Let’s discuss the management of diverticulitis based on the Hinchey classification. Remember, Hinchey
1 through 4 is a continuous spectrum of severity of disease. Hinchey 1 is the simplest to take care of.
We usually can advance diet fairly quickly as soon as the patient’s symptoms resolve. That means
the resolution of pain. We keep the patient on the antibiotics to cover the colonic flora.
We wait for symptomatic relief. When the patient feels better, we advance the diet. We discharge the patient.
Remember, for Hinchey 1 classification patients, oftentimes many of these people can be observed and managed
in an outpatient setting. How about Hinchey 2-4? Well, these are a little bit more complex
than the Hinchey 1 patients. They may require interventional percutaneous drainage of the abscess.
Recall that Hinchey 2 have a pericolonic abscess formation. These abscesses unfortunately have very poor
antibiotic penetration. For us to get surgical source control, usually we have to call a radiologist.
Now, on the examination presented with the scenario of a patient who comes in with a Hinchey 2-4
classification, as long as the patient does not have any rebounds or guardings suggestive
of peritoneal signs, the patient can be safely managed with antibiotics and interventional percutaneous
drainage. However, if the patient’s disease progresses, interventional radiologists are not available,
or the interventional percutaneous drainage is not successful in the drainage, the patient may require
surgery particularly with clinical deterioration. If you decide surgery is necessary and it’s important
to stress that surgery is not first line therapy for diverticulitis, antibiotics are. We usually reserve surgery
for patients who have severe complications of diverticulitis or failure of progression or resolution based
on nonoperative management. But should surgery become a necessity then we want to discuss
what the surgical options are. In this slide, you’ll notice that a black box around the sigmoid colon
has been outlined. Let’s say that this black box is the area that’s affected by diverticulitis.
Resection limits usually require us to go down past the sigmoid-rectal junction, not necessarily peritoneal
reflection. Proximally, we want to get to a point of soft, viable healthy colon. Remember, it’s not
necessary to get rid of all diverticular disease as diverticulosis may be quite scattered throughout
the entire length of the colon. Generally speaking, it’s safe to perform a primary anastomosis
after the resection as long as it’s not an emergency situation. During emergency, it may be necessary
to do a temporary ostomy. How do we guard against diverticulitis? We don’t really know.
Based on some evidence, that low fiber diet and left side of predominance suggest that there is
a high intraluminal pressure related to diverticulosis and subsequent diverticulitis.
Generally, we recommend a high-fiber diet and keeping our bowel movements regular and soflty-formed.
But it’s questionable if seeds and nuts exacerbate the disease. Traditional teaching has always been
avoid corn, popcorn, things that may “get stuck in one of the diverticulum." But no scientific
evidence has ever proven that to be the case. Some important clinical pearls: Patients should
undergo colonoscopy to exclude cancer. Remember, prior to surgery, it’s absolutely particularly in
patients who are within an age group to exclude cancer prior to doing definitive therapy
for diverticulosis or diverticulitis. The number of episodes of diverticulitis is no longer an important
determinant of the necessity for surgery. It used to be that in young patients, we would offer
surgery after the second episode. One of the fears is that the subsequent episodes of diverticulitis
may be clinically more severe and may require emergency surgery. Further studies have demonstrated
that not to be the case. The decision to pursue surgery for diverticulitis is a very personal one
between the patient and the surgeon. Here are some complications that most likely would require
surgery and this is high-yield information for the examination: bleeding, obstruction, perforation,
and septic shock. Recall that bleeding is much more common in diverticulosis than diverticulitis
but one can bleed and one can bleed significantly from diverticular disease. If the patient has
localizable bleeding then regional resection is reasonable. Bleeding patients who undergo
massive transfusions in excess of six units of packed red blood cells or who become hemodynamically
unstable will likely require a surgery. Patients who have a bowel obstruction, large bowel obstruction
as a result of diverticulitis likely have developed a phlegmon significant enough to cause proximal dilation.
Some indications of operation for large colon obstruction are patients who have signs of small
bowel obstruction, cecal dilation. As you know, the cecum is the thinnest portion of the colon
and governed by LaPlace’s law, also the most likely area to perforate. Frank perforations in excess
of the microperforations in significant pneumoperitoneum is an indication for surgery. Finally, septic
shock in a patient who’s clinically deteriorating. One of the other complications that can result from
diverticulitis is an anomalous connection between the colon and the bladder. This is called the
colovesical fistula. You notice on these images that there is air in the bladder filled with contrast
fluid where there should be rarely any air in the bladder. This is called pneumaturia. A colovesical fistula
can result or present itself firstly with pneumaturia. Patients will often present complaining of
interruptions of the voiding stream with pockets of air. Additionally, frequent urinary tract infection
may lead you to believe that the patient has a colovesical fistula. How do we manage
colovesical fistulas? Recall, a fistula is an abnormal connection between two epithelialized surfaces.
In this situation, it’s between the colon and the bladder. There’s only one way to fix that problem
and that’s surgically. What we want to do intraoperatively is to break down the fistula.
The connection between the colon and the bladder needs to be separated. Once separated,
the hole in the bladder is repaired. Some high-yield information for your USMLE examination: Remember,
many uncomplicated diverticulitis cases can be treated with oral antibiotics as outpatient alone.
Many of these patients don’t need to be admitted into the hospital. Recall that the number of
episodes of diverticulitis is no longer in and of itself an indication for surgery. Lastly, if your patient
is decompensating as is the case in any question or scenario, the answer choice usually
involves operating on that patient. Thank you very much joining me on this discussion of acute diverticulitis.