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Failure of Conservative Treatment of Acute Diverticulitis with Extradigestive Air
P A Colas1,2, E Duchalais3, Q Duplay1,2
1Department of Visceral Surgery, University Hospital of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
Background:
Medical management for perforated diverticulitis without abscess or peritonitis (PDwAP) has a success rate of 40-70%. Identifying patients with a risk of medical treatment failure would improve outcomes. The aim of this study was to identify the risk factors for failure of medical treatment in patients admitted with PDwAP.
Methods:
This multicenter retrospective observational study included all consecutive patients admitted for PDwAP and not surgically treated over a 7-year period. Peritonitis classified on the Hinchey scale was excluded. Potential clinical, biological and radiological risk factors for medical treatment failure were collected and compared between the group of patient with a failure of medical treatment (F) and the group in which treatment did not fail. Data were collected at referral.
Results:
Ninety-one patients were included, and 29 had a failure of treatment (31.9%). The median heart rate was different between the two groups (p < 0.001), at approximately 100/min in the F group. A blood level of C-reactive protein (CRP) ≥150 mg/mL was associated with a higher rate of failure (p = 0.021), but it was not confirmed in multivariate analysis. Pneumoperitoneum ≥5 mm and intraperitoneal liquid located in the pouch of Douglas were more likely to be present in the F group (respectively, p = 0.001 and p < 0.001). A multivariate analysis showed independent risk factors as being the highest pneumoperitoneum diameter >5 mm (OR 5.193; p = 0.015) and peritoneal fluid location in the pouch of Douglas (OR 4.103; p = 0.036).
Conclusion:
The severity of sepsis (tachycardia and CRP ≥150 mg/mL) and of imaging signs (pneumoperitoneum ≥5 mm and peritoneal fluid in the pouch of Douglas) were risk factors for medical treatment failure of PDwAP requiring special supervision so as not to lose time in undertaking surgical management.
Insights
Identifying risk factors for medical treatment failure in perforated diverticulitis without abscess or peritonitis (PDwAP) is crucial. Key indicators include significant pneumoperitoneum and fluid in the pouch of Douglas, guiding timely surgical intervention.
Area of Science:
- Gastroenterology
- Surgical Gastroenterology
- Emergency Medicine
Background:
- Medical management for perforated diverticulitis without abscess or peritonitis (PDwAP) has variable success rates (40-70%).
- Identifying patients at risk for medical treatment failure is essential for improving outcomes.
- This study aimed to pinpoint risk factors for medical treatment failure in PDwAP admissions.
Purpose of the Study:
- To identify clinical, biological, and radiological risk factors associated with medical treatment failure in patients diagnosed with perforated diverticulitis without abscess or peritonitis.
- To improve patient outcomes by enabling earlier surgical intervention when medical management is likely to fail.
Main Methods:
- A multicenter retrospective observational study was conducted over seven years.
- Included were consecutive patients admitted for PDwAP who did not undergo immediate surgical treatment (excluding Hinchey stage III/IV peritonitis).
- Clinical, biological (e.g., C-reactive protein), and radiological data (e.g., pneumoperitoneum size, fluid location) were collected and compared between treatment failure and success groups.
Main Results:
- Of 91 patients, 29 (31.9%) experienced medical treatment failure.
- Higher median heart rate (approx. 100/min) and C-reactive protein (CRP) ≥150 mg/mL were observed in the failure group, though CRP was not significant in multivariate analysis.
- Significant independent risk factors identified via multivariate analysis included pneumoperitoneum diameter >5 mm (OR 5.193) and peritoneal fluid in the pouch of Douglas (OR 4.103).
Conclusions:
- Tachycardia and elevated CRP indicate sepsis severity, while significant pneumoperitoneum and fluid in the pouch of Douglas are key imaging indicators of potential medical treatment failure in PDwAP.
- These identified risk factors necessitate close supervision and prompt consideration of surgical management to avoid delays.
- Early recognition of these risk factors can optimize treatment strategies for PDwAP.
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