Antibiotics have been the mainstay of therapy for most patients with Patients with clinically mild diverticulitis, typically with Hinchey stage 0. Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of. Introduction: Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. The Hinchey system is a surgical classification and as such it is not.
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Diverticular disease of the sigmoid colon prevails in Western society. Its presentation may vary greatly per individual patient, from symptomatic diverticulosis to perforated diverticulitis.
Since publication of the original Hinchey classification, several modifications and new grading systems have been developed. Yet, new insights in the natural history of the disease, the emergence of the computed tomography scan, and new treatment modalities plead for evolving classifications.
This article reviews all current classifications for diverticular disease. A three-stage model is advanced for a renewed and comprehensive classification system for diverticular disease, incorporating up-to-date imaging and treatment modalities. Diverticular disease of the sigmoid colon is a common condition in Western society. Its presentation among patients may vary from symptomatic diverticulosis to perforated diverticulitis.
Although diverticular disease is more common among elderly patients, a dramatic rise of its incidence is seen in the younger c,asificacion groups [ 2 ]. Furthermore, depending on the severity of the disease, the treatments for the various presentations of the disease will differ. Accordingly, diagnostic tools, indications for surgery as well as treatment modalities have been evolving, resulting in more options in the therapy for diverticular disease.
Unfortunately, these different classifications of diverticular disease have led to conflicting terminology in current literature. Moreover, none of the classifications seem to sufficiently embrace the entire spectrum of the disease. This calls for a thorough review and a new parameter. The current classifications of diverticular disease are based on clinical, radiological, or operative findings, yet most lack a translation into daily clinical practice. Given a useful classification system ought to guide clinical decision making and management, this review serves to combine the available classifications with current knowledge of practice into a more useful practice parameter for treating diverticular disease.
An extensive literature analysis was performed using the PubMed database. Only a few classifications for diverticular disease were revealed.
In most publications, the results of a clinical study on imaging or treatment modalities are described, and rarely the proposal of a new classification system. A second analysis using manual cross reference search of the bibliographies of relevant articles located studies not found in the first search.
All articles in Diverticulitiw, German, and Dutch have been included. A total of nine classifications and modified classifications for diverticular disease were collected.
A proper classification system can improve mutual communication between doctors of different specialties and support clinical decision making. Uniform classification in clear subgroups of diverticular disease could help the clinician in predicting outcomes and prognosis clasficacion accurately. InHinchey et al. This most widely used classification was actually based on an earlier clinical division of acute diverticulitis published by Hughes et al. Since the introduction of the computed tomography CT scan in the s, this imaging modality has established itself as the primary diagnostic tool in the assessment of diverticular disease see Fig.
The much more detailed information provided by CT scans led earlier to modifications of the original Hinchey classification. Subcategories could be defined by taking the radiological findings into diverticultis. Hence, inSher et al. This modification also implied the use of new treatment strategies, such as Diverticulitid percutaneous drainage of abscesses.
Hughes classification Hughes et al. CT scan images resembling the four Hughes stages.
I Pericolic phlegmon with small associated abscess. II Large intraabdominal abscess. III Small amounts of free air and fluid. IV Massive pneumoperitoneum and free fluid. InWasvary et al. This modification diverticilitis the original Hinchey classification by not only addressing perforated disease, but also including mild clinical disease stage 0.
Additionally, a difference was made between confined pericolic inflammation or phlegmon stage Ia and a confined pericolic abscess stage Ib. These aspects make it probably the most useful classification in clinical practice; however, it has rarely been adopted in international literature. Another German classification published in by Siewert et al.
Each classification accentuates different aspects of diverticular disease, creating its own strength and limitation. One must consider that a large number of patients with complaints of pain in the left lower quadrant, fever, and soiling are probably out of clinical sight, consulting only their general practitioner.
Such complaints are considered to be self-limiting, sometimes assisted by antibiotic therapy. Published data on clinical episodes of diverticulitis do not account for these subjective complaints, leading to an underestimation of the real scale of these mild manifestations of diverticular disease.
Furthermore, limitations uinchey the clinical diagnosis of diverticulitis have to be regarded paea 10 ]. Clinical episodes are characterized by focus on more objective signs, like raised infectious parameters in laboratory tests and typical findings on CT scan or colonoscopy [ 1 ].
Yet, this does not discount the initial subjective complaints. It is the combination of specific symptoms that still form the basis for a differential diagnosis and the indication for additional examinations. For instance, impaired passage of a stool is suggestive for a stenosis, in which a colonoscopy can differentiate between post-diverticulitis stenosis or cancer; diverticular bleeding is the most common cause of recurrent rectal blood loss, but again cancer should be ruled out by a colonoscopy; and pneumaturia is pathognomic for a colovesical fistula, usually a CT scan will reveal its pathway.
Furthermore, a generalized peritonitis is only diagnosed by physical examination. The combination of the following symptoms should be suspected: A CT scan is often mandatory in uncovering its cause and confirming the absolute indication for surgery.
Complications such as stenosis, fistula, or recurrent diverticular bleeding are clear indications for an elective sigmoid resection, but also the prevention of perforated diverticulitis by performing an elective sigmoid resection has been standard policy for several decades.
Review of current classifications for diverticular disease and a translation into clinical practice
Recently, these recommendations have been challenged because new data on the natural history of diverticulitis has shown that most perforations do not occur after recurrences, but at the first attack of acute diverticulitis [ 11 ]. Furthermore, conservative management of recurrent non-perforated diverticulitis is associated with low rates of morbidity and mortality. These new insights resulted in a more individualized and conservative approach to mild diverticular disease, making the extent of subjective complaints even more important [ 212 ].
The original Hinchey classification was based on both clinical and surgical findings. Since then diagnostic tools have widely been improved and new modalities have been developed. The usual tests performed at the acute phase of diverticular disease are the following: Especially when an associated abscess is suspected, a CT scan can be very helpful to demonstrate its presence.
Also, the possibility of direct percutaneous drainage makes it a valuable attribute in the treatment of complicated diverticular disease [ 16 ]. The role of interventional radiology is yet to be determined, occasional successes of highly selective arterial embolization are described [ 17 ]. A colonoscopy is indicated when there is doubt about cancer, persisting or recurrent complaints in the left lower quadrant, and suspicion of a stenosis or recurrent blood loss.
Colonoscopy enables biopsies for histological diagnosis, and cessation of diverticular bleeding may be attempted by endoscopic measures, such as clipping, coagulation, or adrenaline injections [ 18 ]. Routine colonoscopy divulges the majority finds of asymptomatic diverticular disease. In recent years, magnetic resonance imaging MRI has gained popularity, because it lacks the ionizing radiation of a CT scan, yet matches its sensitivity and specificity [ 19 ].
Additional advantages of MRI over CT scan are its better visualization of fistulae and the possibility of virtual colonoscopy, thereby making invasive colonoscopy unnecessary.
To current date, the availability of the MRI and experienced radiologists are often limited and therefore not suitable for routine use. The wide use of CT scans initiated modifications to the Hinchey classification, but also several new radiological classifications for diverticular disease were developed. The publications on the role of CT scans in diverticular disease by Ambrosetti et al.
In this approach, the CT scan provides the physician guidance in the treatment of acute complications, as well as a prognostic factor in the development of chronic complications after a first conservatively treated episode [ 21 ]. The wide spectrum of diverticular disease warrants a differentiated approach to the different manifestations.
Treatment options for mild disease, associated abscesses, perforations, bleeding, and post-inflammatory complications are discussed separately. Also, the role of elective or preventive sigmoid resection will be addressed.
Moderate cases of diverticular disease, such as phlegmon or small abscesses, can be treated conservatively. Initial prescriptions are often antibiotics and an easily digestible diet, although no clear evidence exists for both their beneficial actions.
Preventive measures are thought to be more successful by several authors, high-fiber diet, and prevention of obesity and treatment of comorbidities are the usual ingredients [ 22 — 24 ]. Newer insights into the pathophysiology of diverticular disease, comparable to inflammatory bowel disease, have led to research on the potentials of 5-aminosalicylic acid Mesalazine and probiotics as adjunctive treatments for diverticular disease. This procedure may relieve symptoms or function as a bridge to elective surgery.
Nuevas tendencias en el manejo de la diverticulitis y la enfermedad diverticular del colon
In these severe circumstances, acute surgical intervention is warranted. Several authors clasifiicacion a primary anastomosis a safe option in purulent peritonitis, diverticuliyis or without defunctioning stoma. Even in fecal peritonitis, successful series of primary anastomosis have been published [ 29 diverticulitid.
InMyers et al. Since then, several series have been published, but evidence from a randomized controlled trial is still to be awaited [ 30 ]. Diverriculitis order to prevent complicated disease after two hincuey of acute diverticulitis, it has been considered good practice for years to perform elective sigmoid resection after two episodes of symptomatic diverticulitis and even doing so after one episode in the younger patients [ 31 ].
These recommendations drawn up by the American Society of Colorectal Surgeons in have recently been challenged. It is now thought that after a hhinchey treated episode, diverticular disease usually follows a rather benign course and that complications occur mostly at first presentation [ 103233 ].
Therefore, elective sigmoid resections should be restricted for use in treating complicated disease, such as symptomatic stenosis, fistulas to a hollow organ, or recurrent diverticular bleeding. Furthermore, recent publications on the natural course of diverticular disease suggest applying early elective sigmoid resection in high-risk patients, such as the use of immune suppression therapy, having chronic renal failure, or collagen—vascular diseases.
The management of diverticular disease in young patients remains controversial. A more hazardous course has been suggested. In contrast, opponents account the longer lifespan responsible for more recurrences and complications and thereby a higher cumulative risk of emergency surgery. An individual approach, weighing symptoms and peri-operative risks on a case by case basis, seems the most appropriate policy [ 3435 ].
Since the mids, laparoscopic sigmoid resections for diverticular disease have gained popularity.
Several retrospective series after laparoscopic sigmoid resections suggested improvements in minor complication rates, earlier resumption of food, and shorter hospital stay [ 36 — 38 ]. In Januarythese beneficial effects were confirmed by a randomized controlled trial; the short-term results showed that a laparoscopic approach delivered a significant Therefore, laparoscopic sigmoid resection may well be the procedure of choice for patients requiring elective resection for diverticular disease.