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Kodadek LM, Davis KA. Current diagnosis and management of acute colonic diverticulitis: What you need to know. J Trauma Acute Care Surg 2024; 97:1-10. [PMID: 38509056 DOI: 10.1097/ta.0000000000004304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
ABSTRACT Acute colonic diverticulitis is a common disease treated by acute care surgeons. Acute uncomplicated colonic diverticulitis involves thickening of the colon wall with inflammatory changes and less commonly requires the expertise of a surgeon; many cases may be treated as an outpatient with or without antibiotics. Complicated diverticulitis involves phlegmon, abscess, peritonitis, obstruction, stricture, and/or fistula and usually requires inpatient hospital admission, treatment with antibiotics, and consideration for intervention including operative management. This review will discuss what the acute care surgeon needs to know about diagnosis and management of acute colonic diverticulitis.
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Affiliation(s)
- Lisa M Kodadek
- From the Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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2
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Gan T, Liu X, Liu R, Huang J, Liu D, Tu W, Song J, Cai P, Shen H, Wang W. Machine learning based prediction models for analyzing risk factors in patients with acute abdominal pain: a retrospective study. Front Med (Lausanne) 2024; 11:1354925. [PMID: 38903814 PMCID: PMC11188420 DOI: 10.3389/fmed.2024.1354925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/15/2024] [Indexed: 06/22/2024] Open
Abstract
Background Acute abdominal pain (AAP) is a common symptom presented in the emergency department (ED), and it is crucial to have objective and accurate triage. This study aims to develop a machine learning-based prediction model for AAP triage. The goal is to identify triage indicators for critically ill patients and ensure the prompt availability of diagnostic and treatment resources. Methods In this study, we conducted a retrospective analysis of the medical records of patients admitted to the ED of Wuhan Puren Hospital with acute abdominal pain in 2019. To identify high-risk factors, univariate and multivariate logistic regression analyses were used with thirty-one predictor variables. Evaluation of eight machine learning triage prediction models was conducted using both test and validation cohorts to optimize the AAP triage prediction model. Results Eleven clinical indicators with statistical significance (p < 0.05) were identified, and they were found to be associated with the severity of acute abdominal pain. Among the eight machine learning models constructed from the training and test cohorts, the model based on the artificial neural network (ANN) demonstrated the best performance, achieving an accuracy of 0.9792 and an area under the curve (AUC) of 0.9972. Further optimization results indicate that the AUC value of the ANN model could reach 0.9832 by incorporating only seven variables: history of diabetes, history of stroke, pulse, blood pressure, pale appearance, bowel sounds, and location of the pain. Conclusion The ANN model is the most effective in predicting the triage of AAP. Furthermore, when only seven variables are considered, including history of diabetes, etc., the model still shows good predictive performance. This is helpful for the rapid clinical triage of AAP patients and the allocation of medical resources.
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Affiliation(s)
- Tian Gan
- Department of Emergency Medicine, Wuhan Puren Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Xiaochao Liu
- Department of Emergency Medicine, Wuhan Puren Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Rong Liu
- Department of Emergency Medicine, Wuhan Puren Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Jing Huang
- Department of Emergency Medicine, Wuhan Puren Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Dingxi Liu
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Wenfei Tu
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Jiao Song
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Pengli Cai
- School of Medicine, Wuhan University of Science and Technology, Wuhan, China
| | - Hexiao Shen
- College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, China
- Maintainbiotech. Ltd. (Wuhan), Wuhan, Hubei, China
| | - Wei Wang
- Department of Emergency Medicine, Wuhan Puren Hospital, Wuhan University of Science and Technology, Wuhan, China
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3
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Gunby SA, Strate LL. Acute Colonic Diverticulitis. Ann Intern Med 2024; 177:ITC33-ITC48. [PMID: 38466995 DOI: 10.7326/aitc202403190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Acute colonic diverticulitis is a gastrointestinal condition that is frequently encountered by primary care and emergency department practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It is often diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, the presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.
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Affiliation(s)
- Sarah A Gunby
- University of Washington School of Medicine, Seattle, Washington (S.A.G., L.L.S.)
| | - Lisa L Strate
- University of Washington School of Medicine, Seattle, Washington (S.A.G., L.L.S.)
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4
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Vijfschagt ND, de Boer MR, Berger MY, Burger H, Holtman GA. Accuracy of diagnostic tests for acute diverticulitis that are feasible in primary care: a systematic review and meta-analysis. Fam Pract 2024; 41:1-8. [PMID: 38271592 PMCID: PMC10901479 DOI: 10.1093/fampra/cmad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Recognition of acute diverticulitis is important to determine an adequate management strategy. Differentiating it from other gastrointestinal disorders is challenging as symptoms overlap. Clinical tests might assist the clinician with this diagnostic challenge. Previous reviews have focussed on prognostic questions and imaging examinations in secondary care. OBJECTIVE To evaluate the diagnostic accuracy of clinical tests feasible in primary care for acute diverticulitis in suspected patients. METHOD We have systematically searched multiple databases for diagnostic accuracy studies of tests feasible in primary care compared to a reference standard in suspected patients. Two reviewers independently selected studies, extracted data, and assessed study quality with the QUADAS-2 tool. We have meta-analysed the results in the case of more than four studies per index test. RESULTS Seventeen studies were included, all studies were performed in secondary care (median prevalence 48%). Individual signs and symptoms showed a wide range in sensitivity (range 0.00-0.98) and specificity (range 0.08-1.00). Of the four laboratory tests evaluated, CRP >10 mg/l had the highest sensitivity (range 0.89-0.96) with specificity ranging from 0.28 to 0.61. Ultrasound had the highest pooled sensitivity and specificity of 0.92 (95% CI 0.86-0.96) and 0.94 (95% CI 0.88-0.97), respectively. CONCLUSION None of the studies were performed in primary care. Individual signs and symptoms alone are insufficiently informative for acute diverticulitis diagnosis. CRP showed potential for ruling out and ultrasound had a high diagnostic accuracy. More research is needed about the diagnostic accuracy of these tests in primary care. PROSPERO REGISTRATION NUMBER CRD42021230622.
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Affiliation(s)
- Natasja D Vijfschagt
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel R de Boer
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Huibert Burger
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gea A Holtman
- Department of Primary- and Long-term Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Long B, Werner J, Gottlieb M. Emergency medicine updates: Acute diverticulitis. Am J Emerg Med 2024; 76:1-6. [PMID: 37956503 DOI: 10.1016/j.ajem.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS An understanding of literature updates can improve the ED care of patients with acute diverticulitis.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Jessie Werner
- Department of Emergency Medicine, UCSF Fresno, Fresno, CA, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Mahmood MW, Schmidt PT, Olén O, Hellsing C, Hjern F, Abraham-Nordling M. Identification of diverticular disease in Swedish healthcare registers: a validation study. Scand J Gastroenterol 2024; 59:176-182. [PMID: 37936435 DOI: 10.1080/00365521.2023.2278422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The Swedish National Patient Register (SNPR) is frequently used in studies of colonic diverticular disease (DD). Despite this, the validity of the coding for this specific disease in the register has not been studied. METHODS From SNPR, 650 admissions were randomly identified encoded with ICD 10, K572-K579. From the years 2002 and 2010, 323 and 327 patients respectively were included in the validation study. Patients were excluded prior to, or up to 2 years after a diagnosis with IBD, Celiac disease, IBS, all forms of colorectal cancer (primary and secondary), and anal cancer. Medical records were collected and data on clinical findings with assessments, X-ray examinations, endoscopies and laboratory results were reviewed. The basis of coding was compared with internationally accepted definitions for colonic diverticular disease. Positive predictive values (PPV) were calculated. RESULTS The overall PPV for all diagnoses and both years was 95% (95% CI: 93-96). The PPV for the year 2010 was slightly higher 98% (95% CI: 95-99) than in the year 2002, 91% (95% CI: (87-94) which may be due to the increasing use of computed tomography (CT). CONCLUSION The validity of DD in SNPR is high, making the SNPR a good source for population-based studies on DD.
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Affiliation(s)
- Mahmood Wael Mahmood
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter T Schmidt
- Department of Medical Sciences, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Christine Hellsing
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Hjern
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mirna Abraham-Nordling
- Department of Pelvic Cancer, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Aguilar-Alvarado MY, Baker B, Chiu LS, Shah MK. Benign Colorectal Disorders. Prim Care 2023; 50:461-480. [PMID: 37516514 DOI: 10.1016/j.pop.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Benign conditions of the colon and rectum are a heterogeneous group of conditions that range from inflammatory to infectious to pelvic floor health conditions that affect large segments of the US population. These conditions include diverticular disease, hemorrhoids, and anorectal lesions. The initial presentation of these very common conditions often occurs in the outpatient primary care setting, and most can be managed by the primary care clinician. This article will provide an overview on the prevalence, diagnosis, and management of some of the most common benign colorectal disorders; these are broadly divided into diverticular disease, hemorrhoids, and anorectal conditions.
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Affiliation(s)
| | - Bernadette Baker
- Department of Family and Preventive Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Laura S Chiu
- Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, MA, USA
| | - Megha K Shah
- Department of Family and Preventive Medicine, Emory School of Medicine, Atlanta, GA, USA.
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Sabo CM, Leucuta DC, Simiraș C, Deac IȘ, Ismaiel A, Dumitrascu DL. Hemogram-Derived Ratios in the Prognosis of Acute Diverticulitis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1523. [PMID: 37763641 PMCID: PMC10533113 DOI: 10.3390/medicina59091523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: It is crucial to quickly identify those patients who need immediate treatment in order to avoid the various complications related to acute diverticulitis (AD). Although several studies evaluated the neutrophil-to-lymphocyte ratio (NLR) suggesting its predictive value in assessing the severity of AD, results have been inconclusive. Therefore, we aimed to assess the relationship between the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR), and systemic immune inflammation (SII) with the severity of AD, the ability to predict the presence or absence of complications, and the recurrence rate, based on the values of inflammatory markers. Materials and Methods: We retrospectively reviewed 147 patients diagnosed with AD between January 2012 to February 2023. Patients were divided into 2 groups, uncomplicated and complicated AD. The characteristics and full blood count between both groups were compared. Results: A total of 65 (44.22%) patients were classified as having complicated AD. The area under the ROC curve (AUROC) defining a Hinchey score ≥ 1b was as follows: SII, 0.812 (95% confidence interval (CI), 0.73 -0.888); NLR, 0.773 (95% CI, 0.676-0.857); PLR, 0.725 (95% CI, 0.63-0.813); MLR: 0.665 (95% CI, 0.542 -0.777). An SII cutoff value of > 1200 marked the highest yield for diagnosing complicated AD, with a sensitivity of 82% and a specificity of 76%. The cumulative recurrence rate was not significantly different in the groups of SII ≥ median vs. SII < median (p = 0.35), NLR ≥ median vs. NLR < median (p = 0.347), PLR ≥ median vs. PLR < median (p = 0.597), and MLR ≥ median vs. MLR < median (p = 0.651). Conclusions: Our study indicates that SII, NLR, and PLR are statistically significant and clinically useful classifying ratios to predict higher Hinchey scores. However, they cannot predict recurrences.
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Affiliation(s)
- Cristina Maria Sabo
- 2nd Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (C.M.S.); (A.I.); (D.L.D.)
| | - Daniel-Corneliu Leucuta
- Department of Medical Informatics and Biostatistics, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Constantin Simiraș
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania; (C.S.); (I.Ș.D.)
| | - Ioana Ștefania Deac
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania; (C.S.); (I.Ș.D.)
| | - Abdulrahman Ismaiel
- 2nd Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (C.M.S.); (A.I.); (D.L.D.)
| | - Dan L. Dumitrascu
- 2nd Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (C.M.S.); (A.I.); (D.L.D.)
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9
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Libman H, Nee JW, Lembo AJ, Burns RB. How Would You Manage This Patient With Recurrent Diverticulitis? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:836-843. [PMID: 37307586 DOI: 10.7326/m23-0669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Acute diverticulitis, which refers to inflammation or infection, or both, of a colonic diverticulum, is a common medical condition that may occur repeatedly in some persons. It most often manifests with left-sided abdominal pain, which may be associated with low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction. The American College of Physicians recently published practice guidelines on the diagnosis and management of acute diverticulitis, the role of colonoscopy after resolution, and interventions to prevent recurrence of this condition. Among the recommendations were the use of abdominal computed tomography (CT) scanning in cases where there was diagnostic uncertainty, initial management of uncomplicated cases in the outpatient setting without antibiotics, referral for colonoscopy after an initial episode if not performed recently, and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. Here, 2 gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease.
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Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
| | - Judy W Nee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
| | - Anthony J Lembo
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH (A.J.L.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
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10
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Strate LL, Peery AF. Tips for the Medical Management of Diverticulitis. Am J Gastroenterol 2023; 118:585-589. [PMID: 36434810 PMCID: PMC10065882 DOI: 10.14309/ajg.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/12/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Anne F Peery
- University of North Carolina, Chapel Hill, North Carolina, USA
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Molyneux K, Beck-Esmay J, Koyfman A, Long B. High risk and low prevalence diseases: Mesenteric ischemia. Am J Emerg Med 2023; 65:154-161. [PMID: 36638612 DOI: 10.1016/j.ajem.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Mesenteric ischemia is a rare, frequently misdiagnosed, serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of mesenteric ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Mesenteric ischemia is an abdominal vascular emergency that includes superior mesenteric arterial embolism, arterial thrombosis, venous mesenteric ischemia, and non-occlusive mesenteric ischemia. It is associated with a variety of risk factors including older age, cardiovascular disease, hypercoagulable state, and end-stage renal disease. The presentation depends on the underlying pathophysiology. While arterial embolic disease may present with sudden, severe pain, the early stages of the disease and other forms can present with vague symptoms, including generalized abdominal pain, weight loss, vomiting, and diarrhea. Laboratory testing can suggest the disease with leukocytosis and elevated lactate, but normal values should not be used to exclude the diagnosis. The imaging modality of choice is triple phase computed tomography with non-contrast, arterial, and delayed phases. The initial ED management includes fluid resuscitation, symptomatic therapy, broad-spectrum antibiotics, and anticoagulation. Emergent consultation with a multidisciplinary team including diagnostic and interventional radiologists and cardiovascular and general surgeons is necessary for definitive treatment. CONCLUSIONS An understanding of mesenteric ischemia can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Kevin Molyneux
- Department of Emergency Medicine, Columbia University Irving Medical Center, 622 W 168th St, New York, NY 10032, USA
| | - Jennifer Beck-Esmay
- Department of Emergency Medicine, Mount Sinai Morningside - Mount Sinai West, 1111 Amsterdam Ave, New York, NY 10025, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: Value of current severity classification schemes. RADIOLOGIA 2023; 65:32-42. [PMID: 36842784 DOI: 10.1016/j.rxeng.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/28/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The current management of acute diverticulitis of the left colon (ADLC) requires tests with high prognostic value. This paper analyzes the usefulness of ultrasonography (US) in the initial diagnosis of ADLC and the validity of current classifications schemes for ADLC. PATIENTS This retrospective observational study included patients with ADLC scheduled to undergo US or computed tomography (CT) following a clinical algorithm. According to the imaging findings, ADLC was classified as mild, locally complicated, or complicated. We analyzed the efficacy of US in the initial diagnosis and the reasons why CT was used as the first-line technique. We compared the findings with published classifications schemes for ADLC. RESULTS A total of 311 patients were diagnosed with acute diverticulitis; 183 had ADLC, classified at imaging as mild in 104, locally complicated in 60, and complicated in 19. The diagnosis was reached by US alone in 98 patients, by CT alone in 77, and by combined US and CT in 8. The main reasons for using CT as the first-line technique were the radiologist's lack of experience in abdominal US and the unavailability of a radiologists on call. Six patients diagnosed by US were reexamined by CT, but the classification changed in only three. None of the published classification schemes included all the imaging findings. CONCLUSIONS US should be the first-line imaging technique in patients with suspected ADLC. Various laboratory and imaging findings are useful in establishing the prognosis of ADLC. New schemes to classify the severity of ADLC are necessary to ensure optimal clinical decision making.
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Harold KM, MacCuaig WM, Holter-Charkabarty J, Williams K, Hill K, Arreola AX, Sekhri M, Carter S, Gomez-Gutierrez J, Salem G, Mishra G, McNally LR. Advances in Imaging of Inflammation, Fibrosis, and Cancer in the Gastrointestinal Tract. Int J Mol Sci 2022; 23:16109. [PMID: 36555749 PMCID: PMC9781634 DOI: 10.3390/ijms232416109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Gastrointestinal disease is prevalent and broad, manifesting itself in a variety of ways, including inflammation, fibrosis, infection, and cancer. However, historically, diagnostic technologies have exhibited limitations, especially with regard to diagnostic uncertainty. Despite development of newly emerging technologies such as optoacoustic imaging, many recent advancements have focused on improving upon pre-existing modalities such as ultrasound, computed tomography, magnetic resonance imaging, and endoscopy. These advancements include utilization of machine learning models, biomarkers, new technological applications such as diffusion weighted imaging, and new techniques such as transrectal ultrasound. This review discusses assessment of disease processes using imaging strategies for the detection and monitoring of inflammation, fibrosis, and cancer in the context of gastrointestinal disease. Specifically, we include ulcerative colitis, Crohn's disease, diverticulitis, celiac disease, graft vs. host disease, intestinal fibrosis, colorectal stricture, gastric cancer, and colorectal cancer. We address some of the most recent and promising advancements for improvement of gastrointestinal imaging, including unique discussions of such advancements with regard to imaging of fibrosis and differentiation between similar disease processes.
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Affiliation(s)
- Kylene M. Harold
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | | | | | | | - Kaitlyn Hill
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Alex X. Arreola
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Malika Sekhri
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Steven Carter
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Jorge Gomez-Gutierrez
- Department of Child Health, School of Medicine, University of Missouri, Columbia, MO 65211, USA
| | - George Salem
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Girish Mishra
- Wake Forest Baptist Health, Winston-Salem, NC 27157, USA
| | - Lacey R. McNally
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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14
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Kruis W, Germer C, Böhm S, Dumoulin FL, Frieling T, Hampe J, Keller J, Kreis ME, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Leifeld L. German guideline diverticular disease/diverticulitis: Part I: Methods, pathogenesis, epidemiology, clinical characteristics (definitions), natural course, diagnosis and classification. United European Gastroenterol J 2022; 10:923-939. [PMID: 36411504 PMCID: PMC9731664 DOI: 10.1002/ueg2.12309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.
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Affiliation(s)
| | - Christoph‐Thomas Germer
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieUniversitätsklinikum WürzburgWürzburgGermany
| | | | | | | | - Jochen Hampe
- Medizinische Klinik IUniversitätsklinikum DresdenDresdenGermany
| | - Jutta Keller
- Medizinische KlinikIsraelitisches KrankenhausHamburgGermany
| | - Martin E. Kreis
- Klinik für Allgemein‐, Viszeral‐ und GefäßchirurgieCharité ‐ Universitätsmedizin BerlinCampus Benjamin FranklinBerlinGermany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2Zentrum für Innere Medizin (ZIM)Universitätsklinikum WürzburgWürzburgGermany
| | - Joachim Labenz
- Abteilung für Innere MedizinEvang. Jung‐Stilling‐KrankenhausSiegenGermany
| | - Johann F. Lock
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieUniversitätsklinikum WürzburgWürzburgGermany
| | - Jörg P. Ritz
- Klinik für Allgemein‐ und ViszeralchirurgieHelios Klinikum SchwerinSchwerinGermany
| | - Andreas Schreyer
- Institut für Diagnostische und Interventionelle RadiologieBrandenburg Theodor Fontane Klinikum BrandenburgBrandenburgGermany
| | - Ludger Leifeld
- Medizinische Klinik 3 – Gastroenterologie und Allgemeine Innere MedizinSt. Bernward KrankenhausHildesheimGermany
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Imam A, Steiner E, Imam R, Omari L, Lin G, Khalayleh H, Pines G. Identifying patients with complicated diverticulitis, is it that complicated? Turk J Surg 2022; 38:169-174. [PMID: 36483174 PMCID: PMC9714650 DOI: 10.47717/turkjsurg.2022.5426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/16/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Ashraf Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Israel
| | - Elad Steiner
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Riham Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Israel
| | - Loai Omari
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Lin
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Harbi Khalayleh
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Pines
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
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Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
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17
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Current Guidelines and Controversies in the Management of Diverticulitis. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-021-00240-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, Fitterman N, Shamliyan T, Wilt TJ, Crandall CJ, Cooney TG, Cross JT, Hicks LA, Maroto M, Mustafa RA, Obley AJ, Owens DK, Tice J, Williams JW. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med 2022; 175:399-415. [PMID: 35038273 DOI: 10.7326/m21-2710] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. METHODS The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. TARGET AUDIENCE AND PATIENT POPULATION The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis. RECOMMENDATION 1 ACP suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence). RECOMMENDATION 2 ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting (conditional recommendation; low-certainty evidence). RECOMMENDATION 3 ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence).
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E., T.S.)
| | | | | | | | - Tatyana Shamliyan
- American College of Physicians, Philadelphia, Pennsylvania (A.Q., I.E., T.S.)
| | - Timothy J Wilt
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, Minnesota (T.J.W.)
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Fugazzola P, Ceresoli M, Coccolini F, Gabrielli F, Puzziello A, Monzani F, Amato B, Sganga G, Sartelli M, Menichetti F, Puglisi GA, Tartaglia D, Carcoforo P, Avenia N, Kluger Y, Paolillo C, Zago M, Leppäniemi A, Tomasoni M, Cobianchi L, Dal Mas F, Improta M, Moore EE, Peitzman AB, Sugrue M, Agnoletti V, Fraga GP, Weber DG, Damaskos D, Abu-Zidan FM, Wani I, Kirkpatrick AW, Pikoulis M, Pararas N, Tan E, Broek RT, Maier RV, Davies RJ, Kashuk J, Shelat VG, Mefire AC, Augustin G, Magnone S, Poiasina E, De Simone B, Chiarugi M, Biffl W, Baiocchi GL, Catena F, Ansaloni L. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg 2022; 17:5. [PMID: 35063008 PMCID: PMC8781436 DOI: 10.1186/s13017-022-00408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/27/2021] [Indexed: 02/08/2023] Open
Abstract
Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.
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Affiliation(s)
- Paola Fugazzola
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy.
| | - Marco Ceresoli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Francesco Gabrielli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alessandro Puzziello
- Department of Surgery and Transplants, AOU San Giovanni di Dio and Ruggi d'Aragona, University of Salerno, Fisciano, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Francesco Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Dario Tartaglia
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Paolo Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Nicola Avenia
- Medical School, General Surgery and Surgical Specialties Unit, S. Maria University Hospital University of Perugia, Terni, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ciro Paolillo
- Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Mauro Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matteo Tomasoni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Lorenzo Cobianchi
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Lincoln International Business School, University of Lincoln, Lincoln, UK
| | | | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Michael Sugrue
- Donegal Clinical Research Academy, Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | | | - Gustavo P Fraga
- Surgery Department, Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Imtiaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Sringar, Kashmir, India
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attiko Hospital, MSc "Global Health-Disaster Medicine", National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Nikolaos Pararas
- General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Edward Tan
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Goran Augustin
- Department of Surgery, University Hospital Centre, Zagreb, Croatia
| | - Stefano Magnone
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Elia Poiasina
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Gian Luca Baiocchi
- Department of General Surgery, ASST Cremona, University of Brescia, Cremona, Italy
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luca Ansaloni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
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20
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Nazerian P, Gigli C, Donnarumma E, de Curtis E, Bribani A, Lanzi S, Rovida S, Magazzini S, Grifoni S, Perani C. Diagnostic Accuracy of Point-of-Care Ultrasound Integrated into Clinical Examination for Acute Diverticulitis: A Prospective Multicenter Study. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:614-622. [PMID: 32688404 DOI: 10.1055/a-1161-0780] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis. MATERIALS AND METHODS This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan. RESULTS Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 ± 102 vs. 330 ± 319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity. CONCLUSION Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.
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Affiliation(s)
- Peiman Nazerian
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - Chiara Gigli
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - Emilia Donnarumma
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | | | - Andrea Bribani
- Department of Internal Medicine and Emergency Medicine, Serristori Hospital, Figline Valdarno, Italy
| | - Sabina Lanzi
- Department of Emergency Medicine, Brescia Community Hospital, Brescia, Italy
| | - Serena Rovida
- Department of Emergency Medicine and Trauma Center, Linköping University Hospital, Linköping, Sweden
| | - Simone Magazzini
- Department of Emergency Medicine, Prato New Hospital, Prato, Italy
| | - Stefano Grifoni
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - Cristiano Perani
- Department of Emergency Medicine, Brescia Community Hospital, Brescia, Italy
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21
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Chabok A, Thorisson A, Nikberg M, Schultz JK, Sallinen V. Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis. Scand J Surg 2021; 110:180-186. [PMID: 33934672 PMCID: PMC8258726 DOI: 10.1177/14574969211011032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022]
Abstract
Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.
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Affiliation(s)
- A. Chabok
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - A Thorisson
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
- Department of Radiology, Region Västmanland Hospital, Västerås, Sweden
| | - M. Nikberg
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - J. K. Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - V Sallinen
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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22
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Initial evaluation and imaging in acute left-sided diverticulitis. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Roson Gradaille N, Narbona Díez A, Garriga Farriol MV, Pruna Comella X, Pedraza Gutiérrez S, López Cano M, Badia JM. Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: value of current severity classification schemes. RADIOLOGIA 2021:S0033-8338(21)00028-X. [PMID: 33612278 DOI: 10.1016/j.rx.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS The current management of acute diverticulitis of the left colon (ADLC) requires tests with high prognostic value. This paper analyzes the usefulness of ultrasonography (US) in the initial diagnosis of ADLC and the validity of current classifications schemes for ADLC. PATIENTS This retrospective observational study included patients with ADLC scheduled to undergo US or computed tomography (CT) following a clinical algorithm. According to the imaging findings, ADLC was classified as mild, locally complicated, or complicated. We analyzed the efficacy of US in the initial diagnosis and the reasons why CT was used as the first-line technique. We compared the findings with published classifications schemes for ADLC. RESULTS A total of 311 patients were diagnosed with acute diverticulitis; 183 had ADLC, classified at imaging as mild in 104, locally complicated in 60, and complicated in 19. The diagnosis was reached by US alone in 98 patients, by CT alone in 77, and by combined US and CT in 8. The main reasons for using CT as the first-line technique were the radiologist's lack of experience in abdominal US and the unavailability of a radiologists on call. Six patients diagnosed by US were reexamined by CT, but the classification changed in only three. None of the published classification schemes included all the imaging findings. CONCLUSIONS US should be the first-line imaging technique in patients with suspected ADLC. Various laboratory and imaging findings are useful in establishing the prognosis of ADLC. New schemes to classify the severity of ADLC are necessary to ensure optimal clinical decision making.
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Affiliation(s)
- N Roson Gradaille
- Servicio de Diagnóstico por la imagen, Hospital Universitari Vall d'Hebron, Institut de Diagnòstic per la Imatge (IDI), Barcelona, España.
| | - A Narbona Díez
- Servicio de Diagnóstico por la Imagen, Hospital General de Granollers, Granollers, Barcelona, España
| | - M V Garriga Farriol
- Servicio de Diagnóstico por la Imagen, Hospital Universitari Josep Trueta, Institut de Diagnòstic per la Imatge (IDI), Girona, España
| | - X Pruna Comella
- Servicio de Diagnóstico por la Imagen, Hospital General de Granollers, Granollers, Barcelona, España
| | - S Pedraza Gutiérrez
- Servicio de Diagnóstico por la Imagen, Hospital Universitari Josep Trueta, Institut de Diagnòstic per la Imatge (IDI), Girona, España
| | - M López Cano
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - J M Badia
- Servicio de Cirugía General y Aparato Digestivo, Hospital General de Granollers, Granollers, Barcelona, España; Universitat Internacional de Catalunya, Barcelona, España
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Abstract
Diverticulosis is an anatomic change in the colon that is characterized by outpouching of the mucosa and submucosa through the muscularis. Its prevalence increases with age so most of the elderly patients have this condition. Although diverticulosis is common, diverticular disease, in which there are clinical sequelae, is rare. This collective term includes diverticulitis, diverticular hemorrhage and less well-defined entities such as segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Diverticulitis presents as acute lower abdominal pain, and initial management traditionally includes antibiotics, with surgery reserved for complicated disease, although newer evidence questions the optimal role and timing of both interventions.
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Affiliation(s)
- David Wan
- Division of Gastroenterology and Hepatology, Joan & Sanford I. Weill Department of Medicine, Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Tibor Krisko
- Division of Gastroenterology and Hepatology, Joan & Sanford I. Weill Department of Medicine, Weill Cornell Medicine, 413 East 69th Street, BRB 650, New York, NY 10021, USA.
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25
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Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology 2021; 160:906-911.e1. [PMID: 33279517 PMCID: PMC7878331 DOI: 10.1053/j.gastro.2020.09.059] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 12/02/2022]
Abstract
Colonic diverticulitis is a painful gastrointestinal disease that recurs unpredictably and can lead to chronic gastrointestinal symptoms. Gastroenterologists commonly care for patients with this disease. The purpose of this Clinical Practice Update is to provide practical and evidence-based advice for management of diverticulitis. We reviewed systematic reviews, meta-analyses, randomized controlled trials, and observational studies to develop 14 best practices. In brief, computed tomography is often necessary to make a diagnosis. Rarely, a colon malignancy is misdiagnosed as diverticulitis. Whether patients should have a colonoscopy after an episode of diverticulitis depends on the patient's history, most recent colonoscopy, and disease severity and course. In patients with a history of diverticulitis and chronic symptoms, alternative diagnoses should be excluded with both imaging and lower endoscopy. Antibiotic treatment can be used selectively rather than routinely in immunocompetent patients with mild acute uncomplicated diverticulitis. Antibiotic treatment is strongly advised in immunocompromised patients. To reduce the risk of recurrence, patients should consume a high-quality diet, have a normal body mass index, be physically active, not smoke, and avoid nonsteroidal anti-inflammatory drug use except aspirin prescribed for secondary prevention of cardiovascular disease. At the same time, patients should understand that genetic factors also contribute to diverticulitis risk. Patients should be educated that the risk of complicated diverticulitis is highest with the first presentation. An elective segmental resection should not be advised based on the number of episodes. Instead, a discussion of elective segmental resection should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits.
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Affiliation(s)
- Anne F. Peery
- University of North Carolina, Chapel Hill, North Carolina
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26
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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27
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Covino M, Papa V, Tursi A, Simeoni B, Lopetuso LR, Vetrone LM, Franceschi F, Rapaccini G, Gasbarrini A, Papa A. Development and Validation of Predictive Assessment of Complicated Diverticulitis Score. J Pers Med 2021; 11:jpm11020080. [PMID: 33572940 PMCID: PMC7911244 DOI: 10.3390/jpm11020080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The prevalence of acute diverticulitis (AD) has progressively increased in recent decades, with correspondingly greater morbidity and mortality. The aim of the study is to develop a predictive score to identify patients with the highest risk of complicated AD. The clinical records of 1089 patients referred to the emergency department (ED) over a five-year period were reviewed. In multivariate analysis, male sex (p < 0.001), constipation (p = 0.002), hemoglobin < 11.9 g/dL (p < 0.001), C reactive protein > 80 mg/L (p < 0.001), severe obesity (p = 0.049), and no proton pump inhibitor treatment (p = 0.003) were independently associated with complicated AD. The predictive assessment of complicated (PACO)-diverticulitis (D) score, including these six variables, was applied to the retrospective cohort and then validated prospectively in a cohort including 282 patients. It categorized patients into three risk classes for complicated AD. The PACO-D score showed fair discrimination for complicated AD with an area under the receiver operating characteristic curve of 0.674 and 0.648, in the retrospective and prospective cohorts, respectively. The PACO-D score could be a practical clinical tool to identify patients at highest risk for complicated AD referred to the ED so that appropriate diagnostic and therapeutic resources could be appropriately allocated. Further external validation is needed to confirm these results.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Valerio Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, 70031 Andria, Italy;
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
| | - Loris Riccardo Lopetuso
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy;
- Center for Advanced Studies and Technology (CAST), G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Lorenzo Maria Vetrone
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Gianludovico Rapaccini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Alfredo Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-063-0151
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Abstract
Objective
Diverticulosis is extremely common in western society. A recent study has shown that outpatient, nonantibiotic management of acute uncomplicated diverticulitis may be a feasible and safe option. However, the ability to identify these patients is still difficult. This study explores the ability of white cell count, C-reactive protein, and bilirubin in differentiating patients with complicated and uncomplicated diverticulitis, as well as progression to surgical intervention.
Methods
This is a retrospective study of patients admitted with acute diverticulitis over a 5-year period (2009–2014) at a single institution in Australia. Patients were classified into 3 groups; uncomplicated diverticulitis, complicated diverticulitis without surgery, and complicated diverticulitis with surgery. Analysis of variance (ANOVA) and Bonferroni's post hoc analyses were used to compare markers across the groups.
Results
A total of 541 patients met the inclusion criteria for this study. One-way ANOVA showed a significant difference in white cell count (P < 0.0001), C-reactive protein (P < 0.0001), and bilirubin (P = 0.0006) between all 3 groups. Post hoc analyses showed a significant difference in white cell count, C-reactive protein, and bilirubin when comparing uncomplicated diverticulitis against complicated diverticulitis without surgery (P < 0.05) and complicated diverticulitis with surgery (P < 0.05). White cell count also showed a significant difference when comparing complicated diverticulitis without surgery and complicated diverticulitis with surgery (P < 0.05).
Conclusions
White cell count, C-reactive protein, and bilirubin can distinguish between uncomplicated and complicated diverticulitis.
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29
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Moghadamyeghaneh Z, Talus H, Fitzgerald S, Muthusamy M, Stamos MJ, Roudnitsky V. Outcomes of Minimally Invasive Colectomy for Perforated Diverticulitis. Am Surg 2020; 87:561-567. [PMID: 33118383 DOI: 10.1177/0003134820950295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality. METHODS The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach. RESULTS We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0). CONCLUSION The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis.
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Affiliation(s)
| | - Henry Talus
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Simon Fitzgerald
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Muthukumar Muthusamy
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
| | - Michael J Stamos
- Department of Surgery, University of California, Irvine, CA, USA
| | - Valery Roudnitsky
- Department of Surgery, State University of New York, Downstate, Brooklyn, NY, USA.,NYC Health+ Hospitals, Kings County, Brooklyn, NY, USA
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30
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Abstract
BACKGROUND Diverticular disease is of major clinical and health economic importance in Germany. Treatment recommendations in many international guidelines have changed significantly in recent years. The German national S2k guidelines are currently being revised. OBJECTIVE To summarize the most important clinical aspects in the management of diverticular disease from a surgical perspective. MATERIAL AND METHODS The recommendations were compiled based on current national and international guidelines and a selective literature search. RESULTS Acute uncomplicated diverticulitis without risk factors can be treated on an outpatient basis without antibiotics. For patients with complicated diverticulitis, hospital admission with parenteral antibiotic treatment is recommended. In the case of abscess formation >5 cm, percutaneous drainage can be performed. The indications for immediate sigmoid resection are free perforation and failure of conservative treatment. Elective resection is indicated in chronic recurrent diverticulitis with complications; all other indications are increasingly based on the individual quality of life of the patient. CONCLUSION Uncomplicated diverticulitis is increasingly being treated on an outpatient basis and without antibiotics. Apart from emergency settings, the indications for surgery are increasingly dependent on the quality of life. Elective sigmoid resection should be performed as laparoscopic surgery with primary anastomosis after obtaining results of computed tomography and total colonoscopy.
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31
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Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis 2020; 22 Suppl 2:5-28. [PMID: 32638537 DOI: 10.1111/codi.15140] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
AIM The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. METHODS The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than 90% agreement was considered a consensus. The final phrasing of the statements with < 90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. RESULTS This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.
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Affiliation(s)
- J K Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - G A Binda
- Colorectal Surgery, BioMedical Institute, Genova, Italy
| | - G Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - S Biondo
- Department of General and Digestive Surgery - Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Chabok
- Colorectal Unit, Department of Surgery, Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S T van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Johanssen
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - W Kruis
- Faculty of Medicine, University of Cologne, Cologne, Germany
| | - D Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Post
- Mannheim Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - F Ris
- Division of Visceral Surgery, Geneva University hospitals and Medical School, Geneva, Switzerland
| | - T A Rockall
- Minimal Access Therapy Training Unit (mattu), Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - A Samuelsson
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden.,Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.,Department of General Surgery, ASST Sette Laghi, University Hospital of Varese, University of Insubria, Varese, Italy
| | - D Tartaglia
- Emergency Surgery Unit, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - A Thorisson
- Department of Radiology, Västmanland's Hospital Västerås, Västerås, Sweden.,Centre for Clinical Research of Uppsala University, Västmanland's Hospital Västerås, Västerås, Sweden
| | - D C Winter
- St Vincent's University Hospital, Dublin, Ireland
| | - W Bemelman
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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32
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Ma W, Jovani M, Nguyen LH, Tabung FK, Song M, Liu PH, Cao Y, Tam I, Wu K, Giovannucci EL, Strate LL, Chan AT. Association Between Inflammatory Diets, Circulating Markers of Inflammation, and Risk of Diverticulitis. Clin Gastroenterol Hepatol 2020; 18:2279-2286.e3. [PMID: 31712072 PMCID: PMC7310666 DOI: 10.1016/j.cgh.2019.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Lifestyle and dietary risk factors for diverticulitis also have been associated with chronic inflammation. We performed a prospective study of associations among the inflammatory potential of diets, circulating markers of inflammation, and the incidence of diverticulitis. METHODS We followed 46,418 men, initially free of diverticulitis, from 1986 through 2014 in the Health Professionals Follow-Up Study. We collected data on empiric dietary inflammatory pattern scores, which indicate the inflammatory potential of diets, and determined their association with the risk of incident diverticulitis using Cox proportional hazards regression. We used blood samples provided by 18,225 participants from 1993 through 1995 to conduct a nested case-control study; we used conditional logistic regression to evaluate prediagnostic plasma levels of markers of inflammation, including C-reactive protein (CRP), interleukin 6 (IL6), and tumor necrosis factor-receptor superfamily member 1B, in 310 diverticulitis cases and 310 matched diverticulitis-free individuals (controls). RESULTS We documented 1110 cases of incident diverticulitis over 992,589 person-years of follow-up. Compared with participants in the lowest quintile of empiric dietary inflammatory pattern scores, men in the highest quintile had a multivariable-adjusted hazard ratio for diverticulitis of 1.31 (95% CI, 1.07-1.60; Ptrend = .01). The association did not differ significantly by strata of body mass index or vigorous activity (P for interaction > .05 for each). In the nested case-control study, plasma levels of CRP and IL6 were associated with risk of diverticulitis. When we compared extreme quintiles, the multivariable-adjusted relative risk for diverticulitis was 1.85 for CRP (95% CI, 1.04-3.30) and 2.04 for IL6 (95% CI, 1.09-3.84). CONCLUSIONS In a large prospective cohort of men, we found that the inflammatory potential of diet and prediagnostic plasma levels of markers of inflammation were associated with incident diverticulitis.
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Affiliation(s)
- Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manol Jovani
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Long H Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Fred K Tabung
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, Ohio; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Po-Hong Liu
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yin Cao
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Idy Tam
- Tufts University School of Medicine, Boston, Massachusetts
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Edward L Giovannucci
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa L Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts.
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33
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Perrone G, Sartelli M, Mario G, Chichom-Mefire A, Labricciosa FM, Abu-Zidan FM, Ansaloni L, Biffl WL, Ceresoli M, Coccolini F, Coimbra R, Demetrashvili Z, Di Saverio S, Fraga GP, Khokha V, Kirkpatrick AW, Kluger Y, Leppaniemi A, Maier RV, Moore EE, Negoi I, Ordonez CA, Sakakushev B, Lohse HAS, Velmahos GC, Wani I, Weber DG, Bonati E, Catena F. Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations. Int J Infect Dis 2020; 99:140-148. [PMID: 32739433 DOI: 10.1016/j.ijid.2020.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.
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Affiliation(s)
- Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | | | - Giuffrida Mario
- Department of General Surgery, Maggiore Hospital, Parma, Italy.
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Francesco Maria Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'i, Honolulu, USA
| | - Marco Ceresoli
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, CA, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Salomone Di Saverio
- Department of General Surgery, University Hospital of Varese, University of Insubria, Varese, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Carlos A Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - George C Velmahos
- Trauma, Emergency Surgery, and Surgical Critical Care Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Elena Bonati
- Department of General Surgery, Maggiore Hospital, Parma, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
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Shokoohi H, Nasser S, Pyle M, Earls JP, Liteplo A, Boniface K. Utility of point-of-care ultrasound in patients with suspected diverticulitis in the emergency department. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:337-342. [PMID: 32357249 DOI: 10.1002/jcu.22857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 04/17/2020] [Accepted: 04/19/2020] [Indexed: 06/11/2023]
Abstract
In emergency department (ED) cases with clinically suspected diverticulitis, diagnostic imaging is often needed for diagnostic confirmation, to exclude complications, and to direct patient management. Patients typically undergo a CT scan in the ED; however, in a subset of cases with suspected diverticulitis, point-of-care ultrasound (POCUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management.We review the main sonographic features of diverticulitis and discuss the diagnostic accuracy and potential benefits of a POCUS First model.
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Affiliation(s)
- Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School-Boston, Massachusetts, USA
| | - Sigrid Nasser
- Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Matthew Pyle
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - James P Earls
- Department of Radiology, George Washington University Medical Center, Washington, District of Columbia, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School-Boston, Massachusetts, USA
| | - Keith Boniface
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
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35
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Costi R, Annicchiarico A, Morini A, Romboli A, Zarzavadjian Le Bian A, Violi V. Acute diverticulitis: old challenge, current trends, open questions. MINERVA CHIR 2020; 75:173-192. [PMID: 32550727 DOI: 10.23736/s0026-4733.20.08314-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.
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Affiliation(s)
- Renato Costi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Unit of General Surgery, Department of Surgery, Hospital of Vaio, Fidenza, Parma, Italy.,AUSL di Parma, Parma, Italy
| | | | - Andrea Morini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Romboli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alban Zarzavadjian Le Bian
- Service of General, Digestive, Oncologic, Bariatric, and Metabolic Surgery, Avicenne Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Paris XIII University, Bobigny, France
| | - Vincenzo Violi
- Department of Medicine and Surgery, University of Parma, Parma, Italy.,Unit of General Surgery, Department of Surgery, Hospital of Vaio, Fidenza, Parma, Italy.,AUSL di Parma, Parma, Italy
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36
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Sartelli M, Weber DG, Kluger Y, Ansaloni L, Coccolini F, Abu-Zidan F, Augustin G, Ben-Ishay O, Biffl WL, Bouliaris K, Catena R, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cortese F, Cui Y, Damaskos D, de’ Angelis GL, Delibegovic S, Demetrashvili Z, De Simone B, Di Marzo F, Di Saverio S, Duane TM, Faro MP, Fraga GP, Gkiokas G, Gomes CA, Hardcastle TC, Hecker A, Karamarkovic A, Kashuk J, Khokha V, Kirkpatrick AW, Kok KYY, Inaba K, Isik A, Labricciosa FM, Latifi R, Leppäniemi A, Litvin A, Mazuski JE, Maier RV, Marwah S, McFarlane M, Moore EE, Moore FA, Negoi I, Pagani L, Rasa K, Rubio-Perez I, Sakakushev B, Sato N, Sganga G, Siquini W, Tarasconi A, Tolonen M, Ulrych J, Zachariah SK, Catena F. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020; 15:32. [PMID: 32381121 PMCID: PMC7206757 DOI: 10.1186/s13017-020-00313-4] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023] Open
Abstract
Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.
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Affiliation(s)
| | - Dieter G. Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- General Surgery Department, Bufalini Hospital Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Offir Ben-Ishay
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter L. Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | | | - Rodolfo Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Marco Ceresoli
- Department of General and Emergency Surgery, ASST, San Gerardo Hospital, Monza, Italy
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, CA USA
| | | | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | | | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Belinda De Simone
- Department of Digestive Surgery, Guastalla Hospital, Reggio Emilia, Italy
| | | | - Salomone Di Saverio
- Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Mario Paulo Faro
- Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gustavo P. Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - George Gkiokas
- Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Kenneth Y. Y. Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Kenji Inaba
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- Department of General Surgery, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | | | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY USA
| | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrey Litvin
- Surgical Disciplines, Immanuel Kant Baltic Federal University/Regional Clinical Hospital, Kaliningrad, Russian Federation
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, USA
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Michael McFarlane
- Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Ernest E. Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Ines Rubio-Perez
- General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Norio Sato
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Gabriele Sganga
- Emergency Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Walter Siquini
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Matti Tolonen
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Jan Ulrych
- First Department of Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | | | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Frickenstein AN, Jones MA, Behkam B, McNally LR. Imaging Inflammation and Infection in the Gastrointestinal Tract. Int J Mol Sci 2019; 21:ijms21010243. [PMID: 31905812 PMCID: PMC6981656 DOI: 10.3390/ijms21010243] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/23/2019] [Accepted: 12/25/2019] [Indexed: 02/06/2023] Open
Abstract
A variety of seemingly non-specific symptoms manifest within the gastrointestinal (GI) tract, particularly in the colon, in response to inflammation, infection, or a combination thereof. Differentiation between symptom sources can often be achieved using various radiologic studies. Although it is not possible to provide a comprehensive survey of imaging gastrointestinal GI tract infections in a single article, the purpose of this review is to survey several topics on imaging of GI tract inflammation and infections. The review discusses such modalities as computed tomography, positron emission tomography, ultrasound, endoscopy, and magnetic resonance imaging while looking at up-an-coming technologies that could improve diagnoses and patient comfort. The discussion is accomplished through examining a combination of organ-based and organism-based approaches, with accompanying selected case examples. Specific focus is placed on the bacterial infections caused by Shigella spp., Escherichia coli, Clostridium difficile, Salmonella, and inflammatory conditions of diverticulitis and irritable bowel disease. These infectious and inflammatory diseases and their detection via molecular imaging will be compared including the appropriate differential diagnostic considerations.
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Affiliation(s)
- Alex N. Frickenstein
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019, USA; (A.N.F.); (M.A.J.)
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK 73104, USA
| | - Meredith A. Jones
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019, USA; (A.N.F.); (M.A.J.)
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK 73104, USA
| | - Bahareh Behkam
- Department of Mechanical Engineering, Virginia Tech University, Blacksburg, VA 24061, USA;
| | - Lacey R. McNally
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019, USA; (A.N.F.); (M.A.J.)
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK 73104, USA
- Department of Surgery, University of Oklahoma, Oklahoma City, OK 73104, USA
- Correspondence:
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38
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Varada S, Lacson R, Raja AS, Ip IK, Schneider L, Osterbur D, Bain P, Vetrano N, Cellini J, Mita C, Coletti M, Whelan J, Khorasani R. Characteristics of knowledge content in a curated online evidence library. J Am Med Inform Assoc 2019; 25:507-514. [PMID: 29092054 DOI: 10.1093/jamia/ocx092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/09/2017] [Indexed: 11/12/2022] Open
Abstract
Objective To describe types of recommendations represented in a curated online evidence library, report on the quality of evidence-based recommendations pertaining to diagnostic imaging exams, and assess underlying knowledge representation. Materials and Methods The evidence library is populated with clinical decision rules, professional society guidelines, and locally developed best practice guidelines. Individual recommendations were graded based on a standard methodology and compared using chi-square test. Strength of evidence ranged from grade 1 (systematic review) through grade 5 (recommendations based on expert opinion). Finally, variations in the underlying representation of these recommendations were identified. Results The library contains 546 individual imaging-related recommendations. Only 15% (16/106) of recommendations from clinical decision rules were grade 5 vs 83% (526/636) from professional society practice guidelines and local best practice guidelines that cited grade 5 studies (P < .0001). Minor head trauma, pulmonary embolism, and appendicitis were topic areas supported by the highest quality of evidence. Three main variations in underlying representations of recommendations were "single-decision," "branching," and "score-based." Discussion Most recommendations were grade 5, largely because studies to test and validate many recommendations were absent. Recommendation types vary in amount and complexity and, accordingly, the structure and syntax of statements they generate. However, they can be represented in single-decision, branching, and score-based representations. Conclusion In a curated evidence library with graded imaging-based recommendations, evidence quality varied widely, with decision rules providing the highest-quality recommendations. The library may be helpful in highlighting evidence gaps, comparing recommendations from varied sources on similar clinical topics, and prioritizing imaging recommendations to inform clinical decision support implementation.
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Affiliation(s)
- Sowmya Varada
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ronilda Lacson
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ali S Raja
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ivan K Ip
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Louise Schneider
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David Osterbur
- Harvard Medical School, Boston, MA, USA.,Countway Library of Medicine, Boston, MA, USA
| | - Paul Bain
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nicole Vetrano
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jacqueline Cellini
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Carol Mita
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Margaret Coletti
- Agoos Medical Library/Knowledge Services, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Julia Whelan
- Agoos Medical Library/Knowledge Services, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ramin Khorasani
- Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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39
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Zullo A, Gatta L, Vassallo R, Francesco VD, Manta R, Monica F, Fiorini G, Vaira D. Paradigm shift: the Copernican revolution in diverticular disease. Ann Gastroenterol 2019; 32:541-553. [PMID: 31700230 PMCID: PMC6826076 DOI: 10.20524/aog.2019.0410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo)
| | - Luigi Gatta
- Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore (Luigi Gatta)
| | - Roberto Vassallo
- Gastroenterology and Digestive Endoscopy; “Buccheri la Ferla, Fatebenefratelli”, Hospital, Palermo (Roberto Vassallo)
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia (Vincenzo De Francesco)
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, “Generale” Hospital, Perugia (Raffaele Manta)
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste (Fabio Monica)
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
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40
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La Torre M, Mingoli A, Brachini G, Lanciotti S, Casciani E, Speranza A, Mastroiacovo I, Frezza B, Cirillo B, Costa G, Sapienza P. Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis. Asian J Surg 2019; 43:476-481. [PMID: 31439460 DOI: 10.1016/j.asjsur.2019.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/23/2019] [Accepted: 07/18/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND/OBJECTIVE A preoperative reliable classification system between clinical and computed tomography (CT) findings to better plan surgery in acute complicated diverticulitis (ACD) is lacking. We studied the inter-observer agreement of CT scan data and their concordance with the preoperative clinical findings and the adherence with the intraoperative status using a new classification of diverticular disease (CDD). METHODS 152 patients operated on for acute complicated diverticulitis (ACD) were retrospectively enrolled. All patients were studied with CT scan within 24 h before surgery and CT images were blinded reanalyzed by 2 couples of radiologists (A/B). Kappa value evaluated the inter-observer agreement between radiologists and the concordance between CDD, preoperative clinical findings and findings at operation. Univariate and multivariate analysis were used to evaluate the predicting values of CT classification and CDD stage at surgery on postoperative outcomes. RESULTS Overall inter-observer agreement for the CDD was high, with a kappa value of 0.905 (95% CI = 0.850-0.960) for observers A and B, while the concordance between radiological and surgical findings was weak (kappa values = 0.213 and 0,248, respectively and 95% CI = 0.106 to 0.319 and 95% CI = 0.142 to 0.355, respectively). When overall morbidity, mortality and the need of a terminal colostomy were considered as main endpoints no concordance was observed between surgical and radiological findings and the CDD (P=NS). CONCLUSIONS The need for a more accurate classification of ACD, able to better stage this emergency, and to provide surgeons with reliable information for the best treatment is advocated.
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Affiliation(s)
- Marco La Torre
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Gioia Brachini
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Silvia Lanciotti
- Emergency Department, Department of Radiology, "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele Casciani
- Emergency Department, Department of Radiology, "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Annarita Speranza
- Department of Radiology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Ilaria Mastroiacovo
- Department of Radiology, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Barbara Frezza
- Emergency Department, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Bruno Cirillo
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Gianluca Costa
- Emergency Department, "Sapienza" University, Sant'Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Paolo Sapienza
- Emergency Department, Department of Surgery "Pietro Valdoni", "Sapienza" University, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
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Bolkenstein HE, van de Wall BJ, Consten EC, van der Palen J, Broeders IA, Draaisma WA. Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis. Scand J Gastroenterol 2019; 53:1291-1297. [PMID: 30394135 DOI: 10.1080/00365521.2018.1517188] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Most diverticulitis patients (80%) who are referred to secondary care have uncomplicated diverticulitis (UD) which is a self-limiting disease and can be treated at home. The aim of this study is to develop a diagnostic model that can safely rule out complicated diverticulitis (CD) based on clinical and laboratory parameters to reduce unnecessary referrals. METHODS A retrospective cross-sectional study was performed including all patients who presented at the emergency department with CT-proven diverticulitis. Patient characteristics, clinical signs and laboratory parameters were collected. CD was defined as > Hinchey 1A. Multivariable logistic regression analyses were used to quantify which (combination of) variables were independently related to the presence or absence of CD. A diagnostic prediction model was developed and validated to rule out CD. RESULTS A total of 943 patients were included of whom 172 (18%) had CD. The dataset was randomly split into a derivation and validation set. The derivation dataset contained 475 patients of whom 82 (18%) patients had CD. Age, vomiting, generalized abdominal pain, change in bowel habit, abdominal guarding, C-reactive protein and leucocytosis were univariably related to CD. The final validated diagnostic model included abdominal guarding, C-reactive protein and leucocytosis (AUC 0.79 (95% CI 0.73-0.84)). At a CD risk threshold of ≤7.5% this model had a negative predictive value of 96%. CONCLUSION This proposed prediction model can safely rule out complicated diverticulitis. Clinical practitioners could cautiously use this model to aid them in the decision whether or not to subject patients to further secondary care diagnostics or treatment.
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Affiliation(s)
| | | | - Esther Cj Consten
- b Department of Surgery , Diakonessenhuis , Utrecht , The Netherlands.,c Department of Surgery , Meander Medical Centre , Amersfoort , The Netherlands
| | - Job van der Palen
- d Department of Research Methodology, Measurement & Data Analysis , University of Twente , Enschede , The Netherlands
| | - Ivo Amj Broeders
- b Department of Surgery , Diakonessenhuis , Utrecht , The Netherlands.,e Department of Surgery , Meander Medical Centre , Amersfoort , The Netherlands
| | - Werner A Draaisma
- b Department of Surgery , Diakonessenhuis , Utrecht , The Netherlands.,f Department of Surgery , Jeroen Bosch Hospital , 's-Hertogenbosch , The Netherlands
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Abstract
Diverticulosis of the colon is a common condition, and about one-fourth of those people develop symptoms, which is called 'diverticular disease' (DD). Since there are still some concerns about the diagnosis of DD, the aim of this review was to analyze current and evolving advances in its diagnosis. Area covered: Analysis of clinical, radiology, laboratory, and endoscopic tools to pose a correct diagnosis of DD was performed according to current PubMed literature. Expert commentary: A combination of clinical characteristic of the abdominal pain and fecal calprotectin expression may help to differentiate between symptomatic uncomplicated diverticular disease and irritable bowel syndrome. Abdominal computerized tomography (CT) scan is still the gold standard in diagnosing acute diverticulitis and its complications. CT-colonography may be useful as a predicting tool on the outcome of the disease. Diverticular Inflammation and Complications Assessment (DICA) endoscopic classification shows a significant relationship between severity of DICA score inflammatory indexes, as well as with severity of abdominal pain. Moreover, it seems to be predictive of the outcome of the disease in terms of acute diverticulitis occurrence/recurrence and surgery occurrence. Finally, preliminary data found intestinal microbiota analysis is a promising tool in diagnosing and monitoring this disease.
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Affiliation(s)
- Antonio Tursi
- a Gastroenterology Service , ASL BAT , Andria , Italy
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Lanas A, Abad-Baroja D, Lanas-Gimeno A. Progress and challenges in the management of diverticular disease: which treatment? Therap Adv Gastroenterol 2018; 11:1756284818789055. [PMID: 30046356 PMCID: PMC6056793 DOI: 10.1177/1756284818789055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/11/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico
Universitario Lozano Blesa, C/ San Juan Bosco 15, Zaragoza, 50009, Spain.
University of Zaragoza. IIS Aragón. CIBERehs
| | - Daniel Abad-Baroja
- Servicio de Aparato Digestivo University Clinic
Hospital Lozano Blesa, Spain
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Abstract
Acute colonic diverticulitis is a gastrointestinal condition frequently encountered by primary care practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It can often be diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.
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Affiliation(s)
- Sophia M Swanson
- From the University of Washington School of Medicine, Seattle, Washington. (S.M.S., L.L.S.)
| | - Lisa L Strate
- From the University of Washington School of Medicine, Seattle, Washington. (S.M.S., L.L.S.)
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Grahnat CJ, Hérard S, Ackzell A, Andersson RE. High Probability of an Underlying Colorectal Cancer Among Patients Treated for Acute Diverticulitis. A Population-Based Cohort Follow-Up Study. World J Surg 2017; 40:2283-8. [PMID: 26956904 DOI: 10.1007/s00268-016-3480-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Patients treated conservatively for acute diverticulitis (AD) are recommended colonic assessment to rule out an underlying Colorectal cancer (CRC). This has been questioned in patients with a CT diagnosis of uncomplicated AD. We analyzed the frequency of CRC and compared the characteristics of the CRC patients with controls. METHOD A cohort of patients treated conservatively for AD during 2005-2011 was identified through an administrative database. Patients diagnosed with CRC within 1 year after the index admission and four randomly selected controls were identified. The patients' files were reviewed to verify the diagnosis and obtain information about the clinical characteristics and the management. A blinded review was performed of CT examinations. The expected number of CRC was calculated from age, sex, and period-specific incidence data. The characteristics of the CRC patients were compared with the controls in a nested case-control study. RESULTS 890 patients (298 men and 592 women) were treated conservatively for AD. 12 patients were diagnosed with CRC within 1 year, and ten of them in the sigmoid, giving a Standardized Incidence Ratio of 20.0 (95 % CI 10.2-35.7, p<0.001) for sigmoidal cancer. All CRC patients were aged over 70 years. The cancer was missed in six CT scans at the primary reading and in five at the blinded review. CONCLUSION Patients conservatively treated for AD are at high risk for an underlying CRC, especially if older than 70 years, which motivates routine follow-up. A CT diagnosis of uncomplicated AD does not rule out CRC.
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Affiliation(s)
| | - Sebastian Hérard
- Department of Radiology, County Hospital Ryhov, Jönköping, Sweden
| | - Annicka Ackzell
- Department of Radiology, County Hospital Ryhov, Jönköping, Sweden
| | - Roland E Andersson
- Department of Surgery County Hospital Ryhov, 551 85, Jönköping, Sweden.,Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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Jamal Talabani A, Endreseth BH, Lydersen S, Edna TH. Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis. Int J Colorectal Dis 2017; 32:41-47. [PMID: 27613727 PMCID: PMC5219887 DOI: 10.1007/s00384-016-2644-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The study investigated the capability of clinical findings, temperature, C-reactive protein (CRP), and white blood cell (WBC) count to discern patients with acute colonic diverticulitis from all other patients admitted with acute abdominal pain. METHODS The probability of acute diverticulitis was assessed by the examining doctor, using a scale from 0 (zero probability) to 10 (100 % probability). Receiver operating characteristic (ROC) curves were used to assess the clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain. RESULTS Of 833 patients admitted with acute abdominal pain, 95 had acute colonic diverticulitis. ROC curve analysis gave an area under the ROC curve (AUC) of 0.95 (CI 0.92 to 0.97) for ages <65 years, AUC = 0.86 (CI 0.78 to 0.93) in older patients. Separate analysis showed an AUC = 0.83 (CI 0.80 to 0.86) of CRP alone. White blood cell count and temperature were almost useless to discriminate acute colonic diverticulitis from other types of acute abdominal pain, AUC = 0.59 (CI 0.53 to 0.65) for white blood cell count and AUC = 0.57 (0.50 to 0.63) for temperature, respectively. CONCLUSION This prospective study demonstrates that standard clinical evaluation by non-specialist doctors based on history, physical examination, and initial blood tests on admission provides a high degree of diagnostic precision in patients with acute colonic diverticulitis.
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Affiliation(s)
- A Jamal Talabani
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7602, Levanger, Norway
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - B H Endreseth
- Clinic of Surgery, St Olavs Hospital, University of Trondheim, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - S Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare - Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - T-H Edna
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7602, Levanger, Norway.
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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[Prognostic value of the presence of pericolic air bubbles detected by computed tomography in acute diverticulitis]. CIR CIR 2016; 85:471-477. [PMID: 27955857 DOI: 10.1016/j.circir.2016.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diverticular disease is common in industrialized countries. Computed tomography has been used as the preferred diagnostic method; although different scales haves been described to classify the disease, none of them encompass total disease aspects and behaviour. OBJETIVE To analyze the patients with acute diverticulitis confirmed by computed tomography at the ABC Medical Center Campus Observatorio from January 1, 2010 to December 31, 2012, in whom pericolic free air in the form of bubbles was identified by computed tomography and if this finding can be considered as a prognostic factor for the disease. METHODS A series of 124 patients was analyzed who had acute diverticulitis confirmed by computed tomography, in order to identify the presence of pericolic bubbles. RESULTS Of the 124 patients, 29 presented with pericolic bubbles detected by computed tomography; of these, 62.1% had localized peritoneal signs at the time of the initial assessment, (P<.001); leukocytosis (13.33 vs 11.16, P<.001) and band count (0.97 vs 0.48, P<.001) was higher in this group. Patients with pericolonic bubbles had a longer hospital stay (5.5days vs 4.3days, P<.001) and started and tolerated liquids later (4.24days vs. 3.02days, P<.001) than the group of patients without this finding. CONCLUSIONS The presence of pericolic bubbles in patients with acute diverticulitis can be related to a more aggressive course of the disease.
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IPOD Study: Management of Acute Left Colonic Diverticulitis in Italian Surgical Departments. World J Surg 2016; 41:851-859. [DOI: 10.1007/s00268-016-3800-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Diverticulosis of the colon is a common condition in western countries. Acute diverticulitis may occur in 10% to 25% of the patients, sometimes associated with the presence of complications such as abscess, fistula, and perforation. Early diagnosis and accurate assessment of acute diverticulitis are necessary to start an efficacious treatment promptly, either conservatively or by surgery. The clinical picture may mimic other abdominal conditions; therefore, imaging techniques such as ultrasound or computed tomography are usually recommended, although they are expensive, examiner dependent, and potentially harmful. Recently, there has been increasing interest about the role of biological markers in diverticular disease as noninvasive, reliable, and inexpensive tools, conceivably able to support physicians in the diagnosis, the assessment of activity, and the monitoring of acute diverticulitis. By a MEDLINE search, most of the relevant data derived from C-reactive protein showed that it strongly supported the diagnosis of acute diverticulitis at values of >50 mg/L. It also represents a stronger marker compared with other serum biomarkers, able to correlate with the histologic severity in acute diverticulitis, the risk of perforation, and the response to therapy. Regarding fecal biomarkers, an interesting role has been reported for fecal calprotectin. It significantly correlates with inflammatory infiltrate. More relevantly, it correlates with the response to therapy and may predict the recurrence of colonic diverticulitis, as it is reliable in detecting subclinical intestinal inflammation, as reported already for inflammatory bowel disease. These represent encouraging results, but need to be confirmed in further larger studies.
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