Manejo conservador en diverticulitis aguda perforada con aire extraluminal / Conservative management of perforated diverticulitis with extraluminal air

Resumen Introducción: El tratamiento óptimo de la diverticulitis perforada con aire extraluminal (DPA) es materia de debate. El manejo conservador es controversial; en casos seleccionados puede ofrecer menor morbimortalidad y evitar una ostomía. Objetivo: Describir las características clínicas, imagenológicas, necesidad de intervención quirúrgica y morbimortalidad de pacientes con DPA tratados con manejo conservador. Materiales y Método: Estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de DPA hemodinámicamente estables sin evidencia de peritonitis entre los años 2009 y 2015. Resultados: Se hospitalizaron 162 pacientes con diagnóstico de diverticulitis aguda (DA), el 53,1% fueron diverticulitis agudas complicadas (DC), de las cuales el 43% (37 casos) eran DPA, la edad promedio fue 59,6 años, la mayoría eran mujeres (54,1%). Las manifestaciones clínicas más comunes fueron dolor abdominal (97,3%), signos peritoneales (59,5%) y fiebre (40,5%). La tomografía axial computada de abdomen y pelvis (TC AP) mostró burbujas extracolónicas en el 78,4% y neumoperitoneo en el 21,6%. El manejo conservador fue exitoso en el 87,8%. Durante el seguimiento de 71,2 meses la recurrencia fue 28,1% y el 31,3% se realizó sigmoidectomía electiva. La falla del tratamiento médico se presentó en 5 casos (12,2%), uno de los cuales fallece. Conclusión: el manejo conservador de la DPA es una alternativa válida de tratamiento con alto porcentaje de éxito en pacientes hospitalizados seleccionados. La decisión de cirugía de urgencia y de sigmoidectomía electiva posterior a una DPA tratada médicamente debe ser individualizada.

Background: The conservative management of perforated diverticulitis with extraluminal air (PDA) is controversial. In selected hospitalized patients may offer less morbidity and mortality and avoid an ostomy. Aim: To describe its clinical and imagenologic characteristics, the need for surgical procedure and morbimortality of patients with perforated diverticulitis with extraluminal air in conservative management. Materials and Methods: Retrospective descriptive study of hemodynamically stable hospitalized patients with a PDA diagnosis without evidence of peritonitis during the years 2009 and 2015. Results: 162 patients were admitted with the diagnosis of acute diverticulitis. 53.1% of cases were acute complicated diverticulitis, 43% (37 cases) were PDA. The average age was 59.6 years and most of them women (54.1%). The most common clinical manifestations were abdominal pain (97.3%), peritoneal signs (59.5%) and fever (40.5%). The abdomen and pelvic computerized axial tomography scan showed extra-colonic bubbles in 78.4% and pneumoperitoneum in 21.6%. The conservative management was successful in 87.8% of cases. After a 71.2-month follow-up, the recurrence was 28.1% and 31.3% had an elective sigmoidectomy. 5 cases did not respond to medical treatment, one of them resulting in death. Conclusion: The conservative management of PDA is a valid treatment option with a high degree of success in the selected sample of hospitalized patients. The decision of having emergency surgery and elective sigmoidectomy post DPA should be evaluated individually.

Clinical Features and Factors Associated With Surgical Treatment in Patients With Complicated Colonic Diverticulitis

PURPOSE: Colonic diverticulitis is uncommon in Korea, but the incidence is rapidly increasing nowadays. The clinical features and the factors associated with complications of diverticulitis are important for properly treating the disease. METHODS: A retrospective review of the medical records of 225 patients that were prospectively collected between October 2007 and September 2016 was conducted. RESULTS: Diverticulitis was detected mainly in men and women aged 30 to 50 years. Diverticulitis more frequently affected the right colon (n = 194, 86.2%), but age was higher in case of left colonic involvement (42 years vs. 57 years, P < 0.001). Percentages of comorbidities (65.6% vs. 23.8%, P < 0.001), complications (65.6% vs. 6.2%, P < 0.001), and surgical treatment (50.0% vs. 4.1%, P < 0.001) were significantly higher in patients with left colonic diverticulitis. In the multivariate analysis, a risk factor for complicated diverticulitis was left colonic involvement (P < 0.001; relative risk [RR], 47.108; 95% confidence interval [CI], 12.651–175.413). In complicated diverticulitis, age over 50 was the only significant risk factor for surgical treatment (P = 0.024; RR, 19.350; 95% CI, 1.474–254.023). CONCLUSION: In patients over 50 years of age with left colonic diverticulitis, a preventive colectomy should be reconsidered as one of the options for treatment.

Tratamiento actual de la diverticulitis aguda: [revisión] / Current treatment of the acute diverticulitis acute: [review]

Cuando la diverticulitis aguda es diagnosticada tardíamente y los síntomas clínicos son evidentes aumenta el riesgo de complicaciones y la mortalidad. El objetivo principal de esta revisión es recordar la importancia de la valoración inicial y recordar la importancia de considerar esta patología en el diagnóstico diferencial hecho en el servicio de urgencias. La diverticulitis es una alteración que se puede presentar en la población menor de 50 años de una manera agresiva, afectando el colon izquierdo, principalmente. Es una enfermedad subdiagnosticada y, cuando se hace el diagnóstico en forma tardía, aumentan la estancia hospitalaria y las secuelas. Se ha clasificado en diverticulitis aguda complicada y no complicada. El manejo médico incluye la administración de antibióticos —por vía oral o intravenosa—, según la condición del paciente, y el drenaje percutáneo previo diagnóstico tomográfico. La cirugía se practica cuando el paciente presenta perforación, pero la primera elección es el manejo médico y, después, practicar la cirugía electiva.

When acute diverticulitis is belatedly diagnosed and the clinical symptoms are evident, the risk of complications and mortality increases, therefore the main purpose of this review is to remind the importance of approach and consider this pathology into the differential diagnosis made in emergency room. Diverticulitis is a pathology that compromises the elderly population, but more aggressive when occur in the population under 50 years old; this pathology affects the left colon. It is usually sub-diagnosed and once it is diagnosed, both hospital stay and recurrence arise. Diverticulitis is classified in two stages: complicated and uncomplicated; treated by oral antibiotics or intravenously, and in most cases patients are treated with percutaneous drainage. However, if the patients present with perforations, a surgical intervention will be required. The first choice is medical management but when necessary the elective surgery might be considered.