Acute colonic diverticulitis: an update on clinical classification and management with MDCT correlation

Free perforation during the first episode of acute diverticulitis: can it be avoided?

The aims of the present study are to compare the severity of acute diverticulitis in the first episode and in later bouts, and to determine whether there are risk factors for the presence of free perforation at the onset of diverticulitis. A single-center retrospective study was conducted of patients who developed a first episode of acute diverticulitis between January 2011 and August 2021 diagnosed by computed tomography and followed up for at least 1 year. Free perforation was considered to be present in patients with diverticulitis stage III and IV according to the Hinchey classification (modified by Wasvary). The analysis included 394 patients (224 men and 170 women) with a mean age of 58 years. Forty-eight patients (12.2%) presented free perforation at some point in the course of the disease, 43 during the first episode and 5 during subsequent bouts. The perforation subgroup showed higher rates of stoma creation and mortality (relative risks of 12.3 and 23.5, respectively). In the multivariate analysis, age (OR: 1.041 95% CI 1.016-1.067), lung disease (OR 2.154 95% CI 1.038-4.472) and immunosuppression (OR: 2.812 95% CI 1.315-6.015) were independent factors for free perforation at diverticulitis onset. Free perforation occurs more frequently during the first episode of acute diverticulitis. Older patients, immunosuppressed patients and those with respiratory disease have a greater risk of presenting freely perforated diverticulitis. Therefore, it is essential to maintain a high level of clinical suspicion in these patients to activate early focus control and thus avoid fatal outcomes.

Neutrophil- and Platelet-Lymphocyte Ratio as Biomarkers of Severity in Complicated Diverticular Disease

INTRODUCTION

Diverticulitis is a prevalent gastrointestinal disease that may require surgical intervention. The aim of the study was to investigate the involvement of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) as biomarkers of severity in complicated diverticular disease (CDD) in Mexican patients and their correlation with the need for surgical intervention, the length of hospital stay, and mortality.

MATERIAL AND METHODS

An observational, longitudinal, and retrospective study performed from 2017 to 2021 was considered in patients over 18 years of age, with a diagnosis of CDD by using computed tomography and with a hemogram taken in the first 24 hours upon admission to the emergency department to describe the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) of NLR and PLR in the CDD.  Results: A total of 102 Mexican patients suffering from CDD, 54% women and 46% men with a mean of 59 years, were analyzed. According to Hinchey's classification, 79 (77.5%) patients showed type I, 12 (12.8%) type II, 5 (4.9%) type III, and 6 (5.9%) type IV. The mean hospital stay was 8.8 days, with a mortality rate of 3.9%. The cut-off value was established at 5.1 for NLR according to the results of the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.633, a sensitivity of 90%, a specificity of 43%, PPV of 21.8%, and NPV of 96% for the prediction of CDD. A cut-off value for PLR at 72 was established according to the results of the ROC curve with an AUC of 0.482, a sensitivity of 78%, a specificity of 40%, PPV of 96%, and NPV of 9% for the prediction of CDD.

CONCLUSION

The NLR and PLR are easily calculable and accessible biomarkers that can be part of the decision-making for the diagnosis and treatment of CDD in Mexican people as has been observed in other populations. However, more prospective, multicenter comparative studies are needed to assess the efficacy and safety of these biomarkers in relation to those already described.

Surgeon-Performed Point-of-Care Ultrasound in the Diagnosis of Acute Sigmoid Diverticulitis: A Pragmatic Prospective Multicenter Cohort Study

Background and purpose Early diagnosis and risk stratification of sigmoid diverticulitis rely heavily on timely imaging. Computerized tomography (CT), the gold standard diagnostic test, may be delayed due to resource constraints or patient comorbidity. Point-of-care ultrasound (POCUS) has an established role in trauma evaluation, and could potentially diagnose and stage acute diverticulitis, thus shortening the time to definitive treatment.  Aims This study aimed to benchmark the accuracy of surgeon-performed POCUS against CT in diagnosing and staging acute diverticulitis. A secondary aim was to evaluate the duration between the POCUS and the confirmatory CT scan report. Patients and methods A pragmatic prospective multicenter cohort study (ClinicalTrials.gov Identifier: NCT02682368) was conducted. Surgeons performed point-of-care ultrasound as first-line imaging for suspected acute diverticulitis. POCUS diagnosis and radiologic Hinchey classification were compared to CT as the reference standard. Results Of 45 patients with suspected acute diverticulitis, POCUS classified 37 (82.2%) as uncomplicated diverticulitis, four (8.8%) as complicated diverticulitis, and four (8.8%) as other diagnoses. The POCUS-estimated modified radiologic Hinchey classification was largely concordant with CT staging with an accuracy of 88.8% (95% CI, 75.95-96.2%), a sensitivity of 100% (95% CI, 90.2- 100%) and a specificity of 44.4% (95% CI, 13.7-78.8%). The positive predictive value (PPV) was 87.8% and the negative predictive value (NPV) was 100%. There was moderate agreement between CT and POCUS, with a Cohen's kappa coefficient of 0.56. The mean delay between CT and POCUS was 9.14 hours (range 0.33 to 43.5). Conclusion We examined the role of POCUS in the management of acute diverticulitis and our findings suggest that it is a promising imaging modality with the potential to reduce radiation exposure and treatment delays. Adding a POCUS training module to the surgical curriculum could enhance diagnosis and expedite the management of acute diverticulitis.

Value of computed tomography scores in complicated acute diverticulitis

BACKGROUND

Diverticular disease remains one of the most common conditions in the western world. Up to 25% of patients with diverticular disease require hospitalization, 15-30% of those of which require surgical intervention. CT scoring systems have been proposed as means to drive assessment and stratify patients necessitating hospital intervention. To assess and correlate CT scoring systems with clinical and surgical outcomes.

METHODS

Retrospective cohort analysis at a single institution. Single institutional assessment with patients presenting to emergency with a CT diagnosed episode of acute diverticulitis. One hundred and eighty-nine patients were included in the study, 61% of which were male. Patient demographics, comorbidities, medications, biochemistry and inflammatory markers, type of complication following acute diverticulitis, operative/procedural intervention, hospital outcome and mortality were measured. CT scoring systems assessed included modified Hinchey, modified Neff, World Society of Emergency Surgery (WSES) and modified Siewert scoring systems.

RESULTS

Majority of patients had left-sided diverticulitis (91%) with localized air (88%) and pericolic abscess (49%) the most common radiological findings. 28% of patients required radiological and/or surgical management with 12% requiring intensive care unit (ICU) admission. There was a general trend for surgical/radiological intervention as the scores increased in severity. The four scoring systems were found to be statistically significant predictors of any intervention and of ICU admission with minimal statistical differences across the different scoring systems.

CONCLUSION

Radiological CT scores for complicated diverticulitis are at best, moderate predictors of clinical and surgical outcomes and may serve to guide management with minimal statistical differences across different scores.

Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O₂ therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.

Ultrasound can differentiate complicated and noncomplicated acute colonic diverticulitis: a prospective comparative study with computed tomography

OBJECTIVE

To prospectively assess the diagnostic value of intestinal ultrasound (US) compared to computerized tomography (CT) in differentiating uncomplicated and complicated acute colonic diverticulitis (ACD).

MATERIALS AND METHODS

During a period of 14 months patients referred to the department of Radiology with clinical suspicion of ACD underwent an US examination. All confirmed US ACD diagnosis were included and subsequently underwent an emergency abdominal CT, used as gold standard. The WSES (World Society for Emergent Surgery) classification of diverticulitis was used. Diverticulitis was prospectively classified as either uncomplicated or complicated. Sensitivity, specificity, positive predictive value, and negative predictive values of US were evaluated. Before CT scan, the radiologist indicated whether they would have required or not a complementary CT scan, based on US findings.

RESULTS

Of the 240 patients included in our study, 71 (29.6%) were Stage 0, 127 (53%) Stage 1A, and 42 (17.5%) were moderate-severe ACD (stages 1B, 2A, 2B, 3 and 4). The sensitivity of US for diagnosing complicated ACD was 84% and specificity of 95.8%. Most patients (24 of 27) misclassified by US as uncomplicated diverticulitis were classified on CT as stage 1A. From the 148 cases in which the radiologist considered CT unnecessary, only 3 of these revealed signs of complicated ACD on CT; none of them required emergency surgery.

CONCLUSION

US is an effective technique to differentiate complicated from uncomplicated ACD. Our results suggest that US, may be a valuable alternative to CT for the initial radiologic evaluation in patients with clinical suspicion of ACD.

Will a flexi-sig' do? A retrospective review of colonoscopies indicated by diverticulitis alone

BACKGROUND

The incidence of colonic diverticulitis is increasing. In Australia the majority of diverticulitis occurs in the left colon and patients typically undergo colonoscopy following an attack. At present debate exists regarding the utility of this costly procedure and a flexible sigmoidoscopy has been proposed as a cheaper, less invasive alternative. This paper seeks to examine whether significant pathology is being detected in the right and transverse colon to warrant colonoscopy, as opposed to a flexible sigmoidoscopy.

METHODS

A retrospective review of colonoscopies performed between August 2016 and August 2018, indicated by diverticulitis alone, performed in a single Australian metropolitan hospital.

RESULTS

189 patient colonoscopies were reviewed in combination with the pathology forms. Only 1 primary colonic malignancy was detected, found in the left colon. 110 traditional adenomas and 35 sessile serrated adenomas were detected. 41.8% of patients had a polyp detected with an average of 1.9 polyps per patient. 38.6% of polyps were resected from the left colon while 61.4% were removed from the right and transverse colon. In total 30 polyps > 10 mm or with high-risk histological features were resected, 18 (60%) from the left colon and 12 (40%) from the right and transverse. 20 patients (10.6%) met the criteria for high-risk adenomas and 50% of those had > 40% of their polyps in the right and transverse colon. There was no significant difference in age between patients with polyps and those without.

CONCLUSION

Despite over half the patients having no polyps and only one left sided malignancy. This study demonstrates that the right and transverse colon is responsible for over 50% of the polyps removed and similar proportion of the advanced polyps. Where endoscopic surveillance after acute colonic diverticulitis is performed, this study supports the use of colonoscopy and cautions against flexible sigmoidoscopy alone.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

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.

Neutrophil-to-lymphocyte ratio as a predictor of complicated acute diverticulitis: A retrospective cohort study

Introduction

Currently, the debate on the usefulness of Neutrophil to Lymphocyte Ratio (NLR) as a predictor of complications in acute diverticulitis (AD) remains open, especially, the relation to the severity of the disease, the clinical impact, and the necessity of minimally invasive or emergency surgical procedures. On the other hand, its diagnostic efficacy has not been studied even in our field. The objective of the present study was to determine the utility and diagnostic precision of NLR in complicated acute diverticulitis (cAD).

Methods

Descriptive, retrospective cohort and analytical study. Patients older than 18 years with a diagnosis of AD were included, from 2013 to 2018. Demographic variables, days of hospitalization, leukocyte count, neutrophils, lymphocytes, ESR, CRP, and NLR were analyzed. The sensitivity and specificity for the diagnosis of cAD were determined using ROC curves.

Results

325 patients were included. Of these 196 (60%) were men. The median age was 52 years. A total of 30 (9%) were categorized as cAD. The patients with cAD presented mean values in the leukocyte count (14.02 ± 4.49 × 10⁹/l; p < 0.01), CRP (119.60 ± 87.67; p < 0.01) and NLR (7.61 ± 4.03; p < 0.01). An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD, with a sensitivity of 80%, a specificity of 64%, NPV of 96%, and PPV of 18%.

Conclusion

NLR is a predictive marker of cAD, with a cut-off point of 4.2 being the best diagnostic approach.

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About 10–15% of patients with acute diverticulitis (AD) can develop complications.

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The neutrophil-lymphocyte ratio (NLR) is a useful biomarker in predicting of severity of AD.

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The purpose was to determine the usefulness and diagnostic accuracy of NLR in complicated acute diverticulitis (cAD).

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An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD.

Clinical outcome for management of colonic diverticulitis: characteristics and surgical factor based on two institution data at South Korea

PURPOSE

The aim of this study was to analyze clinical outcomes after surgical and/or conservative management of patients with colonic diverticulitis.

MATERIAL AND METHODS

Between January 2001 and November 2018, data for 1175 patients (right (Rt.) side: n = 1037, left (Lt.) side: n = 138) who underwent conservative management (n = 987) and surgical management (n = 188) for colonic diverticulitis were retrieved from a retrospective database. The Rt. sided was defined up to the proximal two-thirds of the transverse colon and Lt. sided was defined from the distal one-third of the transverse colon.

RESULTS

The overall incidence of colonic diverticulitis is gradually increasing. The mean age of all patients was 43.2 ± 17 and was significantly higher in patients with Lt.-sided (57.0 ± 15.7) than with Rt.-sided (41.4 ± 13.4) diverticulitis (p = 0.001). The most common lesion site was cecum (71.7%, n = 843). First-time attacks were the most common (91.0%, n = 1069). The surgical rate was 12.2% on the right. sided and 44.9% on the left sided (p < 0.005). The mean age, age distribution, BMI, open surgery rate, stoma formation rate, and Hinchey types III and IV rate were significantly higher in Lt. sided than in Rt. sided (p < 0.005). Older age, higher BMI (≥ 25), and Hinchey types III and IV were significantly associated with surgical risk factors of diverticulitis (p < 0.005).

CONCLUSION

Base on present study, Lt.-sided colonic diverticulitis tends to be more severe than Rt. sided, and surgery is more often required. In addition, colonic diverticulitis that requires surgery seems to be older and more obese on Lt. sided.

Management and Outcomes of Diverticulitis After Lung Transplantation

INTRODUCTION

Most lung transplant patients are older than 50 years. Complications from colonic diverticula are not uncommon, especially with chronic immunosuppression. However, limited data exist regarding the optimal management of these patients. We sought to investigate the incidence, risk factors, and outcomes of diverticulitis after lung transplant.

METHODS

We conducted a retrospective study to review patients undergoing lung transplant between 2007 and 2016 with posttransplant acute colonic diverticulitis. Patients were grouped based on medical or surgical management.

RESULTS

Of 512 transplant recipients, 17 (3.32%) developed 26 episodes of diverticulitis over a median follow-up of 39 months. Nine patients had documented diverticulosis on pretransplant colonoscopy. These patients had a higher incidence of surgical intervention for diverticulitis, were more likely to have recurrent diverticulitis, and had longer lengths of stay than patients without pretransplant diverticulosis. Six (35.3%) of 17 patients required surgery (ie, Hartmann procedure; 4 during the initial episode and 2 during their third and fourth episodes); 11 patients (64.7%) were managed with antibiotics alone. Patients in the surgical group presented earlier posttransplant (P = .004) and were on higher doses of tacrolimus (P = .03). Six (46.1%) of 13 patients with medically managed first episodes of diverticulitis experienced recurrence. No recurrence occurred after surgical management. No deaths were attributable to diverticulitis in either group.

CONCLUSIONS

Patients with pretransplant diverticulosis experienced earlier, more complicated episodes of diverticulitis posttransplant than patients without. Surgical patients received higher doses of tacrolimus and presented earlier than medical patients. Uncomplicated diverticulitis in posttransplant patients can be managed medically, even in the case of recurrent, uncomplicated disease.

Acute diverticulitis: old challenge, current trends, open questions

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.

Effects of Radiation Dose Reduction on Diagnostic Accuracy of Abdominal CT in Young Adults with Suspected Acute Diverticulitis: A Retrospective Intraindividual Analysis

RATIONALE AND OBJECTIVES

To assess the effects of radiation dose reduction on image quality and diagnostic accuracy of abdominal computed tomography (CT) in young adults with suspected acute diverticulitis.

MATERIALS AND METHODS

Fifty-four patients ≤40 years who received contrast-enhanced abdominal CT for suspected acute diverticulitis were included. Low-dose CT (LDCT) datasets (25%, 50%, and 75% of the original dose) were generated using sinogram synthesis and quantum noise modeling. A five-point scale was used to assess images qualitatively (overall image quality, noise, artefacts, and sharpness) and for diagnostic confidence (5 being the best possible outcome). Furthermore, the diagnostic accuracy was determined for the presence of acute diverticulitis.

RESULTS

Among 54 patients (mean age: 35.2 ± 5.3 years, 77.8% male), the prevalence of acute diverticulitis was high (57.4%). Subjective image quality was highest for original datasets and lowest for LDCT datasets with 25% of the original dose (median [interquartile range]: 5 [5] vs. 3 [2-3], p < 0.001). Diagnostic confidence was high for all datasets down to 50% of the original dose, while 25% LDCT datasets were associated with a significantly decreased diagnostic confidence (p < 0.001). Diagnostic accuracy was high for all LDCT and original datasets (sensitivity: 100%, negative predictive value [NPV]: 100% for 75% and 100% dose levels; sensitivity: 96.8%, NPV: 95.8% for 50% dose level; sensitivity: 93.6%, NPV: 91.7% for 25% dose level, respectively). Inter-rater agreement regarding the detection of diverticulitis was almost perfect at doses ≥50% (kappa: >0.81), while lower for datasets of 25% of the original radiation dose agreement (kappa: 0.67-0.78).

CONCLUSION

Radiation dose reduction down to 50% of the original radiation exposure permits high image quality, diagnostic confidence, and accuracy for the assessment of acute diverticulitis in abdominal CT in young adults without the use of iterative reconstruction algorithms.

The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon

Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.

Current Status of the Radiologic Assessment of Diverticular Disease

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