Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

WSES/SIS-E/WSIS/AAST/GAIS · 2021 · international

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Authors: Federico Coccolini, Mario Improta, Massimo Sartelli et al.
Title: Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines
Journal: World Journal of Emergency Surgery : WJES, 2021
DOI: 10.1186/s13017-021-00380-1
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC8352154

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Research strategy

- Diagnosis and treatment in immunocompromised patients must be multidisciplinary (GoR moderate based on low LoE). - High clinical suspicion must be kept in the presence of an immunocompromised patient presenting with signs and/or symptoms of possible intrabdominal infection (GoR moderate based on low LoE). - Immunocompromised patients usually do not present specific signs and symptoms. A reliable diagnosis may be reached only by combining signs, symptoms, patient history, and radiological evaluation (GoR moderate based on low LoE). - Clinical signs may not be reliable in immunocompromised patients; the more the immunocompromission, the less the reliability (GoR moderate based on low LoE). - Laboratory tests may not accurately reflect the severity of the clinical condition of the patient immunocompromised (GoR moderate based on low LoE). - Plane radiographs and ultrasound are often not sufficiently sensitive and specific to allow for a definitive diagnosis in immunocompromised patients (GoR moderate based on low LoE). - Contrast-enhanced CT scan, whenever feasible, is the most reliable exam to diagnose intrabdominal disease in immunocompromised patients (GoR moderate based on low LoE). - In the event of diarrhea, with or without acute abdomen, a specific test for Clostridioides difficile and its toxin should be performed (GoR moderate based on low LoE). - Additional microbiologic tests for a specific disease should be performed only if clinically congruent (GoR moderate based on low LoE). - Diagnostic workup for acute abdomen in patients with HIV infection should always consider surgical diseases specifically associated with HIV (i.e., Abdominal tuberculosis, Mycobacterium avium complex infections)GoR moderate based on low LoE

Specific acute abdominal infections in immunocompromised patient

- Neutropenic enteritis and typhlitis have a high mortality rate if misdiagnosed or underestimated; accurate differential diagnosis is mandatory (GoR moderate based on low LoE). - Treatment of neutropenic enteritis and typhlitis should be nonoperative, including broad-spectrum antibiotics and bowel rest. Emergency surgery must be reserved only for those patients presenting with signs of perforation or ischemia (GoR moderate based on low LoE). - A damage control approach in complicated neutropenic enteritis and typhlitis should be adopted in severely sick patients with physiological derangementGoR moderate based on low LoE
- Cytomegalovirus colitis has a high mortality rate if misdiagnosed or underestimated. Accurate differential diagnosis is of paramount importance (GoR moderate based on low LoE). - Treatment of cytomegalovirus colitis should be nonoperative, including antiviral therapy, broad-spectrum antibiotics, and bowel rest. Emergency surgery must be reserved only for those patients presenting with signs of toxic megacolon, fulminant colitis, perforation, or ischemiaGoR moderate based on low LoE
- A damage control approach in complicated cytomegalovirus colitis should be adopted in severely sick patients with physiological derangement (GoR moderate based on low LoE). - No sufficient data exist to indicate whether to perform subtotal or segmental colectomy resecting only the involved colon segment. - Patients with severe Clostridioides difficile colitis who progress to systemic toxicity should undergo appropriate medical treatment and early surgical consultation (GoR moderate based on intermediate LoE). - Resection of the entire colon should be considered in the treatment of patients with fulminant colitis (GoR moderate based on intermediate LoE). - Diverting loop ileostomy with colonic antibiotic lavage is an effective alternative to subtotal colectomy (GoR moderate based on intermediate LoE). - A damage control approach in severe Clostridioides difficile should be adopted in severely sick patients with physiological derangementGoR moderate based on low LoE

In transplanted patients, the epidemiology of acute surgical diseases varies, with gallbladder disease being one of the most common problems after heart and/or lung transplantation and intestinal perforation due to diverticulitis being the most common disease following kidney and liver transplants (GoR moderate based on intermediate LoE).

- Laparoscopic cholecystectomy is feasible and should be preferred whenever possible in transplanted patients experiencing acute cholecystitis (GoR moderate based on intermediate LoE). - Transplanted patients with acute cholecystitis should undergo cholecystectomy as soon as possible after the diagnosis (GoR moderate based on intermediate LoE). - Percutaneous cholecystostomy may be a useful temporary or permanent procedure in patients with acute cholecystitis of both calculous and acalculous origin, who are unfit for surgery (GoR moderate based on intermediate LoE). - Prophylactic cholecystectomy in patients who are candidates for transplantation may be considered in selected patientsGoR weak based on low LoE
- There is no data to recommend conservative treatment of acute appendicitis in transplanted patients. Given the high rate of complicated appendicitis and the good clinical outcomes observed after surgical intervention, operative management may be considered safer (GoR weak based on low LoE). - Transplanted patients with acute appendicitis should undergo appendectomy as soon as possible and usually within 24 h from the diagnosis (GoR moderate based on intermediate LoE). - Laparoscopic appendectomy should be preferred whenever feasible and not contraindicatedGoR moderate based on intermediate LoE
- Acute left side colonic diverticulitis is associated with increased mortality in immunocompromised patients. Accurate diagnosis and follow-up are mandatory in this cohort of patients (GoR moderate based on intermediate LoE). - Kidney and liver transplanted patients, as well as patients on immunosuppressant drugs (chronic steroid/immunosuppressant therapy), have higher incidence and higher severity of acute colonic diverticulitis compared to the general population (GoR moderate based on intermediate LoE). - Transplanted patients admitted for acute uncomplicated colonic diverticulitis may receive a trial of medical therapy with bowel rest, intravenous antibiotics, and supportive care (GoR moderate based on intermediate LoE). - When complicated acute colonic diverticulitis occurs in transplanted patients, or the patients fail to improve with medical therapy, surgical intervention is indicated. It should be performed as soon as possible from the decision to operate (GoR moderate based on intermediate LoE). - Emergency surgery for acute left side colonic diverticulitis is associated with higher mortality and morbidity in immunocompromised patients (GoR moderate based on intermediate LoE). - Hartmann procedure is effective and safe in severely sick immunocompromised patients affected by acute left side colonic diverticulitis (GoR moderate based on intermediate LoE). - Damage control approach is a viable alternative in severely sick immunocompromised patients affected by acute left side colonic diverticulitis in which it is not feasible to achieve complete source control or whenever an abbreviated surgical procedure is required by clinical conditions (GoR moderate based on low LoE) - No sufficient data exist to define conditions for sigmoidectomy and primary anastomosis associated with a diverting ileostomy during emergency surgery for acute colonic diverticulitis in immunocompromised patients. - There are not sufficient data to support a laparoscopic over an open approach in acute complicated diverticulitis in transplanted patients. - Transplanted patients healed from an episode of uncomplicated acute diverticulitis do not require mandatory colic resection but should be advised about the slightly higher recurrence rate compared to the general population (GoR moderate based on intermediate LoE). - Elective sigmoidectomy may be proposed to immunocompromised patients after an episode of complicated acute left-sided colonic diverticulitis treated nonoperatively, especially after a recurrence (GoR moderate based on low LoE). - In transplanted patients, elective sigmoidectomy has a mortality and morbidity rate similar to the general population (GoR moderate based on intermediate LoE). - Patients with chronic kidney disease and/or patients on chronic steroid medication should be advised of the risk of having a more severe acute diverticulitis episode and may benefit from elective colectomy if fit for the procedure (GoR moderate based on intermediate LoE). - Adult polycystic kidney disease patients listed for kidney transplantation and with known diverticular disease should not be offered elective sigmoidectomy as a standard approach (GoR moderate based on intermediate LoE). If living donor transplantation is planned, the possibility of elective laparoscopic sigmoidectomy should be discussed with the patient.

Diagnosis

Diagnosis and treatment in immunocompromised patients must be multidisciplinaryGoR moderate based on low LoE
High clinical suspicion must be kept in the presence of an immunocompromised patient presenting with signs and/or symptoms of possible intrabdominal infectionGoR moderate based on low LoE
Immunocompromised patients usually do not present specific signs and symptoms. A reliable diagnosis may be reached only by combining signs, symptoms, patient history, and imaging evaluationGoR moderate based on low LoE
Clinical signs may not be reliable in immunocompromised patients; the more the immunocompromission, the less the reliabilityGoR moderate based on low LoE
Laboratory tests may not accurately reflect the severity of the clinical condition of the patient immunocompromisedGoR moderate based on low LoE
Plain radiographs and ultrasound are often not sufficiently sensitive and specific to allow for a definitive diagnosis in immunocompromised patientsGoR moderate based on low LoE
Contrast-enhanced CT scan, whenever feasible, is the most reliable exam to diagnose intrabdominal disease in immunocompromised patientsGoR moderate based on low LoE
In the event of diarrhea, with or without acute abdomen, a specific test for Clostridioides difficile and its toxin should be performedGoR moderate based on low LoE
Additional microbiologic tests for a specific disease should be performed only if clinically congruentGoR moderate based on low LoE
Diagnostic workup for acute abdomen in patients with HIV infection should always consider surgical diseases specifically associated with HIV (i.e., Abdominal tuberculosis, Mycobacterium avium complex infections)GoR moderate based on low LoE

Neutropenic enterocolitis

Statements are as follows: • Neutropenic enteritis and typhlitis have a high mortality rate if misdiagnosed or underestimated; accurate differential diagnosis is mandatory (GoR moderate based on low LoE). • Treatment of neutropenic enteritis and typhlitis should be nonoperative, including broad-spectrum antibiotics and bowel rest. Emergency surgery must be reserved only for those patients presenting with signs of perforation or ischemia (GoR moderate based on low LoE). • A damage control approach in complicated neutropenic enteritis and typhlitis should be adopted in severely sick patients with physiological derangementGoR moderate based on low LoE

Cytomegalovirus colitis

Statements are as follows: • Cytomegalovirus colitis has a high mortality rate if misdiagnosed or underestimated. Accurate differential diagnosis is of paramount importance (GoR moderate based on low LoE). • Treatment of cytomegalovirus colitis should be nonoperative, including antiviral therapy, broad-spectrum antibiotics, and bowel rest. Emergency surgery must be reserved only for those patients presenting with signs of toxic megacolon, fulminant colitis, perforation, or ischemia (GoR moderate based on low LoE). • A damage control approach in complicated cytomegalovirus colitis should be adopted in severely sick patients with physiological derangement (GoR moderate based on low LoE). • No sufficient data exist to indicate whether to perform subtotal or segmental colectomy resecting only the involved colon segment.

Clostridioides difficile colitis

Statements are as follows: • Patients with severe Clostridioides difficile colitis who progress to systemic toxicity should undergo appropriate medical treatment and early surgical consultation (GoR moderate based on intermediate LoE). • Resection of the entire colon should be considered in the treatment of patients with fulminant colitis (GoR moderate based on intermediate LoE). • Diverting loop ileostomy with colonic antibiotic lavage is an effective alternative to subtotal colectomy (GoR moderate based on intermediate LoE). • A damage control approach in severe Clostridioides difficile should be adopted in severely sick patients with physiological derangementGoR moderate based on low LoE

Common acute abdominal infections in transplanted patients

In transplanted patients, the epidemiology of acute surgical diseases varies, with gallbladder disease being one of the most common problems after heart and/or lung transplantation and intestinal perforation due to diverticulitis being the most common disease following kidney and liver transplantsGoR moderate based on intermediate LoE

Acute cholecystitis

Statements are as follows: • Laparoscopic cholecystectomy is feasible and should be preferred whenever possible in transplanted patients experiencing acute cholecystitis (GoR moderate based on intermediate LoE). • Transplanted patients with acute cholecystitis should undergo cholecystectomy as soon as possible after the diagnosis (GoR moderate based on intermediate LoE). • Percutaneous cholecystostomy may be a useful temporary or permanent procedure in patients with acute cholecystitis of both calculous and acalculous origin, who are unfit for surgery (GoR moderate based on intermediate LoE). • Prophylactic cholecystectomy in patients who are candidates for transplantation may be considered in selected patientsGoR weak based on low LoE

Acute appendicitis

Statements are as follows: • There is no data to recommend conservative treatment of acute appendicitis in transplanted patients. Given the high rate of complicated appendicitis and the good clinical outcomes observed after surgical intervention, operative management may be considered safer (GoR weak based on low LoE). • Transplanted patients with acute appendicitis should undergo appendectomy as soon as possible and usually within 24 h from the diagnosis (GoR moderate based on intermediate LoE). • Laparoscopic appendectomy should be preferred whenever feasible and not contraindicatedGoR moderate based on intermediate LoE

Patients with HIV/AIDS

Statements are as follows: • HIV infection itself should not guide therapeutic decisions or prognostic counseling in patients with acute abdominal problems since most of the preoperative prognostic factors of HIV patients are similar to those of the general population (GoR moderate based on low LoE). • Patients with HIV should be stratified according to the current stage of the disease and the presence or absence of AIDS-defining conditions, as well as the associated prognostic factors (GoR moderate based on low LoE). • CD4 count and viral load should always be measured in HIV/AIDS patients undergoing emergency abdominal surgery in an attempt to predict a higher rate of postoperative complications (GoR moderate based on intermediate LoE). • HIV-infected patients with normal CD4 count (> 200 cells/mm3) have mortality and morbidity rate similar to the general population (GoR moderate based on intermediate LoE). • Worse perioperative outcomes have been observed in HIV/AIDS patients with lower CD4 count and higher viral load (GoR moderate based on intermediate LoE). • HIV and AIDS patients should continue antiretroviral therapy per os as long as possible when an indication for surgery exist. If suspended, they should resume it as soon as possible after surgical interventionGoR moderate based on intermediate LoE

Perioperative steroid management

Statements are as follows: • In patients currently on steroid therapy or that have been in steroid therapy for the last year, there is no evidence regarding the necessity of the administration of a push-dose steroid in the event of a surgical intervention (GoR moderate based on intermediate LoE). • No sufficient data exist to suggest the suspension of steroid medication before emergency surgery. Patients on steroids should remain on their usual regimen, and the treating physician should be aware of a higher rate of surgical complications when planning the intervention (GoR moderate based on low LoE). • In the event of an inexplicable and fluid unresponsive hypotensive event immediately prior/after/during surgery, adrenal insufficiency should be part of the differential diagnosis and an i.v. push dose of 100 mg hydrocortisone should be administeredGoR moderate based on low LoE

Abstract

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.

This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Contents of the original publication

The section headings of the original.

Introduction
Material and methods
Research strategy
Definitions
Notes on the use of the guideline
Diagnosis
Specific acute abdominal infections in immunocompromised patient
Neutropenic enterocolitis
Cytomegalovirus colitis
Clostridioides difficile colitis
Common acute abdominal infections in transplanted patients
Acute cholecystitis
Acute appendicitis
Acute diverticulitis
Other transplant-related diseases
Patients with HIV/AIDS
Perioperative steroid management
Perioperative and anesthesiologic management
Conclusions
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