Failure of Conservative Treatment of Acute Diverticulitis with Extradigestive Air.

Abstract

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. 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. 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) ≥150mg/mL was associated with a higher rate of failure (p=0.021), but it was not confirmed in multivariate analysis. Pneumoperitoneum ≥5mm 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 >5mm (OR 5.193; p=0.015) and peritoneal fluid location in the pouch of Douglas (OR 4.103; p=0.036). The severity of sepsis (tachycardia and CRP ≥150mg/mL) and of imaging signs (pneumoperitoneum ≥5mm 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.