Is an emergency room visit warranted for sigmoid colon diverticulitis with a contained perforation and what is the recommended treatment plan?

Emergency Management of Sigmoid Colon Diverticulitis with Contained Perforation

An emergency room visit is absolutely warranted for sigmoid colon diverticulitis with a contained perforation measuring 2.1 x 1.2cm, as this represents a potentially life-threatening condition requiring prompt surgical evaluation and intervention. 1

Assessment and Initial Management

• Immediate evaluation: The contained perforation (2.1 x 1.2cm) represents complicated diverticulitis that requires urgent assessment in an emergency setting
• Initial stabilization:
  • IV fluid resuscitation
  • Broad-spectrum antibiotics covering anaerobes and gram-negative bacteria
  • NPO (nothing by mouth)
  • Pain management
  • Laboratory studies (CBC, CMP, lactate)

Surgical Considerations

The 2020 World Society of Emergency Surgery (WSES) guidelines provide clear direction for this case:

• Surgical consultation is mandatory - The CT finding of a contained perforation measuring 2.1 x 1.2cm indicates complicated diverticulitis requiring surgical evaluation 2
• Surgical approach: For stable patients with contained perforation, surgical resection with primary anastomosis is preferred over Hartmann's procedure (which has a higher mortality rate of 9.4% vs 4.3% for primary anastomosis) 1
• Laparoscopic vs. open approach: Laparoscopic sigmoidectomy may be feasible if:
  • Patient is hemodynamically stable
  • Surgeon has appropriate technical skills and equipment
  • No diffuse peritonitis is present 2

Risk Stratification

The management approach should be tailored based on:

1. Hemodynamic stability: Unstable patients require immediate surgical intervention
2. Extent of peritonitis: Localized vs. diffuse
3. Comorbidities: Multiple comorbidities favor Hartmann's procedure over primary anastomosis 1
4. Size of perforation: The 2.1 x 1.2cm perforation is significant and warrants surgical intervention

Treatment Algorithm

1. If hemodynamically stable with contained perforation:

   • Surgical resection with primary anastomosis (with or without diverting stoma)
   • Consider laparoscopic approach if expertise available

2. If hemodynamically unstable or multiple comorbidities:

   • Hartmann's procedure (sigmoid resection with end colostomy)

3. If severe physiological derangement:

   • Consider damage control surgery with staged laparotomies 2

Common Pitfalls to Avoid

• Delaying surgical intervention: A contained perforation of this size (2.1 x 1.2cm) should not be managed conservatively as it carries a high risk of failure and progression to diffuse peritonitis 1
• Overreliance on conservative management: While some patients with minimal extraluminal gas can be managed non-operatively, a contained perforation of this size has a high failure rate with non-operative management (57-60%) 2
• Attempting laparoscopic approach without adequate experience: This should only be performed by surgeons with appropriate expertise 1

Follow-up Care

• Post-surgical monitoring for complications
• Colonoscopy 6-8 weeks after resolution to rule out malignancy (diverticulitis with abscess has been associated with cancer in 11.4% of cases) 2

This case represents a surgical emergency requiring prompt intervention. The contained perforation significantly increases the risk of progression to diffuse peritonitis, sepsis, and potentially death if not managed appropriately.