Radiological investigation in acute diverticulitis

Identifying patients with complicated diverticulitis, is it that complicated?

OBJECTIVES

Discriminating simple from complicated diverticulitis solely on clinical bases is challenging. The aim of this study was to identify clinical predictive factor for the need for invasive treatment for patients presenting with acute diverticulitis in the emergency room.

MATERIAL AND METHODS

The records of all patients, who were discharged from a university hospital between January 2010 and March 2018 with "diverticulitis" diagnosis, were reviewed. Data collected included clinical features, whether this was a first or recurrent episode, WBC, and Hinchey score. Patients were divided into conservative and invasive treatment groups. Groups were compared by age, sex, BMI, fever, WBC and CT findings. Hinchey score groups were also compared by age, sex, BMI, fever, WBC.

RESULTS

A total of 809 patients were included. Mean age was 60.6 years, with 10% below 40 years. Most patients were treated conservatively (95.9%) while only 4.1% were treated invasively. WBC at presentation was significantly higher in those who required invasive treatment in comparison with the conservative group (13.72 vs. 11.46K/uL, p= 0.024). A statistically significant higher WBC was found among patients with a higher Hinchey score (13.16 vs 11.69, p <0.005). No difference between the groups was found in terms of age, sex, fever or BMI.

CONCLUSION

This study showed that patients who present with acute diverticulitis and an elevated WBC are prone to a more severe disease and a higher Hinchey score. Prudence should be taken with these patients, and CT scan is warranted as there is a greater chance that invasive treatment will be required.

Changes in spatiotemporal drought characteristics over northeast China from 1960 to 2018 based on the modified nested Copula model

Drought forecasting is helpful for understanding the inherent mechanism of hydrological extremes and taking corresponding measures to mitigate drought impacts. Northeast China, which is an important, major grain-producing area in China, has been challenged by substantial losses due to frequent drought. In this study, to predict the spatiotemporal variation in drought events over Northeast China, a model-based simulation framework is proposed based on precipitation data at 70 meteorological stations from 1960 to 2018. The core of the model framework is run theory, modified Copula model- based Bayesian-MCMC, Gibbs sampling, and a new definition of drought intensity center and drought intensity accumulation area. The results showed that a total of 6408 drought events occurred at the 70 meteorological stations in Northeast China over the past 59 years. The empirical distribution functions of longitude, latitude, and time can be used to fit the edge distribution of the original variable. In comparison to the traditional maximum likelihood method, the Bayesian-MCMC method is more accurate for parameter estimation of the Copula model. The Frank Copula is the optimum joint function of longitude and latitude, while the Gaussian Copula is the optimum joint function of location and time. Gibbs sampling can provide a relatively larger sample size for predicting future drought conditions. The spatiotemporal variation in drought in Northeast China changes similarly throughout the year. Drought is mainly concentrated in southwestern Liaoning from February to April. The drought intensity center moves to the northeast from May to September. Western Heilongjiang is the main drought-stricken area from October to November. The drought intensity center moves southwest from December to January of the following year. This study provides a method for effectively predicting drought events and is of great significance to the protection, development, and utilization of water resources.

Current Status of the Radiologic Assessment of Diverticular Disease

Radiologic assessment plays a vital role in the management of diverticulitis. It not only helps in the diagnosis, but also helps to guide the management. As technology has progressed, different modalities have offered insight into the treatment of this disease process. Through various trials and studies, certain modalities stand above the rest in terms of sensitivity and specificity. Computed tomography (CT) imaging has also proved to help us guide the management through a grading system. Newer studies show us the advantages of other modalities such as ultrasound and magnetic resonance imaging (MRI). Though there is much research yet to be done with these modalities, they do show a lot of potential.

Management of complicated diverticulitis of the colon

Diverticular disease of the colon occurs quite frequently in developed countries, and its prevalence has recently increased in Japan. The appearance of diverticulosis increases with age, although mostly remaining asymptomatic. Approximately 20% of cases require treatment. As the Western lifestyle and number of elderly people increase, the need for medical treatment also increases. Computed tomography (CT) is the gold standard for diagnosing diverticulitis. Complicated diverticulitis is classified by the size and range of abscess formation and the severity of the peritonitis. Each case should be classified based on clinical and computed tomography (CT) findings and then treated appropriately. Most patients with uncomplicated diverticulitis (stages 0–Ia) can be treated conservatively. Diverticulitis with a localized abscess (stages Ib–II) is generally resolved with conservative treatment. If the abscess is larger or conservative treatment fails, however, percutaneous drainage or surgery should be considered. Operative treatment is considered standard therapy for severe diverticulitis with perforation and generalized peritonitis (stages III–IV). Colonic diverticulitis treated conservatively frequently recurs. Elective surgery after recovery should be considered carefully and decisions made on a case‐by‐case basis. Because cases of colonic diverticulitis will undoubtedly increase in Japan, it is likely that we will be confronted with increasing numbers of treatment decisions. We therefore need to have a systematic strategy for treating the various stages of colonic diverticulitis appropriately. We herein review the management of complicated diverticulitis.

Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review

PURPOSE

To estimate the prevalence of underlying adenocarcinoma of the colon in patients in whom acute diverticulitis was diagnosed at computed tomography (CT) and to compare that to the prevalence of colon cancer in the general population.

MATERIALS AND METHODS

A comprehensive literature review was performed to find articles in which patients with CT diagnosis of acute diverticulitis underwent surgery, colonoscopy, or barium enema study within 24 weeks. Patients meeting these criteria were included for analysis. A pooled prevalence of cancer was calculated on the basis of a random effects model and compared qualitatively with the prevalence of cancer in the general population. The 95% confidence intervals around the prevalence of cancer in the study populations were determined.

RESULTS

Ten articles met the inclusion criteria. Data from these articles included only 771 patients who underwent surgery, colonoscopy, or barium enema study within 24 weeks of diagnosis. Fourteen patients were found to have colon cancer, for a prevalence of 2.1% (95% confidence interval: 1.2%, 3.2%). This compares to a calculated estimated prevalence of 0.68% among U.S. adults older than 55 years.

CONCLUSION

There are limited data to support the recommendation to perform colonoscopy after a diagnosis of acute diverticulitis.

WSES consensus conference: Guidelines for first-line management of intra-abdominal infections

Intra-abdominal infections are still associated with high rate of morbidity and mortality.A multidisciplinary approach to the management of patients with intra-abdominal infections may be an important factor in the quality of care. The presence of a team of health professionals from various disciplines, working in concert, may improve efficiency, outcome, and the cost of care.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bologna on July 2010, during the 1st congress of the WSES, involving surgeons, infectious disease specialists, pharmacologists, radiologists and intensivists with the goal of defining recommendations for the early management of intra-abdominal infections.This document represents the executive summary of the final guidelines approved by the consensus conference.

Prospective randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicillin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis

INTRODUCTION

Medical treatment of uncomplicated acute diverticulitis is not standardized, and there is an enormous diversity in clinical practice. Our aim was to demonstrate that uncomplicated diverticulitis can be managed with orally administered amoxicillin plus clavulanic acid and a short hospital admission.

METHODS

A prospective randomized trial was established to compare patients with uncomplicated diverticulitis who received oral antibiotic after a short course of intravenous antibiotic with those who received intravenous antibiotic for a longer period. The antibiotic treatment consisted of amoxicillin plus clavulanic acid 1 g every 8 h. We included 50 patients, 25 in each group. Patients in group 1 began oral antibiotic as soon as they improved and were discharged the day after. Patients in group 2 received intravenous antibiotic for 7 days. Both groups received oral antibiotic at discharge. The endpoint of the study was "failure of treatment," which was defined as the impossibility of discharging on the expected day, emergency admission, or hospital readmission.

RESULTS

Both groups were comparable in patient demographics and clinical characteristics. Most patients clearly improved between 24 and 48 h after admission. There were no significant differences between the groups when comparing failure of treatment. Treatment of patients in group 1 represented a savings in hospitalization costs of 1,244<euro> per patient.

CONCLUSIONS

Most patients with uncomplicated diverticulitis can be managed safely with oral antibiotic; thus, a very short hospital stay is a safe option.

The out-patient management of patients with acute mild-to-moderate colonic diverticulitis

BACKGROUND

There are no management criteria for optimum out-patient care in mild-to-moderate acute colonic diverticulitis.

AIM

To enable such patients to be managed in an out-patient setting, by establishing criteria and treatment protocols.

METHODS

We conducted an open trial and follow-up study from 1997 to 2002. On the basis of ultrasonography, we defined and categorized mild-to-moderate acute colonic diverticulitis ranging from limited inflammation within diverticulum to an abscess < 2 cm in diameter. Subjects were treated as out-patients and followed a 10-day treatment protocol consisting of an oral antibiotic and a sports drink for the first 3 days. Physical examination and laboratory testing helped determine whether or not a patient could resume a liquid diet on day 4, and a regular diet on day 7.

RESULTS

Of the 70 patients, 68 were successfully treated. Two patients required hospitalization. Of the 65 patients who were tracked over several months [median (intraquarter range) = 30.8 (11.9-44.2) months], 16 had one or more clinical recurrences. The medical cost per episode was 80% lower than in-patient treatment.

CONCLUSIONS

Patients with mild-to-moderate acute colonic diverticulitis can be safely and successfully treated as out-patients using this protocol.

Imaging of colonic diverticular disease

Diverticular disease affects approximately two thirds of the population over the age of 70. While only a small fraction of these patients will develop diverticulitis, adequate radiological evaluation of diverticulitis and its complications is imperative in determining proper medical and surgical treatment. Clinical examination and laboratory tests alone have been found to be inaccurate in defining many aspects of the disease in up to 60% of cases. Over the past 30 years, contrast enema, computed tomography, and ultrasound have all been used extensively to diagnose the complications of diverticular disease. More recently, magnetic resonance imaging has been studied in patients with complicated diverticulitis. This article reviews the use of these different radiological modalities in diagnosing acute colonic diverticulitis and its complications.

Endoscopic findings of diverticular inflammation in colonoscopy patients without clinical acute diverticulitis: prevalence and endoscopic spectrum

OBJECTIVE

Experienced colonoscopists sometimes encounter endoscopic findings of diverticular inflammation in patients without clinical evidence of acute diverticulitis. Our aim was to describe the spectrum and prevalence of such endoscopic findings in a consecutive series of patients undergoing colonoscopy.

METHODS

During elective colonoscopy performed by a single endoscopist on 2566 consecutive outpatients, 21 patients were identified with endoscopic evidence of diverticular inflammation.

RESULTS

Endoscopic findings included erythema and edema of a diverticular opening (n = 8), pus emanating from a diverticular orifice (n = 8), and a polypoid mass of granulation tissue in a diverticular orifice (n = 15). Follow-up was obtained by telephone in 17 patients at a mean of 11.9 months after colonoscopy. Only one patient had symptoms of diverticulitis at the time of colonoscopy. This patient improved with antibiotic therapy. Six of the 21 patients had experienced symptoms of abdominal pain or fever, but only one had a diagnosed episode of acute diverticulitis before colonoscopy. None of the patients had acute diverticulitis during the follow-up interval.

CONCLUSIONS

Endoscopic findings of diverticular inflammation were identified in about 0.8% of patients undergoing colonoscopy without clinical evidence of diverticulitis. Most patients are asymptomatic at the time of colonoscopy, and antibiotic therapy is generally unnecessary.

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.

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.

Diverticular disease in the elderly

Diverticular disease is common among the elderly. Because of the advanced age and muted symptoms and signs of many of those affected, diagnosis can be difficult. Consequently, great demands are placed on the physician to diagnose and treat clinically evident diverticular disease. Endoscopic, radiologic, and surgical advances have increased the availability of more definitive therapies for patients with complicated diverticular disease and diverticular hemorrhage.

Investigation of colonic disease

Bowel cancer awareness among the general public has heightened in recent years. The promotion of prompt referral and the pressure on early diagnosis will alter our previous strategies on colonic evaluation. This article gives an overview of the colonic investigations currently available.

Acute left colonic diverticulitis--compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients

PURPOSE

The most valuable radiologic examination to be done initially when acute left colonic diverticulitis is suspected is still a matter of controversy. This study compares the performance between water-soluble contrast enema and computed tomography.

METHODS

From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a contrast enema and a computed tomography within 72 hours of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiologic examinations showed signs of acute diverticulitis or diverticulitis was surgically removed and histologically proven or both. Diverticulitis was considered moderate when computed tomography showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and contrast enema showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess or extraluminal air or contrast or all three were observed on computed tomography and when one or both of the last two signs were seen on contrast enema. Of 542 patients, 420 who had both computed tomography and contrast enema entered the study.

RESULTS

The performance of computed tomography was significantly superior to contrast enema in terms of sensitivity (98 vs. 92 percent; P = 0.01), which was calculated from patients who had their colon removed and whose diverticulitis was histologically proven, and in the evaluation of the severity of the inflammation (26 vs. 9 percent; P = 0.02). Moreover, of 69 patients who had an associated abscess seen on computed tomography, only 20 (29 percent) had indirect signs of this complication on contrast enema.

CONCLUSIONS

In the diagnostic evaluation of acute left-colonic diverticulitis, computed tomography should be preferred to contrast enema as the initial radiologic examination because of its statistically significant superiority in sensitivity and for its significantly better performance in the detection of severe infection, especially when an abscess is associated with the disease.

Early flexible sigmoidoscopy in the evaluation of acute left iliac fossa pain

OBJECTIVE

To evaluate the feasibility, safety and diagnostic yield of flexible sigmoidoscopy as an early diagnostic tool in the investigation of the colonic causes of acute left iliac fossa pain.

PATIENTS AND METHODS

A 1-year prospective study was conducted in which flexible sigmoidoscopy was performed as soon as possible by two consultant coloproctologists within their normal theatre sessions on all emergency patients admitted with acute left iliac fossa pain. The clinical details, flexible sigmoidoscopy findings and subsequent outcome were recorded on a proforma.

RESULTS

It was possible to perform early flexible sigmoidoscopy on 86% (62/72) of patients referred during their in-patient stay at a median delay of 4 days from time of admission. Eighty-four percent of the examinations resulted in a diagnosis or exclusion of a colonic cause for their acute left iliac fossa pain. There was low morbidity and one unrelated death in the study.

CONCLUSION

This study has shown that it is feasible to use early flexible sigmoidoscopy as a first line investigation for patients presenting with acute left iliac fossa pain. Flexible sigmoidoscopy is a quick and safe procedure in skilled hands with a high diagnostic yield, although the potential risks involved in performing this procedure in the acute period mandate that it should only be undertaken by experts.

Acute diverticulitis in patients 40 years of age and younger

Acute colonic diverticulitis typically occurs in patients older than 60 years of age but is uncommon in patients under the age of 40, which may lead to a delay in diagnosis. Because abdominal pain is a very common presenting symptom in emergency department patients, we retrospectively analyzed the cases of 21 patients 40 years of age and younger diagnosed with acute diverticulitis and characterized the presenting signs and symptoms, laboratory and radiographic findings, treatment, and outcome. There were 17 men and 4 women with a mean age of 34.1 +/-5.9 years. All patients had abdominal pain, with 14 (67%) patients noting pain in the left lower quadrant (LLQ) and 5 (24%) patients noting right lower quadrant (RLQ) pain. Nausea was present in 18 (86%) patients and fever in 15 (71%) patients. The mean pulse rate was 103 +/- 16 and the mean temperature was 100.7 +/- 1.4 F. Leukocytosis was present in 19 (90%) patients. Plain abdominal radiographs were obtained in 19 (91%) patients and were normal in 15 (79%) of these cases. Computed tomographic (CT) scans were obtained in 15 (71%) patients which revealed findings consistent with acute diverticulitis in 14 (93%) patients. The admitting diagnosis was diverticulitis in 10 of the 12 patients with LLQ tenderness and appendicitis in 4 of the 6 patients with RLQ tenderness. Overall, six patients were taken to surgery: three patients had cecal diverticulitis and three patients had perforated colonic diverticulitis. General treatment measures included bowel rest in 18 (86%) patients, and intravenous fluids and antibiotics in all patients. All patients survived. In conclusion, acute diverticulitis is uncommon in patients under 40 years of age; however, this condition may be confused with other conditions, usually acute appendicitis. As a result, clinicians should consider acute diverticulitis in young patients with acute abdominal pain, especially if they are male with nausea, fever, tachycardia, and leukocytosis, and consider obtaining a CT scan to aid in the diagnosis.

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.

Prospective evaluation of ultrasonography in acute colonic diverticulitis

BACKGROUND

The clinical diagnosis of acute colonic diverticulitis (ACD) can be difficult and ultrasonography by experts is valuable in establishing the diagnosis. This prospective observational trial aimed to assess the diagnostic accuracy and clinical value of ultrasonography performed routinely by surgical residents in training.

METHODS

The clinical course of 187 unselected consecutive patients admitted with suspected ACD was studied prospectively. Patients who had surgery for generalized peritonitis were excluded, leaving 143 for evaluation. Ultrasonographic findings and clinical assessment on admission were correlated with the patient's clinicopathological data and discharge diagnosis respectively.

RESULTS

Of 74 patients with proven ACD (prevalence 52 per cent) the diagnosis was made by ultrasonography in 62, with an accuracy of 88 per cent, sensitivity 84 per cent and specificity 93 per cent. Ultrasonography gave a false-negative result in 12 patients (negative predictive value (NPV) 84 per cent) and there were five false-positive findings (positive predictive value (PPV) 93 per cent). The final diagnosis in the latter five patients was colitis (two patients), caecal carcinoma (one), colonic ileus due to perforated sigmoid carcinoma (one) and suppurative pyosalpingitis with involvement of the sigmoid colon (one). The accuracy of clinical evaluation on admission was 71 per cent (sensitivity 82 per cent, specificity 55 per cent, PPV 72 per cent, NPV 68 per cent); however, in only 53 per cent of patients was the diagnosis considered clinically unequivocal.

CONCLUSION

Ultrasonography is a useful and valid modality for imaging ACD and its differential diagnoses in the hands of sonographically trained surgeons. It is especially helpful when the clinical findings are equivocal.

Computed tomography in acute left colonic diverticulitis

BACKGROUND

The use of computed tomography (CT) in acute left colonic diverticulitis remains controversial. The purpose of this study was to define the value of CT both during the acute phase of inflammation and, later, to indicate secondary complications after successful medical treatment.

METHODS

Some 423 patients with radiologically or histologically proven diverticulitis were studied prospectively from 1986 to 1995. Diverticulitis was considered moderate when CT showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat; it was considered severe when abscess and/or extraluminal air and/or extraluminal contrast were observed.

RESULTS

The sensitivity of CT was 97 per cent. Of 42 patients who failed conservative treatment, 32 had severe diverticulitis on CT, compared with 74 (24 per cent) of 303 who had successful conservative treatment (P < 0.0001). After a median follow-up of 46 months, 60 (20 per cent) of 300 patients had secondary complications despite initially successful conservative treatment: 28 (47 per cent) of these had initial severe diverticulitis on CT compared with 44 (19 per cent) of 236 patients who had no complications (P < 0.0001).

CONCLUSION

Abscess formation and extracolonic contrast or gas are findings that may be used to predict failure of medical treatment during the first admission and a high risk of secondary complications after initially successful medical management of acute diverticulitis.