Treatment of perforated diverticulitis, Localized > 의학

Localized perforation (ie, abscesses) — Localized perforations present acutely as a mesocolic or pelvic abscess (Hinchey I or II). Hinchey I or II diverticulitis is characterized by one or more localized abscesses in the pericolonic, mesenteric, or pelvic locations. In contemporary practice, diverticular abscesses are typically treated with percutaneous image-guided drainage or with intravenous antibiotics if the abscess is too small (<4 cm) or inaccessible to percutaneous drainage. Surgery may be indicated for patients who deteriorate or fail to improve within two to three days of percutaneous intervention or antibiotic therapy as a persistent intra-abdominal abscess is unlikely to respond to further nonoperative management. (See "Acute colonic diverticulitis: Medical management", section on 'Abscess'.)

Patients with a localized perforation can usually tolerate a preoperative bowel preparation. Thus, if the phlegmon or abscess can be resected with the colonic segment, a primary anastomosis can be performed in these patients. (See 'Colon resection with primary anastomosis' below.)

If there are concerns about either contamination or inflammation involving the surrounding tissue (eg, with a large pelvic abscess) but the bowel is not edematous, a primary anastomosis with or without a protective ostomy, depending upon the condition of the local tissue, can be performed. This is preferred to a Hartmann's procedure as a protective stoma is easier to reverse than an end colostomy with a rectal stump [52,53]. (See 'Primary anastomosis with proximal diversion' above.)

Microperforation — Microperforation, usually indicated by one or a few extraluminal air bubbles on CT images, and phlegmon are not considered complicated diverticulitis and thus can be managed nonoperatively with intravenous antibiotics and bowel rest [10]. (See "Acute colonic diverticulitis: Medical management", section on 'Microperforation'.)

Those with extraluminal air bubbles only on initial CT may develop an abscess on subsequent studies. In one study, the rate was 19 percent [54]. Patients with microperforation and an associated abscess should be treated accordingly as having complicated disease. (See "Acute colonic diverticulitis: Medical management", section on 'Abscess'.)