Management of Ruptured Diverticula
The management of ruptured diverticula requires prompt surgical intervention with damage control surgery (DCS) and staged laparotomies in hemodynamically unstable patients with diffuse peritonitis due to diverticular perforation. 1
Initial Assessment and Classification
- Ruptured diverticula typically present with abdominal pain (often in left lower quadrant), elevated temperature, tenderness, and signs of peritonitis 1
- CT with IV contrast is the preferred imaging modality to confirm diagnosis and assess severity, showing intestinal wall thickening, signs of inflammation in pericolonic fat, and evidence of perforation (extraluminal gas, intra-abdominal fluid) 1
- Laboratory markers including increased white blood cell count, leucocyte shift to left (>75%), elevated C-reactive protein, and procalcitonin help assess severity 1
Surgical Management for Ruptured Diverticula
For Hemodynamically Unstable Patients:
- Damage control surgery (DCS) with staged laparotomies is recommended for physiologically deranged patients 1
- Initial surgery should focus on source control through limited resection or closure of perforation with temporary abdominal closure 1
- Patient should then be transferred to ICU for physiologic optimization 1
- A second reconstructive operation should be performed 24-48 hours later when the patient is stabilized 1
- This approach has shown to reduce stoma creation rates compared to traditional strategies 1
For Stable Patients:
- Primary resection and anastomosis with or without a diverting stoma is recommended for clinically stable patients without significant comorbidities 1
- Hartmann's procedure (resection with end colostomy) is preferred for patients with multiple major comorbidities 1
Antibiotic Therapy
- Antibiotic therapy should be initiated immediately and continued for 4 days in immunocompetent and non-critically ill patients if source control is adequate 1
- For immunocompromised or critically ill patients, antibiotic therapy should be continued for up to 7 days based on clinical condition and inflammation markers 1
- For patients with inadequate source control or at high risk of infection with ESBL-producing Enterobacterales, ertapenem (1g q24h) or eravacycline (1 mg/kg q12h) is recommended 1
- In septic shock, carbapenems (meropenem, doripenem, imipenem/cilastatin) or eravacycline are recommended 1
Special Considerations
- Laparoscopic approach may be feasible in selected patients with generalized peritonitis but should only be performed by experienced surgeons 1
- Open abdomen approach is recommended only in significantly physiologically deranged patients with ongoing sepsis 1
- Bowel continuity can be restored in approximately 76-84% of patients following damage control surgery 1
Potential Complications and Pitfalls
- Damage control strategy carries risks including formation of entero-atmospheric fistula and high costs 1
- Anastomotic leak rates of approximately 13% have been reported after staged procedures 1
- Mortality rates of approximately 9.8% have been reported in patients with perforated diverticulitis managed with damage control surgery 1
- Patients who have ongoing signs of infection beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1