Hinchey III Diverticulitis in a Steroid-Treated, Obese Patient
Mrs R is 68, with a BMI of 35, and takes prednisolone 15 mg daily for rheumatoid arthritis. She presents with four days of left iliac fossa pain, fever of 38.9 °C and generalised peritonitis. CT shows Hinchey III diverticulitis with free gas and fluid. At laparotomy there is purulent peritonitis with faecal contamination and a perforated sigmoid; the proximal colon is inflamed but viable. After 4 L of crystalloid, 2 units of red cells and three hours of operating, she is on noradrenaline 0.3 µg/kg/min, temperature 35.2 °C, lactate 5.1 mmol/L, and the small bowel is distended and oedematous. She lives independently and has no other comorbidity.
1. Which operation do you perform and why? Address Hartmann's procedure, resection with primary anastomosis and diverting stoma, and laparoscopic lavage.
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The decision hinges on physiology, not on the disease alone She has four independent risk factors for anastomotic failure: high-dose steroid, obesity, faecal contamination with generalised peritonitis, and vasopressor-dependent shock with a lactate of 5.1 and a temperature of 35.2 °C (the beginnings of the lethal triad).
Laparoscopic lavage Excluded. It is for purulent, non-faeculent Hinchey III in a stable patient with no immunosuppression; faecal contamination and shock are contraindications, and it leaves a perforated segment in situ.
Resection with primary anastomosis and diverting ileostomy Oncologically and functionally attractive, but in this physiology the leak rate is unacceptably high. A defunctioning stoma protects against the consequences of a leak but does not prevent the leak.
Hartmann's procedure The safest option: resect the perforated segment, stapled rectal stump, end colostomy. No anastomosis, no leak, short operating time. Take the splenic flexure only if needed for a tension-free stoma.
Practical points
- Give hydrocortisone 100 mg with induction and cover perioperatively for adrenal suppression.
- In this haemodynamic state, consider a damage-control variant: staple the rectal stump and the proximal colon, leave the abdomen temporarily closed, and return in 24–48 hours to mature the stoma once she is warm, perfusing and off vasopressors.
2. Describe your plan for the next 48 hours should you choose a damage-control approach, and when you would consider restoring bowel continuity.
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Immediate postoperative care
- ICU: active warming, balanced crystalloid, blood products to correct coagulopathy (target fibrinogen >1.5 g/L, platelets >50, INR <1.5), calcium replacement, and vasopressors only to a mean arterial pressure of about 65 mmHg.
- Temporary abdominal closure with a negative-pressure dressing; measure intra-abdominal pressure - if it exceeds 20 mmHg with new organ dysfunction, return earlier.
Planned relook at 24–48 hours Criteria to proceed rather than postpone: temperature >35.5 °C, lactate falling and below 2 mmol/L, noradrenaline off or minimal, no ongoing bleeding, and a pH >7.25. At relook: wash out, check the rectal stump and colonic end for ischaemia, mature the colostomy, and close the fascia only if there is no tension and the bowel is not massively oedematous; otherwise continue negative-pressure closure and plan a delayed primary closure or mesh-mediated traction.
Restoring continuity Not in this admission. Steroid use, contamination and critical illness make a reversal at 3–6 months the realistic target: she must be off high-dose steroids, nutritionally replete, and have a colonoscopy (or contrast study) first to exclude a synchronous malignancy - about 3% of emergency resections for presumed diverticulitis harbour a cancer.
3. On day 5 she develops new atrial fibrillation, a rising lactate (from 1.8 to 4.0), a CRP of 320 and increasing abdominal distension. How do you approach this?
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Think anatomically, not just numerically Escalating lactate, CRP and distension after a Hartmann's for faecal peritonitis has a differential that must be ranked by lethality:
- Intra-abdominal collection or residual abscess - commonest; usually a pelvic or left iliac fossa collection.
- Ischaemia of the rectal stump or of the colostomy - pain, rising lactate, bloody rectal discharge; a low threshold for endoscopy or re-look.
- Staple-line blowout of the rectal stump, which behaves like a pelvic perforation.
- Necrotising fasciitis of the laparotomy wound - examine the wound for crepitus, disproportionate pain and skin changes.
- Non-abdominal sources: line sepsis, ventilator-associated pneumonia, Clostridioides difficile, and pulmonary embolism (which also explains the new atrial fibrillation).
Actions
- Blood and urine cultures, wound swabs, rectal stump aspirate, C. difficile testing, chest imaging.
- CT abdomen and pelvis with contrast (she is in ICU; a portable or escorted scan is feasible) - look for gas outside the bowel, a collection, or stump ischaemia.
- A discrete collection → percutaneous drain; free gas, ischaemia or a blowout → return to theatre.
- Do not simply broaden antibiotics and wait; source control is the priority.
- Rate-control the atrial fibrillation and check electrolytes and magnesium, but treat it as a marker of sepsis, not the primary event.