What is the recommended management for perforated colonic diverticulitis causing peritonitis without a detectable abscess?

Management of Perforated Diverticulitis Without Abscess

For perforated diverticulitis causing peritonitis without abscess, hemodynamically stable patients with only pericolic extraluminal gas can be managed non-operatively with IV antibiotics and close monitoring, but those with diffuse peritonitis or distant free gas require immediate surgical resection. 1, 2

Initial Risk Stratification

Hemodynamic status determines the entire treatment pathway:

• Immediate surgery is mandatory for patients with hypotension, tachycardia >100 bpm, signs of shock, or diffuse peritonitis on examination 2, 3
• Hemodynamically stable patients without diffuse peritonitis may be candidates for non-operative management only if they have pericolic gas alone 1, 3
• The presence of distant intraperitoneal free gas carries a 57-60% failure rate with conservative management, even in stable patients 1, 3

Non-Operative Management Protocol (Highly Selected Patients Only)

This approach applies ONLY to stable patients with pericolic gas and no diffuse peritonitis:

• Start broad-spectrum IV antibiotics immediately covering anaerobes and gram-negatives (piperacillin-tazobactam 4g/0.5g q6h or ertapenem 1g q24h) 2, 3
• Re-evaluate every 3-6 hours with vital signs, serial labs (WBC, CRP, lactate), and abdominal examination 2, 4
• Persistent tachycardia beyond 24 hours despite adequate resuscitation indicates inadequate source control and mandates surgery 4
• Continue antibiotics for 4-7 days if clinical improvement occurs 3

Critical Pitfall

Do not attempt non-operative management if distant free gas is present—the World Society of Emergency Surgery data show that large amounts of distant intraperitoneal gas are associated with 57-60% failure rates, and nearly 60% of these patients ultimately require surgery anyway 1. You are simply delaying definitive treatment and risking clinical deterioration.

Surgical Management

For patients with diffuse peritonitis, hemodynamic instability, or distant free gas, proceed directly to surgery:

Surgical Options by Patient Stability

• Hartmann procedure (resection with end colostomy, no anastomosis) is the safest option for:

  • Hemodynamically unstable patients 2
  • Multiple comorbidities 2
  • Fecal peritonitis 5
  • Prolonged symptom duration 5

• Resection with primary anastomosis (with or without diverting ileostomy) for carefully selected stable patients 2, 3

• Damage control surgery with staged laparotomies for physiologically unstable patients 3

Evidence Supporting Resection Over Drainage Alone

Historical data demonstrate that colostomy with drainage alone carries 26% mortality versus 7% mortality with colostomy and resection 5. Seven of nine deaths from persistent sepsis occurred in the drainage-only group 5. Operations that resect or exteriorize the perforated segment at the first operation consistently show lower mortality than procedures that leave the perforated segment in place 6.

Monitoring for Treatment Failure

Convert to surgery if any of the following occur within 48-72 hours:

• Clinical deterioration (worsening fever, leukocytosis, abdominal exam) 3
• Development of hemodynamic instability 3
• Persistent tachycardia beyond 24 hours despite adequate fluid resuscitation 4
• Rising lactate or procalcitonin levels 3

Key Clinical Pearls

• Never attribute tachycardia to anxiety or pain in peritonitis—it represents sepsis until proven otherwise 4
• Colonoscopy is absolutely contraindicated during acute diverticulitis as it can convert contained perforation to free perforation; defer 4-6 weeks 3
• Patients with complicated diverticulitis have an 11% risk of underlying colorectal cancer, mandating delayed colonoscopy 1, 3
• Fecal peritonitis, preoperative hypotension, and prolonged symptom duration predict mortality and should lower your threshold for immediate resection 5