Treating a patient with diverticulitis varies with the severity of symptoms, duration of disease, associated diseases and immune status of your system. Fortunately, most episodes of diverticulitis are mild or moderate, peridiverticulitis presented with or without small localized abscess, and resolved satisfactorily with medical treatment, which is basically liquid diet and oral antibiotics type Trimethoprim + Sulfamethoxazole and metronidazole can perform this treatment on an outpatient basis. Some patients must be hospitalized for parenteral nutrition, nasogastric tube aspiration and intravenous antibiotics, presenting abdominal distension and vomiting. Hospitalization also allows for frequent assessments of the patient in the first 48-72 hours after diagnosis. The antibiotic selection should cover gram negatives, anaerobes and enterobacteria with some options and considerations are shown in Table V, which are related to possible allergies of the patient's experience surgeon and the center of these antibiotics, and also the cost.
The stage of patients, classified by the TAC, can be included or not in the group of entry are supposed to respond to medical treatment, and indeed in the uncomplicated diverticulitis resolves the problem between 70-100% of patients.
After recovery from an initial episode of diverticulitis, the patient will be re-evaluated when the swelling has disappeared, to be a convenient and a sigmoidoscopy barium enema. It is recommended diet waste after inflammatory episode, moving later to a diet rich in fiber, which prevents relapse in more than 70% at five years.
The decision whether or not a patient with diverticulitis continue outpatient treatment or hospital depends on the physician's clinical impression of the severity of the process and the likelihood that the patient's condition, especially social-health, to respond to treatment specimens. In general, immunosuppressed patients, including those treated with corticosteroids, non-subsidiary treatment specimens. The blood will not decide whether the patient will be treated within or tract, but will help us to monitor the therapeutic response. Especially remember is the family environment, and that the assessment on his part to a reliable picture of worsening (intolerance to liquids, increased abdominal pain, fever) which will change the strategy towards hospitalization (19). Anyway, in our context, these digressions are far curly implemented since almost all patients with this condition are admitted to the hospital, but each time raising more should follow ambulatory cost.
The indications for surgical treatment of diverticulitis are determined by the particular clinical situation of each feed, and are described in Table VI.
Diverticulitis complicity.
The complications of acute diverticulitis include abscess, free perforation, fistula, obstruction and lower gastrointestinal bleeding, with special considerations on repeated episodes of diverticulitis, immunocompromised patients, young patients, the right of the colon and diverticulitis the recurrent diverticulitis after resection.
Diverticulitis associated with abscess or phlegmon. The inflammatory process associated with perforation of a diverticulum of the colon is known as diverticulitis. This drill is the beginning of an inflammatory process limited, localized (phlegmon) and may continue to pericallosa or intraabdominal abscess, or lead to a purulent or fecal peritonitis.
Treatment of patients with diverticular abscess depends on the size and location, as well as the patient's clinical condition and the time of diagnosis. Pericallosa small abscesses resolved with antibiotic therapy and complete diet. For patients with larger abscesses, which will not resolve with medical treatment, there are two options, percutaneous drainage or surgery.
Transabdominal percutaneous drainage, either by ultrasound or CT is increasingly used and is the method of choice for most of the pelvic abscess, although these are pluriloculars, reaching a 85% success rate, providing an alternative to immediate surgical intervention with less morbidity, and in particular allows many patients after colon resection with primary anastomosis, avoiding interference in a two-stroke.
Those patients who fail to percutaneous drainage or where symptoms persist after the same shall be subjected to laparotomy. Here the authors differ in the technique of surgical resolution of one, two or three times (primary resection and anastomosis, resection with Hartmann or with colostomy and mucus fistula for reconstruction in a second time, with colostomy or drainage, and then make resection with anastomosis while leaving the protective colostomy above, and perform a third time in its closure). In a series of 259 patients, resection is essential for the affected area, and intervention in a primary-time-anastomosis was indicated if the infection is confined to the mesentery, leaving resection and anastomosis colostomy protection than either technique when Hartmann peritoneal contamination with figures associated with resection of primary reconstruction of 45% in later years. In a series of 403 patients with diverticulitis of requiring surgical intervention, 113 to 90.2% resection was performed, and only a third of these, primary anastomosis, Hartmann to practice in the rest with an overall mortality of 17.7% in the surgery, noting that all were older than 80 years and ASA 3, recommending a range, where possible, between the episode of acute diverticulitis and resection as elective surgery. In a study of 72 patients in the most recent series of work practices emergency colostomy and drainage only 4% of cases, and Hartmann's intervention in 56% with resection and anastomosis primary or associated with colostomy in 31%, to go into surgery standardized to 2% and 94% of Hartmann resection with anastomosis, with an overall mortality of 4%. With a short series of 34 patients, Hartmann's intervention practices in 80% of cases operated on urgently, leaving time for an intervention in most undergoing elective, and that the preparation of the colon, the state of the peritoneum and the patient's condition so warrant, depending on the security of the anastomosis, indicating the high mortality that urgent surgery presents (22%). In the series on 110 patients treated surgically, he practiced primary anastomosis with left hemicolectomy to 82.7%, Hartmann's intervention to 11.8% (only in cases of diffuse peritonitis) and only 5.4% of the resection sigmoid, noting that in recent years the number of deaths dropped dramatically from 14-3% for emergency surgery, with 0% in the elective and the number of dehiscences that has gone from 8% to 2%, giving a mechanical suture.
Diverticulitis associated with drilling freedom.
Free perforation of acute diverticulitis with purulent or fecal peritonitis is an indication of surgical emergency, requiring immediate resuscitation measures with intravenous fluid therapy, broad spectrum antibiotics and cardiovascular support. Moreover, free perforation is an uncommon complication of diverticulitis, but with a mortality that can reach 35%. The procedure of choice in this situation is the immediate resection with colostomy Hartmann type, associated with the usual measures of performance in any peritonitis (thorough washing of the abdominal cavity and drains) by agreeing the majority of authors. However, although this procedure is widely accepted, other authors put more emphasis on a viable alternative is the primary anastomosis, with or without colostomy above.