What is the immediate management for a patient with a perforated sigmoid diverticulum?

Immediate Management of Perforated Sigmoid Diverticulum

For a patient with perforated sigmoid diverticulum, proceed immediately to emergency surgical resection—do NOT insert a nasogastric tube as a primary intervention, as this is a surgical emergency requiring source control through either Hartmann's procedure or primary resection with anastomosis depending on patient stability. 1

Initial Resuscitation and Assessment

• Evaluate hemodynamic stability immediately upon presentation, as unstable patients require aggressive fluid resuscitation and broad-spectrum antibiotics before proceeding to urgent surgery 1
• Assess for peritoneal signs including abdominal tenderness, guarding, and rebound tenderness to determine the urgency and surgical approach 1
• Obtain CT imaging with IV contrast when diagnosis is uncertain or to evaluate for ischemia, though this should not delay surgery in unstable patients 1
• Check lactate levels and blood gas, as these patients may have bowel ischemia even without hyperlactatemia 2

Surgical Management Algorithm

For Hemodynamically Unstable Patients or Feculent Peritonitis:

Hartmann's procedure is the standard approach, involving sigmoid resection with end colostomy 1

• This is indicated for patients with significant comorbidities, hemodynamic instability, or feculent peritonitis 1
• Emergency surgery mortality ranges 12-20%, with surgical site infections being the most common complication 1
• If the patient is in physiological extremis, consider damage control surgery with staged laparotomies—initial surgery focuses on source control (primary closure of perforation or local resection), followed by ICU resuscitation and delayed anastomosis 24-48 hours later 2

For Hemodynamically Stable Patients with Purulent Peritonitis:

Primary resection with anastomosis may be considered in carefully selected stable patients 1

• Observational studies demonstrate a 40% lower mortality compared to Hartmann's procedure (OR 0.60,95% CI 0.38-0.95, p = 0.03) 2, 1
• This approach is only appropriate when the patient is physiologically stable without significant comorbidities 2
• Laparoscopic sigmoidectomy may be performed if technical skills and equipment are available, though evidence remains limited 2, 1

Critical Pitfalls to Avoid

• Never attempt endoscopic intervention in patients with peritoneal signs or frank peritonitis—this is absolutely contraindicated and can convert contained perforation to free perforation 1
• Avoid contrast enema when perforation is suspected, as water-soluble contrast can worsen contamination and barium can cause chemical peritonitis 2, 1
• Do not delay surgery for extensive imaging in unstable patients—clinical assessment and plain radiographs showing free air are sufficient to proceed 1
• NGT insertion is not a primary intervention for perforated diverticulum; it may be placed as part of perioperative management but does not address the surgical emergency

Postoperative Management

• Close ICU monitoring for sepsis and multiorgan dysfunction is essential given the high mortality risk 1
• Continue broad-spectrum antibiotics for a minimum of 7 days, adjusting based on culture results 1