Effectiveness of clinical guidelines in the management of acute sigmoid diverticulitis Results of a prospective diagnostic and therapeutic clinical trial.

BACKGROUND: Evidence-based criteria in the therapeutic choice for sigmoid acute diverticulitis (AD) are lacking. It is necessary to differentiate an acute episode of diverticular disease, not complicated (NCAD) and complicated (CAD) because these stages of diverticular disease needs different approach. METHODS: In a prospective study on 377 consecutive patients admitted for AD, 265 had NCAD and 112 CAD diagnosed with CT scan. Thirty-six of 265 with NCAD were operated on due to two or more previous episodes of AD. On 188 patients with NCAD followed-up, 35 had further episodes of NCAD and 2 had CAD. On 112 CAD patients, 61 had Hinchey I and were submitted to colonic resection. Twenty-three of 24 patients with Hinchey II were treated with percutaneous drainage. All Hinchey II patients were operated on. All the 13 patients with Hinchey III and IV had emergency surgery. RESULTS: We had no mortality and respectively 9.8% and 30% morbidity in Hinchey I and II patients. In Hinchey II patients percutaneous drainage was successful in 21 on 23 (91.3%). In 13 Hinchey III and IV patients the mortality rate was 25%. The comparison of CT findings and pathological results showed a sensitivity of 100% and predictive positive value of respectively 94.4, 96.7, 100 and 100% for NCAD, Hinchey I, Hinchey II and Hinchey III-IV. CONCLUSIONS: The therapeutic approach of diverticular disease needs to differentiate among an acute episode, NCAD and CAD. Evidence-based therapeutic choices can be reached only by homogeneous diagnostic criteria obtained by CT scan.