Acute complicated diverticulitis with extraluminal air: is it possible to avoid surgery?

Resumen El mejor entendimiento de la fisiopatología de la diverticulitis aguda como enfermedad “benigna” unido a factores económicos, quirúrgicos y tecnológicos ha llevado en los últimos años a una tendencia menos invasiva en el tratamiento de esta enfermedad. Mientras el manejo de algunas complicaciones de la diverticulitis como el absceso o la peritonitis está bien sistematizado en nuestra práctica habitual, la presencia de aire extraluminal en una tomografía axial computerizada (TAC) en ausencia de peritonitis provoca controversias. Aunque el manejo estándar recomendado por la mayoría de guías clínicas en estos casos sigue siendo la sigmoidectomía, algunos autores han publicado recientemente buenos resultados con un manejo no operatorio basado en reposo digestivo y antibioterapia con o sin drenaje percutáneo en pacientes seleccionados en ausencia de peritonitis difusa. Se ha revisado la literatura existente hasta la fecha con este manejo más conservador. Se han analizado tasas de éxito/fracaso, factores de riesgo asociados a mayor tasa de fracaso, morbimortalidad asociada al fallo y resultados a medio-largo plazo en términos de recurrencia, aportando nuestra propia experiencia. Finalmente se han dado una serie de recomendaciones para el seguimiento de los pacientes con éxito del manejo conservador y se han mostrado una serie de datos a tener en cuenta a la hora de valorar la necesidad cirugía electiva.

How familiar are we with decision-making concerning the treatment of perforation after endoscopic mucosal resection (EMR) in the colon? A case report

Background and study aims We describe a case of perforation after colonic endoscopic mucosal resection (EMR) that was treated conservatively. We would like to highlight the importance of decision-making mainly based on the endoscopist's point of view in combination with the surgical consultation. Although the radiological imaging is always needed, it cannot solely lead to a decision for operation. Intraperitoneal gas in computed tomography is not always associated with a hole in the endoscopic field and could be possibly explained from a “balloon” phenomenon. The amount of extraluminal air after an EMR does not correlate reciprocally with patient's pain after the procedure. Even though perforation is a radiological diagnosis and endoscopists should be aware of the common post-EMR radiological findings, the surgical examination is mandatory and should be coupled with the endoscopic opinion in order to guide appropriately the treatment in patients with acute pain.

Intra-abdominal Infection

The basic principles of rapid diagnosis, timely physiologic support, and definitive intervention for intra-abdominal infections have remained unchanged over the past century; however, specific management of these conditions has been transformed as a result of numerous advances in technology. This review covers clinical evaluation, investigative studies, options for intervention, early source control and duration of antimicrobial therapy, infections of the upper abdomen, infections of the lower abdomen, other abdominal infections, and special cases. Figures show an algorithm outlining the approach to a suspected upper abdominal infection, abnormal abdominal ultrasounds showing calculi in the gallbladder and confirming the diagnosis of acute acalculous cholecystitis, endoscopic retrograde cholangiopancreatographies showing a distal common bile duct stone in acute pancreatitis, extrinsic compression of the common hepatic duct by a stone in the Hartmann pouch, and endoscopic sphincterotomy for acute biliary decompression in acute obstructive cholangitis, air outlining the gallbladder and bile ducts in emphysematous cholecystitis, abdominal and pelvic CT scans showing pancreatic findings graded by Ranson into five categories, a splenic abscess, an inflamed and thickened appendix with surrounding fat stranding, appendiceal perforation and abscess formation, diverticulitis with a small amount of extraluminal air, left lower quadrant fluid collection consistent with peridiverticular abscess, diffuse inflammation and right upper quadrant extraluminal air, and thickening of the colonic wall with both intramural and extramural air, an algorithm outlining the approach to the patient with a suspected lower abdominal infection, upright chest x-ray and abdominal CT scans of patients with sudden-onset diffuse abdominal pain, and an omental (Graham) patch. Tables list diagnostic indicators of upper abdominal pain and fever, comparison of acute cholecystitis and emphysematous cholecystitis, Hinchey system for classification of perforated diverticulitis, Centers for Disease Control and Prevention (CDC) guidelines for diagnosis of pelvic inflammatory disease, and CDC guidelines for antibiotic treatment of pelvic inflammatory disease. This review contains 16 highly rendered figures, 5 tables, and 238 references