The management of complicated diverticulitis and the role of computed tomography

Emergency Surgery for Acute Complicated Diverticulitis

BACKGROUND

The optimal treatment of acute complicated diverticulitis is a matter of debate and has undergone significant changes. Currently, the main focus of surgical treatment concepts is on controlling the emergency situation triggered by acute complicated sigmoid diverticulitis through interventional and minimally invasive measures.

METHODS

This article presents the current data and recommendations on differentiated treatment of acute complicated sigmoid diverticulitis, which are also summarized in a decision tree.

RESULTS

In general, resection of the diverticular sigmoid is needed to treat acute complicated sigmoid diverticulitis, because without resection the recurrence rate is too high at 40%. Since the morbidity and mortality rates associated with emergency resection are extremely high, resulting in the creation of a stoma, efforts are made to control the acute situation through interventional and laparoscopic measures. Therefore, pericolic and pelvic abscesses (Hinchey stages I, II) are eliminated through percutaneous or laparoscopic drainage. Likewise, laparoscopic lavage and drainage are performed for purulent and feculent peritonitis (Hinchey stages III, IV). After elimination of the acute septic situation, interval elective sigmoid resection is conducted. If emergency resection cannot be avoided, it is performed, while taking account of the patient's overall condition, with primary anastomosis and a protective stoma or as discontinuity resection using Hartmann's procedure.

CONCLUSION

Thanks to the progress made in interventional and laparoscopic treatment, differentiated concepts are now used to treat acute complicated sigmoid diverticulitis.

Validation of a grading system for complicated diverticulitis in the prediction of need for operative or percutaneous intervention

INTRODUCTION

The current surgical management of acute complicated diverticulitis has seen a major paradigm shift from routine operative intervention to a more conservative approach. This has been made possible by the widespread availability of computed tomography (CT) to enable stratification of the disease severity of acute complicated diverticulitis. The aim of this study was to retrospectively validate a CT grading system for acute complicated diverticulitis in the prediction of the need for operative or percutaneous intervention.

METHODS

Hospital and radiology records were reviewed to identify patients with acute complicated diverticulitis confirmed by CT. A consultant gastrointestinal radiologist, blinded to the clinical outcomes of patients, assigned a score according to the CT grading system.

RESULTS

Three hundred and sixty-seven patients (34.6%) had CT performed for acute diverticulitis during the study period. Forty-four patients (12.0%) had acute complicated diverticulitis (abscess and/or free intraperitoneal air) confirmed on CT. There were 22 women (50%) and the overall median age was 59 years (range: 19-92 years). According to the CT findings, there was one case with grade 1, eighteen patients with grade 2, four with grade 3 and twenty-one with grade 4 diverticulitis. Three patients with grade 2, three patients with grade 3 and ten patients with grade 4 disease underwent acute radiological or surgical intervention.

CONCLUSIONS

The use of a CT grading system for acute complicated diverticulitis did not predict the need for acute radiological or operative intervention in this small study. Decision making guided by the patient's clinical condition still retains a primary role in the management of acute complicated diverticulitis.

Efficacy of conservative management in patients with right colonic diverticulitis

BACKGROUND

Although right colonic diverticulitis is more common than sigmoid diverticulitis, and its incidence has been increasing in Asian countries, there is no definitive treatment strategy for right colonic diverticulitis. This retrospective clinical study assessed the effect of conservative management in patients with right colonic diverticulitis.

METHODS

Of the 169 patients who were diagnosed with right colonic diverticulitis at Chonbuk National University Hospital, South Korea, from 2005 to 2012, 152 patients evaluated by abdominopelvic computed tomography (CT) and managed conservatively were included. CT findings were categorized by modified Hinchey classification, with stages Ib, II, III and IV, as well as fistula and obstruction defined as complicated diverticulitis. Factors associated with recurrence of diverticulitis were determined.

RESULTS

The mean age of 152 patients (87 males, 65 females) was 42.9 ± 13.8 years, median follow-up interval was 61 months (range, 17-113 months). At diagnosis, five patients (3.3%) had complicated diverticulitis. After treatment of first attack, 15 patients (9.9%) experienced recurrence of right colonic diverticulitis, including 10 (6.6%) within 12 months. Fourteen of these patients were successfully treated conservatively, whereas one failed conservative management and required surgical resection. Statistical analysis found no variables related to recurrence of right colonic diverticulitis.

CONCLUSION

Right colonic diverticulitis has a low rate of complicated diverticulitis at first attack and a low recurrence rate, with most recurrences being uncomplicated. Therefore, conservative management is effective in patients with right colonic diverticulitis. Close follow-up of patients for 12 months is required because most recurrences may occur within 12 months.

Colorectal emergencies and related complications: a comprehensive imaging review--imaging of colitis and complications

OBJECTIVE

Colorectal emergencies are a common presentation in the emergency medicine setting and their timely diagnosis plays a crucial role in avoiding dreaded complications. The quintessential role of a radiologist lies in identifying the cause, narrowing the differential diagnosis according to imaging features, and, most importantly, identifying the associated complications.

CONCLUSION

This review focuses on imaging features of the spectrum of colitides and the complications related to colitides.

A proposal for a CT driven classification of left colon acute diverticulitis

Computed tomography (CT) imaging is the most appropriate diagnostic tool to confirm suspected left colonic diverticulitis. However, the utility of CT imaging goes beyond accurate diagnosis of diverticulitis; the grade of severity on CT imaging may drive treatment planning of patients presenting with acute diverticulitis. The appropriate management of left colon acute diverticulitis remains still debated because of the vast spectrum of clinical presentations and different approaches to treatment proposed. The authors present a new simple classification system based on both CT scan results driving decisions making management of acute diverticulitis that may be universally accepted for day to day practice.

Benefits of sonography in diagnosing suspected uncomplicated acute diverticulitis

OBJECTIVES

Despite evidence demonstrating equivalent accuracy of sonography and computed tomography (CT) in the workup of mild/uncomplicated acute diverticulitis, CT is overwhelmingly performed as the initial diagnostic test, particularly in the acute setting. Our study evaluated potential radiation and turnaround time savings associated with performing sonography instead of CT as the initial diagnostic examination in the workup of suspected uncomplicated acute diverticulitis.

METHODS

We retrospectively reviewed medical records from January 2010 to December 2012 for patients presenting with clinical symptoms of acute diverticulitis. Patients were categorized as a whole and subgrouped by age (>40 and <40 years). A modified Hinchey classification (Am Surg 1999; 65:632-636) was used to stage the severity of the disease. The effective radiation dose was calculated by multiplying the dose length product from the scanner by the standard conversion coefficient (k= 0.0021 mSv/mGy × cm). The turnaround time for patients was calculated as the time the examination was ordered by the emergency department physician or staff to the time the report was finalized.

RESULTS

Our study included 253 patients (172 male and 81 female; mean age ± SD, 50.2 ± 11.7 years; 132 >40 years and 121 <40 years). The distribution of patients by the modified Hinchey classification was 210 (stages 0 and 1a), 26 (stages 1b and 2), 17 (stages 3 and 4), 0 (fistula), and 0 (obstruction). The estimated CT radiation dose per patient was 21 ± 5.2 mSv. Mean turnaround times for CT and sonography were 138.5 ± 76.9 and 51.3 ± 44 minutes, respectively.

CONCLUSIONS

Sonography is a lower-cost, faster, and radiation-free alternative that measures up to the diagnostic standards of CT for management of suspected mild or uncomplicated acute diverticulitis.

Left colon acute diverticulitis: an update on diagnosis, treatment and prevention

Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis

BACKGROUND

There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis.

OBJECTIVE

The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes.

DESIGN

This is a population-based retrospective cohort study using administrative discharge data.

SETTING

This study was conducted in Ontario, Canada.

PATIENTS

All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012).

MAIN OUTCOME MEASURES

Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics.

RESULTS

There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001).

LIMITATIONS

There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data.

CONCLUSIONS

There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis

BACKGROUND

Initial management of diverticulitis with abscess formation has progressed from a surgical emergency to nonoperative management with antibiotics and percutaneous drainage followed by delayed resection. Controversy has arisen regarding the necessity of elective surgery, when nonoperative management has successfully resolved the index attack.

OBJECTIVE

The aim of this systematic review was to analyze the literature to determine the recurrence rate in those patients who were successfully managed nonoperatively and determine the role of elective surgical resection.

DATA SOURCES

An electronic literature search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Collected Reviews performed from 1986 to 2014. The search terms used were as follows: "diverticulitis," "abscess," "diverticular abscess," "percutaneous drainage," and "surgery."

STUDY SELECTION

Studies included for review evaluated the management of diverticular abscesses and the subsequent role of delayed elective resection.

INTERVENTIONS

All of the studies were systematically reviewed and underwent a meta-analysis.

MAIN OUTCOME MEASURES

End points were the need for surgery and recurrent attacks without surgery.

RESULTS

Twenty-two studies reporting a total of 1051 patients with acute diverticulitis with abscess formation (modified Hinchey grades IB and II) were included in the review. Percutaneous drainage was successful in 49% patients (diameter, >3 cm) and antibiotic therapy in 14% patients. Urgent surgery during the index hospitalization was performed in 30% of patients, elective resection in 36%, and no surgery in 35%. Recurrence rates were high, with 39% in patients awaiting elective resection and 18% in the nonsurgery group, with an overall recurrence rate of 28%. Of the whole cohort, only 28% had no surgery and no recurrence during follow-up.

LIMITATIONS

Sample size, heterogeneity, selection and treatment bias, and limited follow-up of included studies were limitations to this study.

CONCLUSIONS

The evidence from the literature is weak but still suggests that complicated diverticulitis with abscess formation is associated with a high probability of resective surgery, whereas conservative management may result in chronic or recurrent diverticular symptoms.

Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess

BACKGROUND

There are limited data assessing the effectiveness of antibiotics as sole initial therapy in patients with large diverticular abscess. The aim of our study was to compare outcomes of selected patients treated with initial antibiotics alone versus percutaneous drainage.

METHODS

All patients with diverticular abscess ≥3 cm in diameter treated in our institution in 1994-2012 with percutaneous drainage or antibiotics alone followed by surgery were identified from an institutional diverticular disease database. Groups were compared based on patient and disease characteristics, treatment failures and postoperative outcomes.

RESULTS

Thirty-two patients were treated with antibiotics alone because of either technically impossible percutaneous drainage (n = 15) or surgeon preference (n = 17) while 114 underwent percutaneous drainage. Failure of initial treatment required urgent surgery in 8 patients with persistent symptoms during treatment with antibiotics alone (25 %) and in 21 patients (18 %) after initial percutaneous drainage (p = 0.21). Reasons for urgent surgery after percutaneous drainage were persistent symptoms (n = 16), technical failure of percutaneous drainage (n = 4) and small bowel injury (n = 1). Patients treated with antibiotics had a significantly smaller abscess diameter (5.9 vs. 7.1 cm, p = 0.001) and shorter interval from initial treatment to sigmoidectomy (mean 50 vs. 80 days, p = 0.02). The Charlson comorbidity index, initial treatment failure rates, postoperative mortality, overall morbidity, length of hospital stay during treatments, and overall and permanent stoma rates were comparable in the two groups. Postoperative complications following antibiotics alone were significantly less severe than after percutaneous drainage based on the Clavien-Dindo classification (p = 0.04).

CONCLUSIONS

Selected patients with diverticular abscess can be initially treated with antibiotics without adverse consequences on their outcomes.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines

AIM

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient.

RESULTS

Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence.

CONCLUSION

Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Safety of nonoperative management after acute diverticulitis

Purpose

The role of surgery in the management of diverticular disease after an episode of acute diverticulitis (AD) managed in a conservative form is evolving. Age, number of episodes of AD, type of episode, and symptoms after the episodes are factors related to the need for elective surgery. The aim of this study is to evaluate the safety of conservative management and the risk factors for emergency surgery after a first episode of AD managed without surgery.

Methods

We retrospectively evaluated 405 patients diagnosed as having had a first episode of AD. Sixty-nine patients underwent emergency surgery on the first admission, and 69 patients had an elective operation in the follow-up (group A). The remaining 267 patients were managed initially without surgery (group B). Thirteen of these 267 patients needed a further urgent surgical procedure. Factors involved in the decision of elective surgery and the probability of emergency surgery after the first episode of AD managed without surgery were evaluated in relation to demographic factors, risk factors, presence of recurrences, and type of the first episode.

Results

Patients, mean age was 62.7 years, 71 were aged less than 51, and 151 were males. The mean follow-up for patients with nonoperative management was 91.2 months. An elective operation was performed in 69 patients. Compared to patients in group B, those in group A more frequently had a first episode of complicated acute diverticulitis (CAD) (37.1% vs. 16.4%; P = 0.000) and were more likely to be smokers (46.3% vs. 19.3%; P = 0.000) and to suffer more than one episode of AD (42% vs. 26.9%; P = 0.027). Nonoperative management was chosen for 267 patients, but 13 patients needed an emergency operation later. In the multivariate analysis, we found a significant relation between the presence of CAD in the first episode and the need for emergency surgery. There were no differences in surgical mortality between the patients in the two groups, but patients treated with elective surgery had a higher rate of stoma than patients treated non-operatively (7.2% vs. 1.4%; P = 0.028); this difference was not observed in the subgroup of patients with CAD (15.3% vs. 6.8%; P = 0.458).

Conclusion

After an episode of AD, nonoperative management is safe because fewer than 5% of patients will need an emergent procedure in a subsequent attack of AD. A first episode of CAD is the only risk factor for emergency surgery in patients managed conservatively.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Development and validation of algorithms to identify acute diverticulitis

PURPOSE

The objectives of this study were to develop and validate algorithms to accurately identify patients with diverticulitis using electronic medical records (EMRs).

METHODS

Using Kaiser Permanente Southern California's EMRs of adults (≥18 years) with International Classification of Diseases, Clinical Modifications, Ninth Revision diagnosis codes of diverticulitis (562.11, 562.13) between 1 January 2008 and 31 August 2009, we generated random samples for pilot (N = 692) and validation (N = 1502) respectively. Both samples were stratified by inpatient (IP), emergency department (ED), and outpatient (OP) care settings. We developed and validated several algorithms using EMR data on diverticulitis diagnosis code, antibiotics, computed tomography, diverticulosis history, pain medication and/or pain diagnosis, and excluding patients with infections and/or conditions that could mimic diverticulitis. Evidence of diverticulitis was confirmed through manual chart review. Agreement between EMR algorithm and manual chart confirmation was evaluated using sensitivity and positive predictive value (PPV).

RESULTS

Both samples were similar in socio-demographics and clinical symptoms. An algorithm based on diverticulitis diagnosis code with antibiotic prescription dispensed within 7 days of diagnosis date, performed well overall. In the validation sample, sensitivity and PPV were (84.6, 98.2%), (95.8, 98.1%), and (91.8, 82.6%) for OP, ED, and IP, respectively.

CONCLUSION

Using antibiotic prescriptions to supplement diagnostic codes improved the accuracy of case identification for diverticulitis, but results varied by care setting.

Increased faecal calprotectin predicts recurrence of colonic diverticulitis

BACKGROUND AND AIMS

Colonic diverticulitis shows a high recurrence rate, but the role of faecal markers in predicting recurrence is unknown. The aim of this study was to investigate the role of faecal calprotectin (FC) in predicting recurrence of diverticulitis.

PATIENTS/METHODS

A prospective cohort study was performed on 54 patients suffering from acute uncomplicated diverticulitis (AUD) diagnosed by computerized tomography (CT). After remission, patients underwent to clinical follow-up every 2 months. After remission and during the follow-up, FC was analysed. Recurrence of diverticulitis was defined as return to our observation due to left lower-quadrant pain with or without other symptoms (e.g. fever), associated with leucocytosis and/or increased C-reactive protein (CRP). Presence of diverticulitis was confirmed by means of CT.

RESULTS/FINDINGS

The mean follow-up was 20 months (range 12-24 months). Forty-eight patients were available for the final evaluation, and six patients were lost to follow-up. During follow-up, increased FC was detected in 17 (35.4 %) patients and diverticulitis recurred in eight patients (16.7 %). Diverticulitis recurred in eight (16.7 %) patients: seven (87.5 %) patients showed increased FC during the follow-up, and only one (12.5 %) patient with recurrent diverticulitis did not show increased FC. Diverticulitis recurrence was strictly related to the presence of abnormal FC test during follow-up.

CONCLUSIONS

In the present prospective study, increased FC was found to be predictive of diverticulitis recurrence.

Elective operation after acute complicated diverticulitis: Is it still mandatory?

AIM: To investigate recurrence rates, patterns and complications after nonoperatively managed complicated diverticulitis (CD).

METHODS: A retrospective study of patients treated for CD was performed. CD was defined on computed tomography by the presence of a localized abscess, pelvic abscess or extraluminal air. For follow-up, patients were contacted by telephone. Numbers of elective surgeries, recurrences and abdominal pain were analyzed.

RESULTS: A total of 114 patients (median age 57 years (range 29-97)), were admitted for CD. Nine patients required surgical intervention for failure of conservative therapy (Hartmann’s procedure: n = 6; resection and colorectal anastomosis: n = 3). Of the 105 remaining patients, 24 (22.9%) underwent elective sigmoid resection. The 81 (71%) non-operated patients were all contacted after a median follow-up of 32 mo (4-63). Among them, six had developed a recurrent episode of diverticulitis at a median follow-up of 12 mo (6-36); however, no patient required hospitalization. Sixty-eight patients (84%) were asymptomatic and 13 (16%) had recurrent abdominal pain.

CONCLUSION: Conservative policy is feasible and safe in 71% of cases, with a low medium-term recurrence risk.

Percutaneous Drainage of a Diverticular Abscess Should be Limited to Two Attempts for a Resilient Diverticular Abscess

Management of a resilient diverticular abscess poses a big challenge. Currently there are no guidelines for the number of percutaneous drainages to be performed in resilient diverticular abscesses before attempting surgery. All patients (n = 117) who presented with a computed tomography scan-proven diverticular abscess from July 2008 to June 2011 were studied. They were divided into four groups based on the number of percutaneous drainages they underwent for their diverticular abscess: six patients underwent three or more drainages, nine patients underwent two drainages, 27 patients had one drainage, and 75 patients had no drainage. Readjustment, flushing, and upgrading size of the drain were not considered as separate drainage procedures. The size of abscess cavity was significantly higher for the patients who had three or more drainages (mean 8 cm, P < 0.001). A Hartmann's procedure was performed in the majority of patients in the three or more drainage group (83%) but in decreasing frequency as the number of drainages performed dropped: two drainage group (44%), one drainage group (15%), and no drainage group (19%). There was a significantly higher preoperative hospital stay for drainage and antibiotics in the patients from the three or more drainage group ( P < 0.001). Patients with a resilient diverticular abscess are very likely to undergo a Hartmann's procedure after two attempted drainages. By performing additional percutaneous drainages in an attempt to avoid ostomy, patients are at an increased risk of sepsis and peritonitis with prolonged antibiotics and increased healthcare costs. We recommend limiting percutaneous drainage procedures to two attempts to cool down a resilient diverticular abscess before definitive surgery.

Systematic review: outpatient management of acute uncomplicated diverticulitis

PURPOSE OF REVIEW

Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach.

METHODS

Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion.

RESULTS

Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %.

CONCLUSION

Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.

Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients

BACKGROUND

The optimal treatment for diverticulitis with extraluminal air is controversial.

OBJECTIVE

The purpose of this research was to evaluate the safety and effectiveness of nonoperative treatment of acute diverticulitis with extraluminal air.

DESIGN

This was a retrospective cohort.

SETTINGS

The study was conducted at an academic teaching hospital functioning as both a tertiary and secondary care referral center.

PATIENTS

All of the patients with CT-diagnosed acute perforated diverticulitis with extraluminal air from 2006 through 2010 were included in this study.

INTERVENTIONS

Nonoperative treatment composed of intravenous antibiotics, bowel rest, and percutaneous drainage were the included interventions.

MAIN OUTCOME MEASURES

The need for operative management and mortality were measured.

RESULTS

A total of 132 patients underwent nonoperative treatment, whereas 48 patients were primarily operated on. Patients treated nonoperatively were divided into 3 groups on the basis of identified factors that independently predicted risk for failure: 1) patients with pericolic air (n = 82) without abscess had a 99% success rate with 0% mortality. 2) Patients with distant intraperitoneal air (n = 29) had a 62% success ratewith 0% mortality. Abundant distant intraperitoneal air and fluid in the fossa Douglas were identified as risk factors for failure. Patients without these risk factors had an 86% success rate with nonoperative management. 3) Patients with distant retroperitoneal air (n = 14) had a 43% success rate with 7% mortality.

LIMITATIONS

Comparison of nonoperative versus operative treatment cannot be made because of the study's retrospective nature.

CONCLUSIONS

Nonoperative treatment of acute diverticulitis with extraluminal air is safe and effective in patients with a small amount of distant intraperitoneal air or pericolic air without clinical signs of peritonitis.

Inter-observer reliability of computed tomographic classifications of diverticulitis

AIM

The wide use of computed tomography (CT) for diverticulitis has initiated new classifications, but their reliability has not been studied. The aim of the study was to assess the inter-observer agreement of radiologists on the classifications of diverticulitis.

METHOD

A set of 100 CT examinations of patients with an episode of diverticulitis was used to assess inter-observer agreement. Cases were derived from two prospective trials and a retrospective cohort to comprise an evenly distributed case mix of patients. The reference standard was the modified Hinchey classification based on all available information. Three blinded radiologists independently read all CT examinations. We calculated the proportion of agreement and kappa values for the Hinchey and Ambrosetti classifications. For the Dharmarajan classification only inter-observer agreement was calculated.

RESULTS

The agreement with the reference standard was substantial for both the modified Hinchey and the Ambrosetti classifications (P = 0.68 and P = 0.76). Overall inter-observer agreement for the modified Hinchey classification was substantial (median kappa 0.72), for the Ambrosetti classification almost perfect (median kappa 0.83) and for the Dharmarajan classification substantial (median kappa 0.76).

CONCLUSION

The Ambrosetti classification is more reproducible than the modified Hinchey and Dharmarajan classifications. The Ambrosetti and modified Hinchey classifications have a substantial agreement with the reference standard and therefore produce a reliable classification. The Dhamarajan is applicable only in complicated diverticulitis and is an important complementary classification to the other more general classifications of diverticulitis.

Effects of diabetes mellitus in patients presenting with diverticulitis: clinical correlations and disease characteristics in more than 1,000 patients

BACKGROUND

The epidemic increase in the incidence of diabetes mellitus (DM) worldwide represents a potential source of surgical morbidity. The impact of DM on the need for surgical management and its effect on surgical outcomes for colonic diverticulitis have not been well defined.

METHODS

We investigated all DM versus non-DM patients admitted with a diagnosis of acute diverticulitis between January 1, 2003, and December 31, 2011, to a large urban safety net hospital. An administrative database search for patients with diverticulitis was divided into two groups: those with and without DM. They were retrospectively analyzed for severity of diverticulitis (Hinchey and Ambrosetti scores), mortality, length of hospital stay, need for operation, postoperative complications, and readmission rates.

RESULTS

There were 1,019 admissions with acute diverticulitis, 164 (16.1%) of which had DM. DM versus non-DM patients presented with a higher Hinchey score of 3 or 4 (12.2% vs. 9.2%, p < 0.001), a more severe computed tomographic Ambrosetti score (43.9% vs. 31.7%, p < 0.001), older age, and significantly more comorbid conditions. There was no significant difference in the failure of nonoperative management (2.2% DM vs. 2.5% non-DM, p = 1.000), readmission, or death rates. Operated DM patients had a higher incidence of in-hospital infectious complications (28.7% vs. 8.2%, p < 0.001) and a higher incidence of acute renal failure (5.5% vs. 0.7%, p < 0.001).

CONCLUSION

Although diabetic patients with colonic diverticulitis present at a more advanced level (as measured by Hinchey and Ambrosetti scores), the nonoperative success rate is similar to non-DM patients. Surgical management in DM patients is associated with a higher incidence of infectious complications and acute kidney injury. However, DM did not appear to increase operative mortality in surgically managed patients. These data suggest that greater attention should be placed on steps to reduce the negative impact of DM on both immune response and renal function in patients requiring surgery of colonic diverticulitis.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial)

OBJECTIVE

We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs.

BACKGROUND

The most frequent standard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States.

METHODS

This multicenter, randomized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis. All the patients underwent abdominal computed tomography. There were 2 strategies of management: hospitalization (group 1) and outpatient (group 2). The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged. The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission. The secondary end points included quality-of-life assessment and evaluation of costs.

RESULTS

A total of 132 patients were randomized: 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups (P=0.619). The overall health care cost per episode was 3 times lower in group 2, with savings of €1124.70 per patient. No differences were observed between the groups in terms of quality of life.

CONCLUSIONS

Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis. Trial registration ID: EudraCT number 2008-008452-17.

Outcomes of percutaneous drainage without surgery for patients with diverticular abscess

BACKGROUND

Data on percutaneous drainage followed by observation for diverticular abscess is scant.

OBJECTIVE

The aim of this study is to assess outcomes of percutaneous drainage alone in the management of peridiverticular abscess.

DESIGN

This is a retrospective study from a prospectively collected database.

SETTING

This study was conducted in a high-volume, specialized colorectal surgery unit.

PATIENTS

All patients with a diverticular abscess of at least 3 cm in diameter, treated between 2001 and 2012, who had prohibitive comorbidities or refused surgery after percutaneous drainage were included.

MAIN OUTCOME MEASURES

The primary outcome measured was the treatment of diverticular abscess with percutaneous drainage alone.

RESULTS

A total of 18 patients (11 surgery refusal, 7 comorbidity) were followed up until death, surgery for recurrent diverticulitis, or for a median of 90 (17-139) months. The median abscess size was 5 (3.8-10) cm, and the location was pelvic in 8 cases and intra-abdominal in 10. The mean duration of drainage was 20 ± 1.3 days, with the exception of 2 patients who only had aspiration of the abscess because of technical difficulty in drain placement. Three patients died of preexisting comorbidities between 2 and 8 months after percutaneous drainage. Seven of the surviving patients (7/15) experienced recurrent diverticulitis; 3 of these patients underwent surgery between 7 months and 7 years after the index percutaneous drainage. Of the remaining 4 cases of recurrence, one abscess was treated with repeat percutaneous drainage alone and 3 patients had uncomplicated diverticulitis treated with antibiotics. There were no significant associations between long-term failure of percutaneous drainage and the location of the abscess (p = 0.54) or previous episodes of diverticulitis (p = 0.9).

LIMITATIONS

This study was limited because of its retrospective nature, its nonrandomized design, and its small sample size.

CONCLUSIONS

Percutaneous drainage alone was successful in avoiding surgery in the majority of this selected patient population with sigmoid diverticular abscess. Future studies should assess the appropriate indications for a more liberal use of percutaneous drainage not followed by elective surgery.

Colonic diverticulitis in young Asians: a predominantly mild and right-sided disease

BACKGROUND

The management of diverticulitis in young Asian patients remains challenging. This study aimed to highlight the issues of managing diverticulitis in young Asians.

METHODS

A retrospective review of all patients who were admitted for acute colonic diverticulitis from October 2003 to December 2008 was performed. Patients who were ≤50 year old were considered 'young' and formed the study group.

RESULTS

The study group consisted of 142 patients. The majority (n = 126, 88.7%) had right-sided diverticulitis and most (n = 117, 82.4%) were mild in severity. Most of the patients who underwent emergency surgery were for suspected appendicitis (39/56, 69.6%). When we compared between those aged ≤50 and >50 years, the older group had worse diverticulitis (odds ratio (OR), 4.90, 95% confidence interval (CI), 2.00-11.99), been operated for indications other than suspected appendicitis (OR, 13.08, 95% CI, 5.42-31.56) and undergone a colectomy (OR, 9.96, 95% CI, 4.12-24.10). The younger group had a much higher incidence of right-sided disease (OR: 7.80, 95% CI: 4.32-14.07). Over a median follow-up of 40 (6-90) months, 7 (4.9%) patients were readmitted for a total of eight times for recurrent attacks of diverticulitis and all were successfully treated conservatively. Five other patients underwent elective surgery for persistent symptoms.

CONCLUSION

Diverticulitis in young Asians is often right-sided and mild in severity. A significant proportion is only diagnosed when operated for presumed appendicitis. Recurrent attacks are uncommon and can often be treated non-surgically.

Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review

BACKGROUND

It is generally accepted that patients following an episode of diverticulitis should have additional colonoscopy screening to rule out a colorectal malignancy. We aimed to investigate the rate of CRC found by colonoscopy after an attack of uncomplicated diverticulitis.

METHODS

MEDLINE, Embase, and Cochrane databases were searched systematically for clinical trials or observational studies on colonic evaluation by colonoscopy after the initial diagnosis of acute uncomplicated diverticulitis, followed by hand-searching of reference lists.

RESULTS

Nine studies met the inclusion criteria and included a total number of 2,490 patients with uncomplicated diverticulitis. Subsequent colonoscopy after an episode of uncomplicated diverticulitis was performed in 1,468 patients (59%). Seventeen patients were diagnosed with CRC, having a prevalence of 1.16% (95% confidence interval 0.72-1.9% for CRC). Hyperplastic polyps were seen in 156 patients (10.6%), low-grade adenoma in 90 patients (6.1%), and advanced adenoma was reported in 32 patients (2.2%).

CONCLUSION

Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required.

Acute inflammatory surgical disease

Infectious and inflammatory diseases comprise some of the most common gastrointestinal disorders resulting in hospitalization in the United States. Accordingly, they occupy a significant proportion of the workload of the acute care surgeon. This article discusses the diagnosis, management, and treatment of appendicitis, acute cholecystitis/cholangitis, acute pancreatitis, diverticulitis, and Clostridium difficile colitis.

Cauda equina syndrome secondary to complicated diverticulitis

A 58-year-old woman presented to the emergency department with cauda equina syndrome and sepsis. The symptoms were attributed to a complicated episode of sigmoid diverticulitis. MRI showed that the diverticulitis had caused an intra-abdominal fistula to a presacrally localized abscess expanding into the spinal canal, compressing the cauda equina nerves. Although Hartmann's procedure was performed, the neurological symptoms persisted, causing the patient to remain partially paraplegic. This case report illustrates that cauda equina syndrome is a condition that can also be caused by intra-abdominal pathology such as diverticulitis.

Intra-abdominal abscess drainage: interval to surgery

Placement of percutaneous drainage catheters has become first-line therapy in the treatment of patients with intra-abdominal abscesses. Catheters can be used to avoid surgical intervention or to improve surgical outcomes. This article discusses the current evidence describing the optimal interval between percutaneous drainage procedures and surgery, focusing on patients with Crohn's disease, appendicitis, and diverticulitis.

Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis

BACKGROUND

The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013).

RESULTS

Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making.

CONCLUSION

The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.

Acute and elective laparoscopic resection for complicated sigmoid diverticulitis: clinical and histological outcome

BACKGROUND

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

METHODS

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

RESULTS

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

CONCLUSIONS

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.

Application of a modified Neff classification to patients with uncomplicated diverticulitis

AIM

Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management.

METHOD

All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients. Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded.

RESULTS

Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25-90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixty-four (94%) successfully completed the outpatient treatment protocol; four patients were readmitted.

CONCLUSION

Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme.

Dietary restrictions for acute diverticulitis: evidence-based or expert opinion?

PURPOSE

Diet restrictions are usually advised as part of the conservative treatment for the acute phase of a diverticulitis episode. To date, the rationale behind diet restrictions has never been thoroughly studied. This study aims to investigate which factors influence the choice of dietary restriction at presentation. Additionally, the effect of dietary restrictions on hospitalization duration is investigated.

METHODS

All patients hospitalized for Hinchey 0, Ia, or Ib diverticulitis between January 2010 and June 2011 were included. Patients were categorized according to the diet imposed by the treating physician at presentation and included nil per os, clear liquid, liquid diet, and solid foods. The relation between Hinchey classification, C-reactive protein, leucocyte count and temperature at presentation and diet choice was examined. Subsequently, the relation between diet restriction and number of days hospitalized was studied.

RESULTS

Of the 256 patients included in the study 65 received nil per os, 89 clear liquid, 75 liquid diet, and 27 solid foods at presentation. Solely high temperature appeared to be related to a more restrictive diet choice at presentation. Patients who received liquid diet (HR 1.66 CI 1.19-2.33) or solid foods (HR 2.39 CI 1.52-3.78) were more likely to be discharged compared to patient who received clear liquid diet (HR 1.26 CI 1.52-3.78) or nils per os (reference group). This relation remained statistically significant after correction for disease severity, treatment and complications.

CONCLUSION

Physicians appeared to prefer a more restrictive diet with increasing temperature at presentation. Notably, dietary restrictions prolong hospital stay.

Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis

BACKGROUND

The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed.

METHODS

A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities.

RESULTS

The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy.

CONCLUSION

Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.

The evolving role of laparoscopy in colonic diverticular disease: a systematic review

BACKGROUND

A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials.

RESULTS

Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis.

CONCLUSIONS

Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.

Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis

BACKGROUND AND AIM

For years, the natural course of diverticulitis in the young has been debatable in terms of its severity and recurrence rate, and no consensus has been reached regarding its treatment and timing of surgery. Thus, the study aims to evaluate by meta-analysis the natural course of acute diverticulitis in the young.

METHODS

Data were obtained from electronic databases and manual search of studies comparing the course of diverticulitis in young versus elderly patients. The age cut-off was selected to be 40-50 years, and only studies using computed tomography as the sole modality for diagnosis were included. Primary outcomes were surgery during hospitalization and disease recurrence. Relative risks (RRs) with 95% confidence intervals (CIs) are reported.

RESULTS

One thousand eighty publications were found, 12 of which were included. The total number of patients was 4982. Most young patients were males (RR 1.70, 95% CI 1.31-2.21), without tendency toward a more complicated disease at admission (RR 0.95, 95% CI 0.46-1.97). While there was no significant difference in the rate of surgery during hospitalization (RR 0.69, 95% CI 0.46-1.06), young patients underwent more elective surgeries (RR 2.39, 95% CI 1.82-3.15). No mortality was recorded among young patients. The disease recurrence rate was significantly higher than that of elderly patients (RR 1.70, 95% CI 1.31-2.21); however, no study specified the mean follow-up period for each group.

CONCLUSIONS

The course of diverticulitis in the young is not more severe than that in elderly patients; however, the disease tends to recur more often. Therefore, while choosing a therapeutic regimen, factors other than age should also be considered.

Risk factors for severe diverticulitis in computed tomography-confirmed acute diverticulitis in Korea

Background/Aims

Acute complicated diverticulitis can be subdivided into moderate diverticulitis and severe diverticulitis. Although there have been numerous studies on the risk factors for complicated diverticulitis, little research has focused on severe diverticulitis. This study was designed to identify the risk factors for severe diverticulitis in an acute diverticulitis attack using the modified Hinchey classification.

Methods

Patients were included if they had any evidence of acute diverticulitis detected by computed tomography. The patients were subdivided into severe diverticulitis (Hinchey class ≥Ib; abscesses or peritonitis) and moderate diverticulitis (Hinchey class Ia; pericolic inflammation) groups.

Results

Of the 128 patients, 25 exhibited severe diverticulitis, and 103 exhibited moderate diverticulitis. In a multivariate analysis, age >50 years (odds ratio [OR], 5.27; p=0.017), smoking (OR, 3.61; p=0.044), comorbidity (OR, 4.98; p=0.045), leukocytosis (OR, 7.70; p=0.003), recurrence (OR, 4.95; p=0.032), and left-sided diverticulitis (OR, 6.92; p=0.006) were significantly associated with severe diverticulitis.

Conclusions

This study suggests that the risk factors for severe diverticulitis are age >50 years, smoking, comorbidity, leukocytosis, recurrent episodes, and left-sided diverticulitis.

C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications

BACKGROUND

Diverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids.

METHODS

We analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT.

RESULTS

A total of 295 patients were included in the study. Two hundred and forty-three (82 %) were classified with uncomplicated (Hinchey 1a) and 52 (18 %) with complicated disease (Hinchey > 1a). Mean CRP levels were 133.5 and 63.5 mg/ml for those with complicated and uncomplicated disease, respectively (p < 0.001), and 139 and 60 mg/ml, respectively (p < 0.001) in the subgroup of patients taking aspirin (n = 61). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRP > 90 mg/ml had 88 % sensitivity and 75 % specificity for complicated disease.

CONCLUSIONS

The CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.

Appendicitis/diverticulitis: diagnostics and conservative treatment

Appendicitis and diverticulitis are very common entities that show some similarities in diagnosis and course of disease. Both are widely believed to be simple clinical diagnoses, which is in contrast to scientific evidence. An accurate diagnosis has to describe not only the initial detection, but particularly the severity of the disease. It is based mainly on cross-sectional imaging by ultrasound (US) and computed tomography (CT). Appendectomy is the standard treatment for acute appendicitis and is mandatory in complicated cases. Antibiotic therapy is similarly effective in uncomplicated appendicitis, but long-term results are not sufficiently known. Treatment of diverticulitis is related to the disease status. Complications such as perforation and bleeding require intervention. Uncomplicated diverticulitis as graded by US or CT are subject to conservative management, in the form of outpatient or hospital care. It is an unresolved debate as to whether antibiotic treatment offers benefits. Mesalazine seems at least to improve pain. The real challenge is treatment of recurrent diverticulitis. Lifestyle measures such as nutritional habits and physical activity are found to influence diverticular disease. Besides immunosuppression, obesity is a significant risk factor for complicated diverticulitis. Whether any medication such as chronic antibiotics, probiotics or mesalazine offers benefits is unclear. The indication for sigmoid resection has changed; it is no longer given by the number of attacks, but rather by structural changes as depicted by cross-sectional imaging.

Non-operative treatment of right-sided colonic diverticulitis has good long-term outcome: a review of 226 patients

INTRODUCTION

Data highlighting the long-term outcome following an initial episode of right-sided colonic diverticulitis is lacking. This study aims to evaluate and follow up on all patients with right-sided colonic diverticulitis.

METHODS

A retrospective review of all patients who were discharged with a diagnosis of right-sided colonic diverticulitis from January 2003 to April 2008 was performed.

RESULTS

A total of 226 patients, with a median age of 49 (range, 16-93) years, were admitted for acute right-sided colonic diverticulitis. The majority of the patients (n = 198, 87.6 %) had mild diverticulitis (Hinchey Ia and Ib). Seventy-three (32.3 %) patients underwent emergency surgery. The indications of surgery were predominantly suspected appendicitis (n = 50, 22.1 %) and perforated diverticulitis (n = 16, 7.1 %). Right hemicolectomy was performed in 32 (43.8 %) patients, while appendectomy, with or without diverticulectomy, was performed in the rest (n = 41, 56.2 %). There were seven patients who underwent elective right hemicolectomy after their acute admissions.Over a median duration of 64 (12-95) months, there were only nine patients who were readmitted 12 times for recurrent diverticulitis at a median duration of 17 (1-48) months from the index admission. The freedom from failure (recurrent attacks or definitive surgery (right hemicolectomy)) at 60 months was 92.0 % (95 % Confidence interval 86.1 %-97.9 %).

CONCLUSION

Right-sided diverticulitis is commonly encountered in the Asian population and often gets misdiagnosed as acute appendicitis. If successfully managed conservatively, the long-term outcome is excellent.

The value of inflammation markers and body temperature in acute diverticulitis

AIM

To determine the diagnostic value of serological infection markers and body temperature in discriminating complicated from uncomplicated diverticulitis.

METHODS

Patients in whom diverticulitis was pathologically or radiologically proven at presentation were included. Patients were classified as either complicated (Hinchey Ib, II, III and IV) or uncomplicated (Hinchey Ia) diverticulitis. The discriminative value of C-reactive protein (CRP), white blood cell (WBC) count and body temperature at presentation was tested.

RESULTS

A total of 426 patients were included in this study of which 364 (85%) presented with uncomplicated and 62 (15%) with complicated diverticulitis. Only CRP was of sufficient diagnostic value (area under the curve 0.715). The median CRP in patients with complicated diverticulitis was significantly higher than in patients with uncomplicated disease (224 mg/l, range 99-284 vs 87 mg/l, range 48-151). Patients with a CRP of 25 mg/l had a 15% chance of having complicated diverticulitis. This increased from 23% at a CRP value of 100 mg/l to 47% for 250 mg/l or higher. The optimal threshold was reached at 175 mg/l with a positive predictive value of 36%, negative predictive value of 92%, sensitivity of 61% and a specificity of 82%.

CONCLUSION

WBC count and body temperature are of no value in discriminating complicated from uncomplicated diverticulitis. Only CRP can be used as an indicator for the presence of complications, but a low CRP does not mean that complicated disease can safely be excluded. Therefore, radiological examination remains central in the diagnostic work-up of patients presenting with diverticulitis.