Nonoperative management of acute complicated diverticulitis.

See Article on Page 216-221

In the past, the majority of acute complicated diverticulitis patients were managed by using surgical intervention, such as a resection of the perforated bowel and the creation of an end colostomy. However, surgical intervention in cases of acute complicated diverticulitis is associated with high postoperative morbidity and mortality [1]. Although the optimal treatment for acute complicated diverticulitis is controversial, recently, with the evolution of surgical techniques and supportive medical care, such as the advances in the development of antibiotics, interventional radiology techniques, parenteral nutrition, and critical care medicine, significant changes in the treatment of acute complicated diverticulitis have taken place [2]. Computed tomography scans are able to accurately characterize the severity of the disease and to guide therapeutic percutaneous drainage of abscesses [3].

Because of the advances in the supportive medical care, the management of acute complicated diverticulitis can be changed from emergent surgery to elective surgery. Therefore, surgical intervention for acute complicated diverticulitis is needed only for patients in whom aggressive nonoperative management has failed or for patients who are hemodynamically unstable or present with generalized peritonitis. Dharmarajan et al. [4] hypothesized that management with bowel rest, parenteral nutrition, antibiotics, and percutaneous abscess drainage obviated the need for acute surgical intervention in the vast majority of cases.

In this study, the authors showed that in their experience, the presence of recurrent attacks of acute diverticulitis was not a significant risk for emergent surgery. In fact, the first episode of complicated acute diverticulitis was the only risk factor for emergent surgery in patients managed in a conservative form [5].

If appropriate resources are available, aggressive nonoperative management of acute complicated diverticulitis is safe and effective in almost all hemodynamically-stable patients. The decision to use nonoperative management of acute complicated diverticulitis must be based on the patient's clinical physiologic state.