Editing Diverticular disease (section)

== '''Management - acute diverticulitis''' ==

=== '''Uncomplicated     diverticulitis''' ===

** May not be a need for      antibiotics in acute uncomplicated diverticulitis in healthy patients.      Studies not yet showing any significant difference in outcome or      complication rate between observation/Abx.
** No way of predicting adverse      outcomes - antibiotics does not prevent complication in high-risk      patients
** Admit if:
*** Immunocompromise
*** Intolerant to oral intake
*** Sepsis (WCC > 13.5)
*** Lack of social support
*** Frailty or comorbidity
*** Pain
*** No improvement with       adequate treatment at home
** Analgaesia
** Abx
*** Has not been shown to       accelerate recovery or prevent complications or subsequent surgery
** Altered diet - clear fluids,      followed by low-residue diet until the inflammation subsides
** If no improvement after 72      hours in hospital, consider repeating CT
** If no improvement after      another 48 hours, start considering semi-elective resection
** Group of patients who      immediately flare up again when the antibiotics are stopped - start      considering resection if this happens twice

=== '''Hinchey 1a''' ===

** Admit, IV Abx
** Re-scan if deterioration or      worsening bloods

=== '''Micro-perforation''' ===

** A few localised gas bubbles      on CT, either locally or under the diaphragm. In the absence of      peritonism or other indicators of sepsis, should be treated medically.      19% progress to abscess.

=== '''Hinchey 1b     or 2''' (localised     abscesses) ===

** Medical management and IR      drainage if amenable (often defined as >3cm). If they deteriorate or      fail to improve within 3-4 days, surgery is likely indicated.
*** Leave abscess drain in       place until <30mL per day
** Antibiotic therapy alone is      generally sufficient for abscess <3cm, but should be a prolonged      course
** Large abscesses that can't      be reached percutaneously could be considered for laparoscopic      drainage/lavage
** Generally recommend elective      surgery after recovery

=== '''Hinchey 3 or     4''' ===

** Seen at presentation as      sepsis, generalised peritonitis and free air in setting perforated      diverticulitis
*** Stoma marking early
** Life-threatening emergency      requiring surgical exploration
*** Goals - control source of       infection and wash out the contamination
*** Default operation is       Hartmann's procedure
*** If Hinchey 4 is found at       operation, have to do '''Hartmann's'''
*** Reasonable in some selected       patients to start off with a '''laparoscopic lavage''' and upgrade to Hartmann's       if difficult or signs of Hinchey 4. Results in lower stoma rates, but       higher rates of ongoing sepsis and re-operation. It does often delay the       operation to a later date when the patient is in better condition, so       could be worthwhile from that perspective.
**** Don't mobilise the colon,        don't go poking around looking for the perforation
**** Irrigate all four        quadrants and leave a large drain
**** These patients should        improve after 24-48 hours - if not, book for resection
*** If the patient is not       unwell, and can tolerate the longer operation, could do a '''primary       anastomosis with loop ileostomy'''. There is, however, plenty of evidence that reversal       rate is higher with primary anastomosis, with no increase in mortality       or morbidity, when done by an experienced surgeon. Patient needs to be       able to survive a leak and be in good general condition. Much better in       Hinchey 1 and 2 disease.
** In a stable patient with      radiological pneumoperitoneum, without diffuse peritoneal findings, you      can try to convert an emergent operation to a semi-elective one with      medical management
** Note Hartmann's would be      reversed in about a year if faecal contamination, or 3-4/12 if not.