Management of Complicated Diverticulitis
Fistulas occur in 2% of patients with diverticular disease, and they occur when the localized inflammatory process develops into an abscess that then decompresses into an adjacent organ. Most patients with a fistula do not require an emergent intervention because the abscess has decompressed. Abdominal symptoms are infrequent. Recurrent urinary tract infection, dysuria, pneumaturia, and fecaluria suggest a colovesical fistula (CVF) and is the most common type of fistula.19 The poppy seed test is reported to have a sensitivity of 95% to 100% in diagnosing CVF. This involves oral intake of 50 g of poppy seeds mixed in a beverage or yogurt and visual inspection of the urine for 48 hours. Detection of poppy seeds in the urine confirms the diagnosis. Endoscopy of the colon and bladder is of limited value in diagnosing a CVF; its main value is in ruling out malignant disease. Cystoscopy provides additional information about the location of the fistula in relation to the ureteral orifices. At the definitive operation, resect the sigmoid colon (as described in J. Definitive Resection), excise the bladder fistula, close the defect in two layers, and perform a primary colorectal anastomosis. Interpose the omentum between the colon and the bladder. The bladder should be drained with a Foley catheter for 7 days. Colovaginal fistulas occur almost exclusively in women who have undergone previous hysterectomy and frequently seen by a gynecologist with a complaint of vaginal discharge and passing gas per vagina. After a screening colposcopy to rule out cancer, a single-stage sigmoid resection is performed, with pinching of the site of the fistula and interposing omentum. A colocutaneous fistula rarely occurs de novo and is generally seen in patients with a previous incomplete sigmoid resection or a PCD.
Strictures generally occur after multiple attacks of diverticulitis and account for approximately 10% of large-bowel obstructions. Small bowel can become an adherent inflamed stricture, leading to small-bowel obstruction. Treatment depends on whether the obstruction is partial or complete. Partial obstruction can resolve with bowel rest, intravenous hydration, and antibiotics, with a delayed definitive resection. Complete obstruction can cause significant dilation in the proximal colon, and this creates a problem when trying to create a colorectal anastomosis. The HP is therefore performed. One recent alternative is to use a colonic stent and allow the compression of the bowel and then perform a delayed one-stage sigmoid resection. Because the strictures tend to be longer and more angulated than cancer, a stenting diverticular stricture is technically difficult and the stents often migrate. This should be embarked on with caution. In patients who are physiologically deranged, the other option is to perform a proximal decompressive colostomy, allow the patient to stabilize, do a colonoscopy to rule out cancer, and then perform a delayed one-stage resection.