From conservative treatment to Hartmann’s procedure: a case of complicated acute diverticulitis

Abstract

INTRODUCTION: Diverticulosis is characterized by the presence of colonic diverticula, acquired sac-like structures caused by herniation of the mucosa and submucosa through weak points in the muscular layer of the colon, generally where the vasa recta penetrate. It is a common colonoscopic finding and predominates in the sigmoid colon. Inflammation or infection of one or more diverticula is termed diverticulitis, which may be classified as uncomplicated or complicated; complicated forms are associated with abscesses, fistulas, intestinal obstruction, or free perforation. An estimated 20% of patients with diverticulosis develop symptomatic diverticulitis during their lifetime. Major risk factors include advanced age, obesity, smoking, and unhealthy dietary habits. Acute diverticulitis typically presents with left-sided abdominal pain and localized tenderness, generally accompanied by fever and leukocytosis. CASE REPORT: A 73-year-old man was admitted with left iliac fossa pain, fever (38.9°C), and a three-day history of diarrhea. Abdominal computed tomography showed diverticula in the descending and sigmoid colon, with mural thickening and pericolic fat stranding consistent with diverticulitis. Laboratory tests showed leukocytosis and elevated C-reactive protein. Hinchey Ia acute diverticulitis was diagnosed, and conservative treatment with antibiotics (ceftriaxone, metronidazole, and piperacillin–tazobactam) was initiated. Because of clinical deterioration, hemodynamic instability, and suspected complications, left colectomy with Hartmann’s procedure was indicated (Hinchey II). Days later, the patient developed stomal necrosis and underwent exploratory laparotomy, completion colectomy, end ileostomy, and peritoneal lavage. Clinical stabilization followed the procedure, although orotracheal intubation and admission to the intensive care unit were required. DISCUSSION: Diverticulitis is a common complication of diverticulosis and may have a variable clinical course. This case shows progression from an initially mild condition to a complicated form requiring multiple surgical interventions. This course highlights the importance of early diagnosis, close clinical monitoring, and timely intervention, especially in older patients.