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Perforated Diverticulitis

Perforated diverticulitis is a complication of diverticulitis and entails the rupture of an infected diverticulum in the large intestine, primarily the colon. Diverticulitis is a condition that involves a microbial inflammation of the diverticulum.


Presentation

Diverticula are small pouches that develop in any part of the intestine and are mainly found in the colon. They are commonly observed during colonoscopy amongst the population aged over 60 years old. Diverticula alone are asymptomatic; however, inflammation may occur due to a fecal obstruction at the site of a diverticulum that causes infection of the latter, leading to a condition known as diverticulitis or diverticular disease. Perforation of an infected diverticulum is a grave complication that occurs when the inflamed pouch ruptures into the peritoneal cavity.

The symptoms caused by perforated diverticulitis are the same as those seen in any other case of intestinal perforation and subsequent peritonitis. The complication involves either free perforation with purulent peritonitis or fecal peritonitis, which correspond to Hinchey's classification of perforated diverticulitis as stage III and IV respectively [1].

In contradistinction to gastric or duodenal perforation, which lead to alarming, sudden-onset symptoms and generalized pain, perforated diverticulitis, which mainly affects the large intestine, may develop in the presence of pre-existing symptoms, related to the underlying disease (diverticulitis), such as pain in the lower mid- or left quadrant of the abdomen. The symptom of abdominal pain in the lower abdomen may increase in intensity over time, in cases of perforation, and tends not to be of sudden onset. It is also described by the patients as localized, and so is the abdominal tenderness caused by peritonitis. Additional symptoms that complete the clinical picture are vomiting, nausea and loss of appetite. All aforementioned symptoms are exacerbated with the progression of time, with the patients eventually presenting with generalized tenderness and pain in the abdominal area and distention. Generally, perforated diverticulitis is not a complication frequently observed in a clinical setting; even if it occurs, stages III and IV of Hinchey's classification are the less common types of complicated diverticular disease [2] [3].

Fever
  • A 75-year-old man with no relevant medical history visited our hospital complaining of a fever, which had lasted for 2 weeks.[ncbi.nlm.nih.gov]
  • […] primary repair of perforated diverticulitis to eliminate requirement for temporary colostomy This is a 52 years old female who presented to the emergency room with two days history of severe left lower quadrant abdominal pain, nausea, vomiting, and fever[surgicaloasis.com]
  • When clinically explored, he presented hypotension (AT 90/60), tachycardia (113 beats/minute), fever (38.5 C). Abdominal exploration showed inguinoscrotal hernia with hyperemia (Figure 1), pain palpation and tensioning scrotum.[peertechz.com]
  • After surgery, the patient's fever and abdominal pain subsided. He had an uneventful hospital course and was discharged on postoperative day 8 after a short course of ceftriaxone.[hcplive.com]
Tachypnea
  • Distended abdomen Localized or generalized tenderness, depending on the progression of peritonitis Board-like abdomen Guarding Tympanic sound when percussion of the abdomen is performed Hemodynamic changes, such as low blood pressure and increased pulses Tachypnea[symptoma.com]
Acute Abdomen
  • Cause of acute abdomen in this patient was a perforated diverticula with a previous inguinoscrotal hernia. Patient’s clinical evaluation was relevant to obtain a correct diagnosis over decisions in surgical approach.[peertechz.com]
  • abdomen References: [5] [8] [9] We list the most important complications.[amboss.com]
  • Case Report : Here, we present a case of a 70 year old, male patient who was admitted with acute abdomen and intra-operatively diagnosed as perforated duodenal diverticulum.[casereports.in]
  • abdomen from the consensus development conference of the societa italiana di chirurgia endoscopica e nuove tecnologie (SICE), associazione chirurghi ospedalieri Italiani (ACOI), societa italiana di chirurgia (SIC), societa Italiana di chirurgia d'urgenza[karger.com]
Abdominal Distension
  • During your quick, focused assessment, you note abdominal distension, hypoactive bowel sounds, and involuntary guarding. Her vital signs are: BP, 100/62; pulse, 124; respirations, 28; temperature, 102 F (38.9 C); and SpO2, 94% on room air.[journals.lww.com]
  • Case Report A 70 year old, male patient presented to our emergency department with generalised pain abdomen, fever and abdominal distension. Examination showed normotensive patient with tachycardia of 110 beats per minute.[casereports.in]
  • Symptoms Abdominal pain mainly after meals Abdominal distension Difficulty with evacuation of stool and wind. Treatment Balloon dilatation: a balloon can be placed in the area of the stricture and inflated to stretch the narrowing.[familydoctor.co.uk]
Absent Bowel Sounds
  • bowel sounds With regard to imaging modalities that can aid in the diagnosis of perforated diverticulitis, the first step is a plain abdominal radiograph.[symptoma.com]
  • bowel sounds (perforation) Generalized abdominal pain with rebound and guarding (perforation) Urinary tract findings (colovesicular/colovaginal fistula) include suprapubic, flank, costovertebral tenderness; pneumaturia (air in urine); fecaluria (stool[emedicine.medscape.com]
Increased Abdominal Girth
  • The cause of diverticulosis is unclear, but it has been associated with increased pressure from constipation or increasing abdominal girth in obesity.[emedicine.medscape.com]
Tachycardia
  • When clinically explored, he presented hypotension (AT 90/60), tachycardia (113 beats/minute), fever (38.5 C). Abdominal exploration showed inguinoscrotal hernia with hyperemia (Figure 1), pain palpation and tensioning scrotum.[peertechz.com]
  • The cardiac monitor shows sinus tachycardia without ectopy. What's the situation? Mrs. Aston was diagnosed with diverticulosis 5 years ago, during a routine colonoscopy.[journals.lww.com]
  • Diverticulitis is defined as evidence of diverticular inflammation (fever, tachycardia) with or without localised symptoms and signs.[patient.info]
  • […] occurs in around 5% of cases of patients with diverticulosis Caused by erosions around the edge of diverticula Clinical findings Painless hematochezia Severe or ongoing bleeding: significant drop in hemoglobin, hemodynamic instability ( hypotension, tachycardia[amboss.com]
  • Examination showed normotensive patient with tachycardia of 110 beats per minute.[casereports.in]
Fracture
  • The absence of peritonism due to corticosteroid treatment, a history of a recent fall with an ilio- and ischio-pubic fracture and subcutaneous emphysema led to a delay in the diagnosis.[ncbi.nlm.nih.gov]
Renal Impairment
  • Mortality rates are high, particularly in those taking NSAIDs or with pre-existing renal impairment. (c) 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.[ncbi.nlm.nih.gov]

Workup

The workup involved in the assessment of perforated diverticulitis is similar to other differential diagnostic processes entailed in diagnosing acute abdominal pain.

Patients with a history of diverticulosis who report a gradually increasing sensation of pain in the lower abdomen, tenderness in the same region and distention are potential candidates for perforated diverticulitis. The physical examination is expected to reveal:

With regard to imaging modalities that can aid in the diagnosis of perforated diverticulitis, the first step is a plain abdominal radiograph. Intestinal perforation is illustrated in an x-ray by air, located in the subdiaphragmatic regions, a visible falciform ligament, and air-fluid levels. However, plain radiographs are not of much assistance in cases of a perforated diverticulum, since this type of condition does not lead to air that is visible in radiographs. Ultrasonography (US), on the other hand, is a valuable tool in order to detect a suspected perforation, since it can detect free air within the peritoneal cavity. It can also differentiate between a case of diverticular perforation, an appendicular perforation or a gastric perforation. Lastly, a computerized tomography scan (CT) can detect a diverticular abscess, localized perforated diverticula and a variety of alterations in the soft tissues adjacent to the colon, thus rendering a diagnosis possible. A CT scan can also help to evaluate the need for a conservative or surgical treatment in patients with diverticulosis and newly-occurring symptoms [4]. Regarding blood laboratory tests, studies have detected a strong correlation of CRP> 200 mg/l and perforated diverticulitis [5].

Pneumoperitoneum
  • Fig. 8.5 Colonic perforation: evidence of pneumoperitoneum and air bubbles preferentially located in the pericolic fat ( arrows ) In case of free perforation into the peritoneal cavity, the air rapidly reaches the most antideclive position usually in[radiologykey.com]
  • Perforated Diverticulum Plain film Pneumoperitoneum secondary to perforation of diverticulum.[stritch.luc.edu]
  • […] quadrant which is producing compression on the barium-filled sigmoid (red arrow), and there is evidence of extraluminal contrast (red arrow) from a perforated diverticulum, Conventional Radiography Sentinel loop or, less likely, LBO Air bubbles in abscess Pneumoperitoneum[learningradiology.com]
  • Plain X-ray of the abdomen showed air under the diaphragm (pneumoperitoneum). The chest X-ray was normal. Ultrasonography of the abdomen showed free fluid in the abdomen.[saudijgastro.com]
  • One of the reasons is related to a hypothetical risk of increased bacteraemia and hypercapnia due to the pressure of the pneumoperitoneum [ 47, 48 ].[karger.com]
Cavitary Lesion
  • Herein, we present a case with perforated diverticulitis causing pulmonary cavitary lesions and a septic thrombus in the neighboring inferior vena cava.[ncbi.nlm.nih.gov]
Hypercapnia
  • One of the reasons is related to a hypothetical risk of increased bacteraemia and hypercapnia due to the pressure of the pneumoperitoneum [ 47, 48 ].[karger.com]

Treatment

  • BACKGROUND: The treatment of perforated diverticulitis is changing form the current standard of laparotomy with resection, Hartmann procedure, and colostomy to a minimally invasive technique.[ncbi.nlm.nih.gov]

Prognosis

  • The aims of this study were to evaluate long-term survival after discharge from hospital and to identify factors associated with prognosis.[ncbi.nlm.nih.gov]
  • The prognosis varies if complications develop and is particularly serious in the case of peritonitis. About 90% of people who have a colon resection do not have symptoms return after the surgery.[drugs.com]
  • […] gas and fluid into pelvis and peritoneal cavity abscess formation (seen in up to 30% of cases) may contain fluid, gas or both fistula formation (usually a chronic complication) gas in the bladder direct visualization of a fistulous tract Treatment and prognosis[radiopaedia.org]
  • What should you tell the family about the patient's prognosis? In general, the prognosis after an episode of uncomplicated diverticulitis is good.[infectiousdiseaseadvisor.com]

Etiology

  • Right-sided diverticulitis is usually diagnosed in patients with an average age of 40 years, which is older than the typical age of patients who present with appendicitis and younger than those diagnosed with the more common left-sided diverticulitis. 7 Etiology[hcplive.com]
  • Etiology The etiology and pathophysiology of diverticulitis is not fully understood and may vary among patients.[merckmanuals.com]
  • Definition / general Ulceration of colonic mucosa secondary to impacted feces Essential features Inspissated feces can cause rectosigmoid ulceration in elderly patients May perforate and lead to death Etiology Impacted feces stagnate, eventually eroding[pathologyoutlines.com]

Epidemiology

  • This review appraises existing evidence on the epidemiology and mechanisms of perforation, highlights areas of further study, and suggests an epidemiological approach towards preventing the condition.[pmj.bmj.com]
  • : [1] [2] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis. . Accessed July 24, 2018. Tursi A, et al.[mayoclinic.org]
  • Back to Top Incidence and Epidemiology The incidence of diverticulosis in the Western world has progressively increased over the past century.[clevelandclinicmeded.com]
Sex distribution
Age distribution

Pathophysiology

  • "This technique, laparoscopic lavage, needs to be studied from a pathophysiologic perspective," Dr. Haglind said.[consultant360.com]
  • Pathophysiology of diverticular disease. Best Pract Res Clin Gastroenterol. 2002;16(4):563-576. Graham SM, Ballantyne GH. Cecal diverticulitis. A review of the American experience. Dis Colon Rectum. 1987;30(10):821-826. Lo CY, Chu KW.[hcplive.com]
  • Gastrointestinal Surgery: Pathophysiology and Management is an invaluable reference text for surgeons and surgical trainees. Written entirely by Dr. Haile T.[books.google.ro]
  • Review article: The pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Alimentary Pharmacology and Therapeutics. 2015;42:664. Pemberton JH, et al.[mayoclinic.org]

Prevention

  • Abstract The one-stage intracolonic bypass procedure prevents gastrointestinal secretions and fecal content from coming in contact with an anastomotic site without interrupting the intraluminal continuity of the fecal flow from proximal to distal colon[ncbi.nlm.nih.gov]
  • Blog for Colon / Bowel Surgery / Perforated Diverticulitis What a New York Doctor’s Colon Surgery Mistake Really Costs You Library for Colon / Bowel Surgery / Perforated Diverticulitis: What a New York Doctor Could’ve Done to Prevent Your Perforated Bowel[thepaganlawfirm.com]
  • However, in this case to prevent a temporary colostomy and improve the patient quality of life post-operatively, it was decided to repair the micro-perforation primarily and drain the abscess.[surgicaloasis.com]
  • The heparin was used to prevent blood clots or treat existing ones. Surgery, especially abdominal, carries the risk of getting blood clots. It is important to get moving immediately after surgery to prevent the.[wisegeekhealth.com]

References

Article

  1. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85-109
  2. Morris CR, Harvey IM, Stebbings WS, et al. Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008; 95:876–881
  3. Angenete E, Thornell A, Burcharth J. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis. Ann Surg. 2016 Jan; 263(1): 117–122.
  4. Patrick Ambrosetti. Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography. Clin Exp Gastroenterol. 2016; 9: 249–257.
  5. Käser S, Fankhauser G, Glauser PM, Toia D, Maurer CA. Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. World J Surg. 2010 Nov;34(11):2717-22

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Last updated: 2019-06-28 10:14