Tratamiento ambulatorio de la diverticulitis aguda no complicada / Outpatient Treatment of Acute Uncomplicated Diverticulitis

Introducción: La diverticulitis aguda es la complicación más frecuente de la enfermedad diverticular del colon y causa de ingresos hospitalarios. Su tratamiento ha sido evaluado en los últimos años y muestra una tendencia a limitar el tratamiento quirúrgico y potenciar el de tipo conservador. Objetivo: Realizar una revisión sobre la aplicabilidad, la seguridad y la eficacia del tratamiento ambulatorio de la diverticulitis aguda no complicada en pacientes seleccionados. Métodos: Se realizó una revisión bibliográfica en fuentes de información disponibles en las bases de datos SciELO, Medline (Pubmed), así como Google académico, donde se escogieron un total de 36 referencias. Desarrollo: Históricamente los pacientes diagnosticados de diverticulitis aguda han sido internados en centros hospitalarios para estudio y tratamiento dietético, antibiótico y analgésico. En los últimos años ha crecido la tendencia en el mundo a tratar estos pacientes de forma ambulatoria una vez comprobado que no se encuentra complicada, lo que ha demostrado con nivel de evidencia, que estos logran presentar una evolución favorable sin necesidad de ingreso, con menos gastos para el sistema de salud. Conclusiones: El tratamiento ambulatorio de la diverticulitis aguda no complicada no solo es eficaz y seguro, sino también aplicable en la mayoría de los pacientes, siempre que toleren la ingesta oral y dispongan de un entorno familiar adecuado(AU)

Introduction: Acute diverticulitis is the most frequent complication of diverticular colon disease and cause of hospitalizations. Its treatment has been assessed in recent years; there is a tendency to limit surgical treatment and promote conservative treatment instead. Objective: To review the applicability, safety and efficacy of outpatient treatment of acute uncomplicated diverticulitis in selected patients. Methods: A bibliographic review was carried out in sources of information available in the SciELO and Medline (Pubmed) databases, as well as in Google Scholar, by means of which a total of 36 references were selected. Development: Historically speaking, patients diagnosed with acute diverticulitis have been admitted to hospitals for study and dietary, antibiotic and analgesic treatment. In recent years, there has been a growing tendency worldwide to treat these patients on an outpatient basis once it has been proven that the condition is not complicated, which has shown, with level of evidence, that patients present a favorable evolution without the need for admission, with less expenses for the health system. Conclusions: Outpatient treatment of acute uncomplicated diverticulitis is not only effective and safe, but also applicable in most patients, given that they can tolerate oral intake and have an adequate family environment(AU)

Safety and effectiveness of laparoscopic peritoneal lavage in Hinchey III diverticulitis / Segurança e eficácia da lavagem peritoneal laparoscópica na diverticulite Hinchey III

Abstract Introduction: The management of Hinchey III diverticulitis has been subject to investigation over the years. Hartmann's procedure is widely referred as the standard treatment. However, this option is associated with relevant morbidity and mortality which motivated the arise of alternative interventions such as the laparoscopic peritoneal lavage. Aim: The aim of this review is to synthesize the evidence on the safety and effectiveness of laparoscopic peritoneal lavage in the management of diverticulitis with generalized purulent peritonitis in comparison to resection procedures. Materials and methods: The bibliographic research was conducted using the electronic database Medline from Pubmed. Of the 358 articles identified, our criterious selection resulted in a total of 27 articles for review. Results: Overall, laparoscopic lavage revealed low mortality rates with no remarkable differences between procedures. The non-randomized studies tended to show lower recurrence and morbidity rates comparatively to the latest RCTs, in the lavage groups, however, no significant differences have been found. Discussion and conclusion: In this review, laparoscopic peritoneal lavage proved to be safe and comparatively effective, although not superior to resection, reaching mixed results. We believe it can be applied as a damage control operation to treat or as a bridge to elective resection. Still, more studies are needed to determine indications and factors for the success of laparoscopic lavage.

Resumo Introdução: O tratamento da diverticulite por Hinchey III tem sido objeto de investigação ao longo dos anos. A operação tipo Hartmann é amplamente referida como o tratamento padrão. No entanto, esta opção está associada à morbilidade e mortalidade relevante, o que motivou o surgimento de intervenções alternativas, como a lavagem peritoneal laparoscópica. Objetivo: O objetivo desta revisão é sintetizar a evidência sobre a segurança e a eficácia da lavagem peritoneal laparoscópica no tratamento da diverticulite com peritonite generalizada purulenta em comparação com os procedimentos de ressecção. Materiais e métodos: A pesquisa bibliográfica foi realizada na base de dados eletrónica Medline da Pubmed. Dos 358 artigos identificados, a nossa seleção criteriosa resultou num total de 27 artigos para revisão. Resultados: No geral, a lavagem laparoscópica revelou baixas taxas de mortalidade sem diferenças significativas entre os procedimentos. Os estudos não randomizados tenderam a mostrar menores taxas de recorrência e morbilidade comparativamente aos últimos ensaios clínicos randomizados, nos grupos submetidos à lavagem, no entanto, nenhuma diferença significativa foi encontrada. Discussão e conclusão: Nesta revisão, a lavagem peritoneal laparoscópica mostrou-se segura e comparativamente eficaz, embora não superior à ressecção, não alcançando resultados constantes. Nós acreditamos que pode ser aplicada como um procedimento de controlo de danos para tratamento ou como ponte para cirurgia eletiva. Ainda assim, são necessários mais estudos para determinar indicações e fatores para o sucesso da lavagem laparoscópica.

Revisión de la clasificación de Hinchey (diverticulitis) y su correlación terapéutica / Hinchey's (Diverticulitis) classification review and it's therapeutic implacations

Resumen La diverticulosis es una entidad que predomina en países occidentales. Su prevalencia aumenta con la edad, presentándose en aproximadamente el 80% de la población mayor de 85 años. Los divertículos colónicos adquiridos son herniaciones saculares de la mucosa y submucosa (pseudodivertículos) y predominan en sigma, en países occidentales; los congénitos poseen las tres capas parietales (divertículos verdaderos) y predominan en colon derecho, en países asiáticos. Aproximadamente un 10%-25% de dichos pacientes con diverticulosis presentarán a lo largo de su vida un cuadro de diverticulitis aguda, representando una de las causas más frecuentes de abdomen agudo (3,8%). Clínicamente, se expresa por dolor abdominal en fosa ilíaca izquierda (excepción en dolicosigma/divertículos congénitos derechos) y pueden presentar complicaciones como flemones, abscesos, pileflebitis, peritonitis, con consiguiente riesgo de vida. La tomografía computada (TC) permite el diagnóstico oportuno, identificación de complicaciones y planificación terapéutica. A dicho fin se establecieron diferentes clasificaciones y modificaciones, siendo la más reconocida la propuesta por Hinchey (modificada por Wasvary y col., Kaiser y col.) y otras estableciendo correlaciones con el tratamiento, como la propuesta por Sartelli y col. El objetivo del presente estudio es realizar una revisión iconográfica de esta última (Sartelli y col.) y evaluar sus implicancias terapéuticas.

Abstract Diverticular disease is an entity with high prevalence in western countries that increases with age, and affects approximately 80% of the population over 85 years of age. Acquired colonic diverticula are saccular mucosal and submucosal herniation (pseudodiverticles) and predominate in sigma, in western countries; the congenital ones possess the three parietal layers (true diverticula) and predominate in right side colon, in Asian countries. Approximately 10%-25% of patients with colonic diverticulosis, in their lifetime will present an episode of acute diverticulitis, which represents one of the most frequent causes of acute abdominal pain (3.8%). Clinically it express by abdominal pain in the left iliac fossa (exception in dolicosigma / right congenital diverticula) and may present complications such as phlegmon, abscesses, pylephlebitis, peritonitis, life threatening conditions. Computed tomography (CT) allows timely diagnosis, identification of complications and therapeutic planning. To this end, several classifications have been used, from which Hinchey's is the most renown (modified by Wasvary et al, Kaiser et al.), and other ones establish therapeutic correlation such as the one proposed by Sartelli et al. The objective of the present study is to make an iconographic review of this last one (Sartelli et al.) and to evaluate its therapeutic implications.

Tomografia computada multidetector en la enfermedad diverticular del intestino delgado / Multislice computed tomography in small-bowel diverticulosis

La enfermedad diverticular del intestino delgado constituye una entidad de rara presentación, que suele confundirse con otras patologías más comunes cuando se complica. Los falsos divertículos son de origen primario o secundario, y asientan mayoritariamente en el duodeno. El divertículo verdadero más frecuente es el de Meckel. Las complicaciones aparecen en menos del 15% de los casos. Entre ellas, se destacan, por frecuencia, la perforación y/o inflamación, la obstrucción, el sangrado, y/o la diarrea crónica. El objetivo de este trabajo es mostrar el rol de la tomografía computada multidetector en el diagnóstico y manejo de la enfermedad diverticular del intestino delgado, exponiendo casos de la práctica diaria con correlato quirúrgico de pacientes evaluados en nuestra institución.

Small bowel diverticula is an uncommon and underdiagnosed pathology. False diverticula may be primary or secondary in origin and are frequently located in the duodenum. Meckel's diverticula is the most common true diverticula. Less than 15% of cases suffer complications, of which the following are, with decreasing frequency: inflammation and perforation, obstruction, bleeding, or chronic diarrhoea. In order to contribute to the best diagnosis and management of small-bowel diverticulosis, cases are presented that were initially evaluated with multislice computed tomography and confirmed surgically in our institution.

Enfermedad diverticular: mitos y realidades / Diverticular disease: myths and realities

Diverticulosis and diverticular disease of the colon are common conditions in Western countries. The incidence and prevalence of these diseases are increasing and becoming significant for health systems. A growing body of knowledge is shifting the paradigm of the pathogenesis and treatment of diverticular disease. Low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to diverticular disease. The risk of developing diverticulitis among individuals with diverticulosis is lower than 10 to 25%. Studies indicate that diverticular disease may become a chronic disorder in some patients, not merely an acute illness. Contrary to the advice from international guidelines, studies have not shown that a high-fiber diet protects against diverticulosis. The evidence about the use of antibiotics in uncomplicated diverticulitis is sparse and of low quality. In relation to surgery, studies support a more conservative approach to prophylactic surgery in patients with recurrent disease or chronic symptoms. Finally, new pathophysiological knowledge suggests that other treatments may be useful (mesalamine, rifaximin and probiotics). However, more research is necessary to validate the safety, effectiveness and cost-effectiveness of these strategies.

Enfrentamiento actual de la enfermedad diverticular complicada. visión del gastroenterólogo / Current approach to complicated diverticular disease by the gastroenterologist

Prevalence of colonic diverticulosis is increasing, although usually asymptomatic. Acute diverticulitis (AD)is the most frequent complications, afflicting 1-2 percent of cases in the long term. Diagnosis and classification of AD can usually be accomplished by simple clinical manifestations and laboratory tests. Ultrasonography and CT scan are the most frequently used imaging tests to confirm diagnosis and detect complications. Modifications to the classical Hinchey classification have incorporated uncomplicated AD (without abscess or perforation), the most frequent presentation, allowing to suggest therapy according to the severity of the disease. Uncomplicated AD usually has a benign course, does not require hospitalization and there is growing evidence suggesting that antibiotics are not required. Recurrence is uncommon and with low risk. The number of recurrences by itself is no more a valid criterion to indicate surgery and most patients should be managed medically, although there are no drugs with proven utility to modify the risk of recurrence. Complicated AD can be managed with intravenous antibiotics and percutaneous drainage of abscesses. Surgery is indicated in case of free perforation or diffuse peritonitis. There is a growing trend to use laparoscopic approach and perform peritoneal lavage, without resection in the emergency setting. However, many patients will require resective surgery during the follow-up. The classical paradigms that have guided the approach to colonic diverticulosis are being challenged by the lack of evidence, but the new ones still have to be constructed. For now, we must tolerate high levels of uncertainty and heterogeneity in the management of this common condition.

La diverticulosis colónica ha aumentado su frecuencia, es generalmente asintomática y se complica entre 1-2 por ciento a largo plazo, siendo la diverticulitis aguda (DA) la complicación más frecuente. El diagnóstico y categorización de la DA puede realizarse en base a las manifestaciones clínicas y exámenes de laboratorio simple. Las imágenes más utilizadas son la ecotomografía y la tomografía computada. Se han sugerido modificaciones a la clásica clasificación de Hinchey, que incorporan la DA no complicada y permiten sugerir la terapia de acuerdo a la gravedad. La DA no complicada (sin absceso ni perforación) es la presentación clínica más frecuente. Su evolución es benigna, no requiere hospitalización y existe evidencia creciente que cuestiona la utilidad de los antibióticos. La recurrencia es infrecuente y de bajo riesgo. El número de recurrencias no es un criterio válido para indicar la cirugía. La DA complicada puede manejarse con antibióticos intravenosos y drenaje percutáneo de abscesos. La cirugía está indicada en caso de perforación libre o peritonitis difusa. Existe una tendencia creciente a realizar aseo por vía laparoscópica, sin resección. La mayor parte de los pacientes con DA complicada requieren cirugía resectiva durante la evolución, mientras que aquellos con DA no complicada son de manejo médico, aunque no existen fármacos con utilidad demostrada para modificar el riesgo de recurrencia. Los paradigmas que han guiado el enfrentamiento de la diverticulosis colónica están siendo cuestionados por la falta de evidencia, por lo que, por ahora, debemos tolerar altos niveles de incerteza y heterogeneidad en el manejo de esta frecuente patología.

Diagnóstico y manejo médico de la enfermedad diverticular complicada / Diagnosis and medical management of complicated diverticular disease

Diverticulosis is a very frequent condition in elderly patients, reaching an incidence of 66 percent among those patients over 80 years old. It is located primarily in the left colon, being the sigmoid colon the most frequent location. The diverticular disease can present complications in different ways: haemorrhage, estenosis, inflammation and infection. The diverticular inflammation or diverticulitis can present a benign and slight course, or present complications. Its course will depend on the inflammation and magnitude of the diverticular perforation. In patients with micro-perforation, the inflammatory reaction is localized in the zone of the affected diverticula. On the other hand, when the patient has a major diverticular perforation, the course of the disease can lead to the formation of abscesses, purulent peritonitis, fecal peritonitis, fistulizations to adjacent organs or estenosis. The preferred diagnosis technique is the abdomino-pelvic CT scan with contrast, which allows the guided drain of collections in some cases. The specific management of complicated acute diverticulitis will depend on the type and location of affectation, requiring surgical treatment in a large number of cases.

La diverticulosis es una condición muy frecuente en pacientes mayores, llegando a una incidencia de 66 por ciento en pacientes mayores de 80 años. Se localiza mayoritariamente en el colon izquierdo, siendo el colon sigmoides la localización más frecuente. La enfermedad diverticular puede complicarse de distintas maneras: hemorragia, estenosis, inflamación e infección. La inflamación diverticular o diverticulitis puede presentar un curso leve y benigno o bien presentar complicaciones. Su curso dependerá del grado de inflamación y magnitud de la perforación diverticular. En pacientes con microperforación la reacción inflamatoria está localizada en la zona del divertículo afectado, en cambio, pacientes con perforaciones diverticulares mayores pueden cursar con formación de abscesos, peritonitis purulenta, peritonitis fecaloídea, fistulizaciones a órganos adyacentes o estenosis. La técnica diagnóstica de elección es el TC de abdomen y pelvis con contraste, el cual permite también el drenaje guiado de algunas colecciones. El manejo específico de la diverticulitis aguda complicada dependerá del tipo de afectación y su localización, requiriendo tratamiento quirúrgico en un gran número de casos.

Diagnóstico e manejo da diverticulite aguda / Diagnosis and management of acute diverticulitis

O presente trabalho destina-se a elucidar o tratamento recomendado para as diferentes fases da diverticulite, assim como também esclarece aspectos da progressão da doença diverticular para o processo inflamatório que ocorre no intestino.

This paper is intended to elucidate the recommended treatment for the different stages of diverticulitis, as well as light aspects of diverticular disease progression to the inflammatory process that occurs in the intestine.

Curso de Atualização em Emergências Médicas: 16: diverticulite aguda / Course of Updating in Medical Emergencies: 16: acute diverticulites

Diverticulite é uma complicação inflamatória aguda dos tecidos peridiverticulares em consequência à perfuração de pseudodivertículos colônicos. A doença diverticulite é a doença colônica mais comum no mundo ocidental. Dois principais fatores estão envolvidos na formação dos divertículos colônicos: uma dieta pobre em fibras e a fragilidade relativa nas áreas de penetração das artérias nutrientes na parede do cólon. Na sua forma complicada - diverticulite - a apresentação mais típica é a dor no quadrante inferior esquerdo (OIE), febre, calafrios e taquicardia. Os autores relata a fisiopatologia, o diagnóstico clínico e o diagnóstico diferencial. Analisam também os exames de imagem utilizados e suas principais indicações, além das complicações e terapêuticas.

Jejunal Diverticulitis

Although uncommon, jejunoileal diverticula are associated with significant morbidity and mortality. Both acute and chronic symptoms can be varied and non-specific, making jejunoileal diverticular disease a diagnostic and therapeutic challenge. We report a case of jejunal diverticular disease, complicated by acute diverticulitis, in a 75-year-old male who was successfully treated with conservative approach. The non-surgical approach was enabled by early assessment with multislice CT and active close observation

Monotherapy with ertapenem versus combined therapy with ceftriaxone/metronidazol for the treatment of acute non-complicated diverticulitis

Background - Acute diverticulitis is the most common complication of diverticular disease. The majority of these patients will require only medical management including bowel rest and antibiotics, whereas some will require surgical treatment. However, the choice of the optimal antibiotic regimen has not yet and antibiotics regimen has not yet been determined. Objective - compare retrospectively a series of patients with diagnosis of non-complicated acute diverticulitis treated by either monotherapy with ertapenm or combined therapy with ceftriaxone/metronidazol / Racional - diverticulite aguda é a mais frequente complicação da doença diverticular. A maioria destes pacientes irá necessitar apenas de tratamento medicamentoso, incluindo descanso intestinal e antibióticos, enquanto que alguns irão necessitar de tratamento cirúrgico. Entretanto, a escolha do melhor antibiótico ainda não está determinada...

Divertículo único do ceco: experiência de um hospital geral brasileiro / Solitary diverticulum of the cecum: experience of a Brazilian general hospital

RACIONAL: A diverticulite cecal é uma condição rara, especialmente em populações ocidentais. Sua importância reside no fato de fazer parte do diagnóstico diferencial da apendicite aguda e do carcinoma ulcerado de ceco. CASUíSTICA E MÉTODOS: Apresenta-se a experiência de um hospital geral do sul do Brasil no tratamento da diverticulite cecal. Descrevem-se quatro casos de divertículo único inflamado de ceco. Um destes teve diagnóstico pré-operatório através de tomografia computadorizada de abdome, tendo o paciente tratado clinicamente com remissão do quadro de diverticulite. Os outros três pacientes foram submetidos a colectomia direita com íleo-transverso anastomose. RESULTADOS: A mortalidade foi nula e nos casos operados não houve complicações pós-operatórias. Quando se consegue obter diagnóstico pré-operatório, pode-se optar por manejo clínico. CONCLUSAO: Recomendamos laparotomia exploradora quando não há certeza diagnóstica. Preconizamos manejo cirúrgico radical quando o diagnóstico é efetuado através de laparotomia.

Tratamiento quirúrgico de la diverticulitis colónica / Surgical treatment of colonic diverticulitis

Antecedentes: La diverticulitis colónica es una enfermedad seria que puede requerir de tratamiento quirúrgico. El diagnóstico y manejo tempranos son necesarios para reducir las cifras de morbimortalidad. Objetivo: Este artículo de revisión se realizó para discutir los avances más recientes en el diagnóstico y manejo de la diverticulitis colónica. Resultados: Los pacientes con diverticulitis aguda deben categorizarse con base en la presencia o ausencia de complicaciones. Los pacientes con diverticulitis complicada deben además categorizarse en I) absceso pericolónico, II) absceso distante (retroperitoneo o pelvis), III) peritonitis purulenta, y IV) peritonitis fecal. En la ausencia de complicaciones, el tratamiento electivo se encuentra principalmente indicado en los pacientes con episodios recurrentes de diverticulitis. En la diverticulitis complicada, las alternativas quirúrgicas dependerán de la categoría clínica. La tendencia actual es intentar un drenaje percutáneo del absceso, seguido por una resección semielectiva. En los pacientes operados de urgencia, una resección con colostomía desfuncionalizante, con o sin anastomosis, es el procedimiento más ampliamente utilizado. Conclusiones: El tratamiento quirúrgico de la diverticulitis aguda dependerá de la presencia de complicaciones y su categoría clínica