Management of Ruptured Diverticula

Initial Assessment and Classification

Ruptured diverticula typically present with abdominal pain, elevated temperature, tenderness, and signs of peritonitis in patients with diverticular perforation 3
CT with IV contrast is the preferred imaging modality to confirm diagnosis and assess severity, showing intestinal wall thickening, signs of inflammation in pericolonic fat, and evidence of perforation in patients with suspected ruptured diverticula 3
Laboratory markers including increased white blood cell count, leucocyte shift to left, elevated C-reactive protein, and procalcitonin help assess severity of diverticulitis in patients with ruptured diverticula 3

Damage control surgery with staged laparotomies is recommended for hemodynamically unstable patients with diffuse peritonitis due to diverticular perforation, according to the World Journal of Emergency Surgery 1, 2
Initial surgery should focus on source control through limited resection or closure of perforation with temporary abdominal closure in hemodynamically unstable patients with ruptured diverticula 1
A second reconstructive operation should be performed 24-48 hours later when the patient is stabilized, reducing stoma creation rates compared to traditional strategies in patients with ruptured diverticula 1, 2
Primary resection and anastomosis with or without a diverting stoma is recommended for clinically stable patients without significant comorbidities, according to the World Journal of Emergency Surgery 3

Antibiotic therapy should be initiated immediately and continued for 4 days in immunocompetent and non-critically ill patients with ruptured diverticula if source control is adequate 3
For immunocompromised or critically ill patients with ruptured diverticula, antibiotic therapy should be continued for up to 7 days based on clinical condition and inflammation markers 3

Laparoscopic approach may be feasible in selected patients with generalized peritonitis due to ruptured diverticula but should only be performed by experienced surgeons, according to the World Journal of Emergency Surgery 2, 4
Open abdomen approach is recommended only in significantly physiologically deranged patients with ongoing sepsis due to ruptured diverticula 1, 2
Bowel continuity can be restored in approximately 76-84% of patients following damage control surgery for ruptured diverticula 1

Damage control strategy carries risks including formation of entero-atmospheric fistula and high costs in patients with ruptured diverticula 1, 2
Anastomotic leak rates of approximately 13% have been reported after staged procedures in patients with ruptured diverticula 1
Mortality rates of approximately 9.8% have been reported in patients with perforated diverticulitis managed with damage control surgery 1

Early colonic evaluation is recommended for patients with diverticular abscesses treated non-operatively to rule out underlying malignancy, according to the World Journal of Emergency Surgery 5
Routine colonoscopy is not necessary for patients with CT-proven uncomplicated diverticulitis treated non-operatively 5, 6