Complications of diverticular disease of the colon in young people

The timing of elective colectomy in diverticulitis: a decision analysis

BACKGROUND

Determining the optimal strategy for elective colectomy in patients with diverticular disease involves a balance of the morbidity, mortality, costs, and quality of life associated with both elective and expectant management. We used decision and cost analysis to simulate the clinical and economic outcomes after recovery from an episode of nonsurgically treated diverticulitis to determine the preferable management strategy.

STUDY DESIGN

A Markov model was constructed to evaluate lifetime risks of death and colostomy, care costs, and quality of life associated with elective colectomy after subsequent episodes of diverticulitis. The analysis was from the payer's perspective, using hypothetical cohorts of 35- and 50-year-old patients who recovered from a nonsurgically treated diverticulitis episode. Probabilities of clinical events and costs for the base-case analysis were derived from a large cohort using a statewide administrative database and published estimates.

RESULTS

Performing colectomy after the fourth rather than the second episode in patients older than 50 years resulted in 0.5% fewer deaths, 0.7% fewer colostomies, and saved US 1,035 dollars per patient. In younger patients, performing colectomy after the fourth episode compared with the first episode resulted in 0.1% fewer deaths, 2% fewer colostomies, and saved US 5,429 dollars per patient. Expectant management through three recurrent episodes with elective colectomy after the fourth episode was the dominant strategy across the full range of the variables tested in the sensitivity analysis compared with earlier intervention.

CONCLUSIONS

This study suggests that expectant management is associated with lower rates of death and colostomy and is cost-saving for both younger and older patients.

Medical treatment of diverticular disease

The medical treatment of diverticulitis is discussed, including its incidence, stages, and presentation, as are the antibiotic and dietary therapies currently recommended for this disease. Because diverticulitis can be a challenge to treat, several pitfalls are listed in this discussion, including diverticulitis in the immunocompromised, in the young, and in patients who do not have true diverticulitis but who present with some signs and symptoms of the disease.

Diverticular disease of the colon

Colonic diverticulosis refers to small outpouchings from the colonic lumen due to mucosal herniation through the colonic wall at sites of vascular perforation. Abnormal colonic motility and inadequate intake of dietary fibre have been implicated in its pathogenesis. This acquired abnormality is typically found in developed countries, and its prevalence rises with age. Most patients affected will remain entirely asymptomatic; however, 10-20% of those affected can manifest clinical syndromes, mainly diverticulitis and diverticular haemorrhage. As our elderly population grows, we can anticipate a concomitant rise in the number of patients with diverticular disease. Here, we review the incidence, pathophysiology, clinical presentation, and management of diverticular disease of the colon and its complications.

Diverticulitis in the younger patient

BACKGROUND

The purpose of this study was to examine the presentation of diverticulitis at an urban county hospital serving predominantly indigent patients and to analyze the differences, if any, in presentation and treatment in younger patients.

METHODS

A retrospective review of medical records from 1995 to 2001 was performed at a single institution to identify patients admitted to the surgical service with the diagnosis of diverticular disease. Inclusion criteria were either diverticulitis confirmed at operation or radiographic findings consistent with the disease. Patient demographics, history, pertinent physical findings, and treatment were recorded. The data were analyzed after dividing the patients into two populations: a younger population 50 years of age or less, and a second population of patients older than 50.

RESULTS

During the interval, a total of 64 patients were admitted to the surgical service with the diagnosis of diverticulitis. The mean age of this population was 45.5 years (range 21 to 86). Forty-six patients were under 50 years of age (72%). Analysis of sex differences, type and timing of surgical procedure, and complication rate with respect to age showed no significant difference between the two age groups.

CONCLUSIONS

We are clearly treating a younger patient population than previous reports on patients with diverticulitis. Although there was a trend toward increased surgical intervention in the younger population, this number did not reach statistical significance. Diverticulitis in young patients at our institution does not appear to take a more aggressive course than the same disease in older patients.

Acute Diverticulitis in the Young Adult is Not “Virulent”

Acute diverticulitis historically has been considered rare before the age of 40 but “virulent” when it does occur and frequently requiring emergency operation. Recent experience suggests that the demographics and management of this disease are changing. Outcomes at Kaiser Permanente Los Angeles Medical Center were reviewed. Between January 1997 and July 2001 261 patients were discharged with the diagnosis of acute diverticulitis; 46 or 18 per cent of these were aged ≤40. Patients' mean age was 35, 76 per cent were men, 65 per cent were Latino, and 72 per cent were obese (body mass index ≥30 kg/m2). An operation at initial presentation was performed on 35 per cent (16/46) patients. Only 19 per cent of these (3/16) had a correct preoperative diagnosis. The 30 patients who were treated nonoperatively all were managed successfully; one required a percutaneous drain. Given the apparent increasing frequency of acute diverticulitis in young adults and the high success rate of initial nonoperative management surgeons should consider this diagnosis in selected patients who present with abdominal symptoms. Knowledge of typical clinical features and judicious use of computed tomography may decrease the number of unnecessary emergency operations in young adults with acute diverticulitis. Our data do not support a “virulent” label for this disease in the young.

Diverticular disease in adolescence

Diverticular disease is rare in the adolescent. Acute diverticulitis is almost never considered as a diagnosis for a young patient presenting with abdominal pain. Unfortunately, unrecognized it may be associated with significant morbidity and mortality. Also, when present, diverticulitis in the young adult is considered to be more aggressive compared to diverticulitis in older adults. Therefore, it is important to recognize, diagnose and manage diverticular disease appropriately in this age group. In tis chapter we will review the available literature on diverticula disease in the adolescent and young adult, discuss epidemiology, aetiology and pathogenesis and suggest guidelines for diagnosis and management.

Clinical features and differential diagnosis of diverticular disease

Colonic diverticulosis occurs in the majority of Western populations with age, but only a small proportion of people experience symptoms. Diverticular disease usually presents with either haemorrhage or diverticulitis. A quarter of patients with diverticulitis will develop complications including perforation, fistulation, obstruction or stricture. This chapter deals with the natural history, risk factors, clinical features and differential diagnoses of symptomatic diverticular disease.

Complicated diverticulosis

"Uncomplicated" diverticulitis can be prevented from progressing into "complicated" diverticulitis by early diagnosis and active medical treatment. Complicated diverticulitis develops from a peridiverticular abscess, to a perforation with peritonitis, to fistulation into adjacent viscera, to luminal narrowing by inflammation or stricture formation causing obstruction. Computer tomography (CT) scanning is the diagnostic imaging modality when diverticulitis is suspected and allows percutaneous drainage of peridiverticular abscesses that will enhance the effect of antibiotic therapy with resolution of the acute episode in 75% of patients. Thus, an emergent or urgent operation is converted to an elective operation and a two-stage operative procedure, namely a temporary stoma and a second operation, is avoided. Interventional surgery is urgent for perforation and obstruction. While a Hartmann's resection and temporary colostomy has been the favoured operative procedure, under favourable conditions resection with primary anastomosis is preferable. Although a temporary stoma may be required with primary anastomosis, and hence the procedure is a two-stage one similar to a Hartmann's, the closure of the stoma is less demanding and has a lower morbidity. A single-stage resection and anastomosis is the standard elective treatment for symptomatic fistulas and strictures.

Epidemiology of diverticular disease

Diverticulosis, which is an acquired condition marked by mucosal herniation through defects in the colonic wall, has been termed both a "disease of the 20th century" and a "disease of Western civilization" due to its increasing prevalence in modern times and its striking geographical variability. Both of these epidemiological observations may provide interesting insights into the pathophysiology of diverticulosis. This chapter will review the known epidemiology of diverticulosis coli and its main complications: diverticulitis and diverticular haemorrhage. Where possible, attempts will be made to place these observational reports in the context of both the cause and clinical behaviour of this disorder.

Diverticulitis in the Young Patient

Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center—Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16–40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3–14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.

New developments and concepts in antimicrobial therapy for intra-abdominal infections

Antimicrobial therapy plays an integral role in the management of intra-abdominal infections. Recent developments include increased prevalence of antimicrobial resistance (eg, Streptococcus pneumoniae and Enterococcus species) coupled with general decline in the antimicrobial susceptibility of anaerobes and gram-negative organisms, new antibiotics and dosing regimens, and better understanding of the role of various microbial pathogens and of prophylactic antimicrobial agents. Therapeutic approaches to intra-abdominal infections, such as the various forms of peritonitis, cholecystitis, cholangitis, and diverticulitis, are reviewed here. Specific recommendations for antimicrobial therapy in various clinical settings are provided, with special emphasis on recent trends and developments that reflect changes in understanding or therapy.

Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Surgical Management of Diverticulitis

Diverticular disease, and particularly diverticulitis, has an increasing incidence in Westernized countries because of low-fiber diet. Diverticular disease may be classified as asymptomatic, atypical, acute or uncomplicated, and complicated. Conservative or medical management is usually indicated for acute or uncomplicated diverticulitis, with elective surgical resection generally being recommended after two documented episodes. Complicated diverticulitis, because of the high rate of recurrent problems, is generally managed promptly with sigmoid resection. Sigmoid resection for diverticulitis, under appropriate circumstances, has one of the highest success rates of any of the common gastrointestinal procedures.

Same Admission Colon Resection with Primary Anastomosis for Acute Diverticulitis

Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate.

Diverticular disease of the colon

Diverticular disease of the colon is quite common in developed countries, and its prevalence increases with age. Although present in perhaps two thirds of the elderly population, the large majority of patients will remain entirely asymptomatic. Nonetheless, an estimated 20% of those affected may manifest clinical illness, mainly diverticulitis, with its potential complications of abscesses, fistulas, and obstruction, as well as lower intestinal hemorrhage. The purpose of this report is to review our understanding of the epidemiology, pathophysiology, clinical presentation, and treatment options for this disorder.

Natural history of diverticular disease: when to operate?

PURPOSE

The natural history of patients admitted because of acute diverticulitis is largely unknown, and the selection of patients for surgical treatment varies notably. This study presents our experience concerning the outcome for 366 patients admitted during a 10-year period.

METHODS

Three hundred sixty-six patients admitted to our hospital with acute diverticulitis from 1981 to 1990 were identified from a computer database, and their clinical data up to the end of 1996 were reviewed from the database and patient records.

RESULTS

There were significantly more males than females in the age group less than 50 years old, and young males underwent surgical treatment during the first treatment period more frequently than the others. Young patients were operated on without mortality, and all their temporary colostomies were closed. Older patients died more often of diseases unrelated to the diverticular disease during the years after the first episode of acute diverticulitis. Recurrences of diverticular disease developed in 22 percent of patients, and they were significantly more common in patients less than 50 years old than in the older age groups. Males less than 50 years old more often developed complications of diverticular disease after two hospital admissions.

CONCLUSIONS

Males first admitted when less than 50 years of age undergo more primary operations and develop more recurrences of diverticular disease than do older people. Based on our data, however, we recommend surgery for all patients after two episodes of acute diverticulitis that resolves after conservative treatment with antibiotics.

Medical versus surgical management of diverticulitis in patients under age 40

BACKGROUND

Diverticulitis in patients under age 40 is a distinct entity. We compared the medical versus surgical management of diverticulitis for complications and outcomes in these patients.

METHODS

A retrospective review was performed for treatment, hospitalizations, complications, and outpatient visits. Complications included readmission, recurrent symptoms after antibiotic therapy, and postoperative problems.

RESULTS

Twenty-nine patients had a radiographic or surgical diagnosis of diverticulitis (18 surgical, 11 medical). Medically managed patients had significantly more emergency department visits (4.7 +/- 6.6 versus 0.3 +/- 0.6, P < or =0.01), and readmissions (7 versus 4, P < or =0.02). Three surgical patients (17%) had a total of 6 complications as compared with 6 medical patients (55%) with 25 complications (chi square, P < or =0.05). All medically treated patients had recurrent symptoms, and 6 required surgery.

CONCLUSION

Medically managed patients had significantly more emergency department visits and complications than those managed surgically. Surgery is the indicated treatment for the first episode of diverticulitis in patients under age 40.

Acute colonic diverticulitis in the young

BACKGROUND

Colonic diverticulitis in the young has been considered to have a virulent course, high morbidity, and high operative rate. As a result, elective resection of the involved colonic segment after the first clinical episode has been the usual practice.

PURPOSE

This study presents our experience with acute diverticulitis in the young.

METHODS

In the last nine years, 63 patients younger than 45 years were treated for acute diverticulitis at our institution. A retrospective review was performed to determine the clinical course and outcome of these patients.

RESULTS

Clinical presentations, radiographic tests, operative findings, and pathology results revealed that 57 patients had a pericolonic contained disease (Hinchey State I). Two patients had a large pelvic abscess (Hinchey Stage II), and four patients had a diffuse peritonitis (Hinchey Stage III). Forty-one patients (65 percent) were successfully treated medically with antibiotics and bowel rest. Of 22 patients (35 percent) who underwent emergent operations, 12 patients' diseases had been erroneously diagnosed preoperatively (9 "appendicitis").

CONCLUSION

Diverticulitis at a young age does not have a specific aggressive nature. Although, it is associated with a high rate of emergency operations, many of these are performed for a mistaken diagnosis. The recommendation for routine elective resection following the first episode of diverticulitis should be reassessed.

Long-term management of diverticulitis in young patients

PURPOSE

This study was designed to determine the natural history of documented diverticulitis that resolves after treatment with intravenous antibiotics and bowel rest in patients under the age of 50.

METHODS

Records of 40 patients aged 50 or under who were hospitalized with the diagnosis of acute diverticulitis between 1980 and 1984 were reviewed to obtain data regarding how the diagnosis was made. Patients successfully treated with antibiotics were contacted five to nine years after their attack and surveyed via telephone questionnaire about symptoms, recurrent attacks, and surgical interventions.

RESULTS

A total of 40 patients were included in the study. Ten patients (25 percent) required surgery during initial admission, and 30 patients were discharged with resolution of their symptoms after treatment with intravenous antibiotics and bowel rest. A five-year to nine-year follow-up was obtained on patients treated medically, one-third of whom underwent operation for diverticulitis during this period, and two-thirds of whom did not require surgery during the follow-up period. All operations were elective with single-stage resections.

CONCLUSION

Based on our data, we do not recommend surgery in this population after a single episode of diverticulitis that resolves after treatment with antibiotics.

Acute diverticulitis in young adults

Diverticular disease of the colon is generally considered a disease of older patients, rarely causing symptoms before age 40. Two recent cases of ruptured sigmoid diverticulitis in young female patients presenting to our Emergency Department prompted a review of the literature on this topic. Diverticulitis is more common in patients under 40 than previously suspected. Presented are the two cases and a brief summary of the literature review.

Acute diverticulitis under age forty

Acute diverticulitis in the young is increasingly common and is not confined to a particular ethnic or socioeconomic group. The majority of cases are in men and occur in the fourth decade of life. Obesity is the major comorbid condition. The disease appears to be an early manifestation of that seen in the elderly based on identical anatomy and histology. The high incidence of surgical intervention and the high incidence of emergent or urgent intervention, particularly following the initial attack, suggests that this manifestation is a more virulent form of the disease. Because of this, any patient under age 40 should undergo resection following the first documented attack of acute diverticulitis.

Uncomplicated diverticulitis. Indications for surgery and surgical management

Diverticulosis is a disease of modern civilization. Complications may develop, the most common being acute diverticulitis. Repeated attacks, particularly those requiring hospitalization, strongly suggest the need for elective surgical resection of the involved colon. Young persons and patients who are immunocompromised require a particularly aggressive surgical approach. Elective resection is considerably safer than emergency operation. Defining which persons will benefit from surgical therapy is the goal to minimize the morbidity and mortality associated with this common colonic disorder.

Surgery for complicated diverticulitis

The surgical treatment of acute, complicated diverticulitis remains controversial. No randomized studies have been performed to clarify which operative procedure best fits each situation. As a result, the surgeon must use accumulated knowledge and judgment to make the correct decisions for an individual patient. The morbidity and mortality of patients with complicated diverticular disease in 1993 depend, not so much on the operative procedure, but on the severity of the disease and the associated comorbid conditions, namely the presence of fecal or purulent peritonitis, past medical problems, immune status, and nutritional status. However, adherence to the several principles detailed in this report will minimize morbidity and mortality. The surgeon should always attempt to convert the patient from an emergency to an urgent or elective operative status. In the absence of free perforation, this goal usually can be achieved. Rushing into surgery in patients with a normal immune system is generally ill advised. It is far preferable to stabilize the patient, percutaneously drain abscesses if possible, prepare the bowel before exploration, and thus keep the option of primary anastomosis open. A primary anastomosis done first thing in the morning is far preferable to an end-stoma created in the middle of the night in an emergency situation. The algorithm displayed in Figure 1 provides a useful guideline for treating patients with complicated diverticulitis.

Virulent diverticular disease in young obese men

Recent treatment of young patients (aged 40 years or less) with complicated diverticulitis prompted us to review our experience. During a 9-year period ending in December 1990, 61 of 238 patients treated for acute diverticulitis were 40 years of age or younger. The younger patients were primarily obese Hispanic males in whom the correct diagnosis was frequently missed. Younger patients more frequently required an operation on an urgent basis for complications of diverticulitis during the initial hospitalization. The most common indication for operation in young patients was perforation compared with recurrent disease for the older age group. The younger group had a sevenfold incidence of enteric fistulas complicating their acute episode of diverticulitis. Our data suggest that diverticular disease in young patients is more common and more likely to require early surgical intervention than previously noted. In addition, obesity may represent an important etiologic factor in the development of diverticular disease.

Prognostic factors from computed tomography in acute left colonic diverticulitis

This prospective study examined factors which may predict a poor outcome (complications and recurrence) after a first attack of diverticulitis which has been successfully managed conservatively. Twenty-four of 107 patients who entered the study had a poor outcome: persistent diverticulitis (nine cases), recurrence (seven cases), colonic stenosis (six cases), residual parasigmoid abscess (one case) and colovesical fistula (one case). Eight of the 18 men aged 50 years or less had a poor outcome compared with 16 of the remaining 89 patients (P = 0.032). Twelve of 76 patients (16 per cent) with mild findings on computed tomography (CT) (localized thickening of colonic wall and inflammation of pericolic fat) had a poor outcome compared with 11 of 23 patients (48 per cent) whose CT was estimated as severe (abscess and/or extraluminal air and/or extraluminal Gastrografin) (P = 0.004). These results suggest that elective colectomy can be proposed after a first attack of acute left diverticulitis in men up to 50 years of age and/or in patients whose initial CT reveals findings of severe diverticulitis.

Safe resection for diverticular disease of the colon

A retrospective study of 83 patients undergoing surgery for diverticular disease over two years at a colorectal specialty hospital was undertaken to assess the safety of resection. No patient had free perforation. Eighty-nine percent of 46 patients with neither abscess nor fistula underwent resection and primary anastomosis, the remainder undergoing other resectional therapy; there was no mortality in this group. Of the 37 patients with abscesses, fistulas, or both, all had resections with or without primary anastomoses and one of these 37 patients died (2.7 percent mortality). In the entire series of 83 patients, the operative mortality was 1.2 percent, although 69 percent had morbidity. Resection can be performed safely for diverticulitis, and primary anastomosis can be safely added in uncomplicated and selected complicated cases.

Acute colonic diverticulitis

Colonic diverticulosis is truly a disease of the 20th century. A direct correlation is thought to exist between the incidence of diverticular disease and the amount of dietary fiber. Acute colonic diverticulitis occurs in approximately 25 per cent of the patients with diverticula, and 20 per cent of the patients with diverticulitis will ultimately require surgical intervention. Because of the often virulent nature of the disease in younger patients and the prevalence in the geriatric population, an aggressive approach is advocated. Primary resection of the involved segment of colon is advocated in all cases requiring operation. A primary anastomosis can be constructed in stage I and some cases of stage II disease. This results in lower morbidity and mortality rates as well as fewer days of hospitalization and disability. Newer techniques such as diagnostic CT scanning, percutaneous drainage of diverticular abscess, and greater application of surgical stapling devices have done much to improve the ultimate outcome of colonic diverticulitis.