colonoscopy or
Antibiotics and dietary changes
Colonoscopy or BE to rule out IBD,
IBS, and cancer
age as needed
Colonoscopy or BE once recovered
Colonoscopy or BE to rule out IBD,
IBS, and cancer
Antibiotics and sepsis-directed
therapies
Emergent procedure required
Antibiotics and sepsis-directed
therapies
Emergent procedure required
BE
Rule out IBD, IBS, and cancer
Elective laparoscopic sigmoid
resection
Laparoscopic sigmoid resection
Laparoscopic stula takedown
and sigmoid resection
Consider omental ap
Laparoscopic or open resection
and anastomosis with/without
loop ileostomy or laparoscopic
Hartmann vs. open procedure
Consider laparoscopic lavage
Laparoscopic or open resection
and anastomosis with/without
loop ileostomy or laparoscopic
Hartmann vs. open procedure
Laparoscopic sigmoid resection
with or without temporary
diversion depending on proximal colon quality
Acute colonic obstruction Stenting as a bridge to surgery (con-
Acute colonic obstruction—
closed-loop obstruction
BE, B
arium enema; IBD, inammatory bowel disease; IBS, irritable bowel syndrome.
cos
t in favor of minimally invasive procedures. Combining laparoscopic
technique with enhanced postoperative recovery programs contributes
even further to optimize patient care and reduce cost and resource utilization. “Converting a hospital” from open to minimally invasive surgery is feasible as a short-term goal. is endeavor requires the addition
of surgeons trained in minimally invasive colorectal procedures to the
sta. Putting enhanced recovery pathways in place requires educating
surgeons, patients, nurses, ancillary sta, residents, and anesthesia colleagues and allows an institution to maximize patient care and resource
utilization. A decrease in cost is a direct by-product of this process.
Although both single-port minimally invasive procedures and
robotic approaches have been described in the treatment of diverticular disease, these techniques may be associated with higher morbidity (i.e., hernia formation aer single-site surgery) and increased
overall cost and operative time (robotic surgery) when compared
Laparoscopic resection and
troversial)
Correct overall patient’s status
Emergent procedure may be required
Emergent procedure required
Special considerations: intact vs.
necrotic cecum
w
ith conventional laparoscopy. e technical aspects of a laparo-
scopic sigmoid colectomy will be discussed later in this chapter.
COMPLIC
Acute Div
ATED DIVERTICULITIS
erticulitis Complicated by Abscess
anastomosis with/without
loop ileostomy or laparoscopic
Hartmann vs. open procedure
Laparoscopic vs. open segmental
colectomy vs. total colectomy
with ileorectal anastomosis
or end ileostomy (necrosis
present)
Formation: Converting an Emergency Situation into
a Semi-Elective Procedure
linical presentations vary from one patient to another and may be
C
masked by immunosuppression, steroid use, and the location of the
infectious process (e.g., a small abscess conned to the mesocolon
or deep in the pelvis versus a large supercial le lower quadrant