Long-Term Evolution of Acute Colonic Diverticulitis After Successful Medical Treatment

Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case-control study

BACKGROUND

This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses.

METHODS

This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed.

RESULTS

Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23).

CONCLUSIONS

Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.

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.

Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group

AIM

Management of diverticulitis with abscess formation in immunosuppressed patients (IMS) remains unclear. The main objective of the study was to assess short- and long-term outcomes between IMS and immunocompetent patients (IC). The secondary aim was to identify risk factors for emergency surgery.

METHODS

A nationwide retrospective cohort study was performed at 29 Spanish referral centres between 2015-2019 including consecutive patients with first episode of diverticulitis classified as modified Hinchey Ib or II. IMS included immunosuppressive therapy, biologic therapy, malignant neoplasm with active chemotherapy and chronic steroid therapy. A multivariate analysis was performed to identify independent risk factors to emergency surgery in IMS.

RESULTS

A total of 1395 patients were included; 118 IMS and 1277 IC. There were no significant differences in emergency surgery between IMS and IC (19.5% and 13.5%, p = 0.075) but IMS was associated with higher mortality (15.1% vs. 0.6%, p < 0.001). Similar recurrent episodes were found between IMS and IC (28% vs. 28.2%, p = 0.963). Following multivariate analysis, immunosuppressive treatment, p = 0.002; OR: 3.35 (1.57-7.15), free gas bubbles, p < 0.001; OR: 2.91 (2.01-4.21), Hinchey II, p = 0.002; OR: 1.88 (1.26-2.83), use of morphine, p < 0.001; OR: 3.08 (1.98-4.80), abscess size ≥5 cm, p = 0.001; OR: 1.97 (1.33-2.93) and leucocytosis at third day, p < 0.001; OR: 1.001 (1.001-1.002) were independently associated with emergency surgery in IMS.

CONCLUSION

Nonoperative management in IMS has been shown to be safe with similar treatment failure than IC. IMS presented higher mortality in emergency surgery and similar rate of recurrent diverticulitis than IC. Identifying risk factors to emergency surgery may anticipate emergency surgery.

How do we diagnose acute diverticulitis? Results of a national survey about the role of imaging techniques

INTRODUCTION

The choice of imaging techniques in the diagnosis of acute diverticulitis is controversial. This study aimed to determine radiologists' preferences for different imaging techniques in the management of acute diverticulitis and the extent to which they use the different radiologic techniques for this purpose.

METHODS

An online survey was disseminated through the Spanish Society of Abdominal Imaging (Sociedad Española de Diagnóstico por Imagen del Abdomen (SEDIA)) and Twitter. The survey included questions about respondents' working environments, protocolization, personal preferences, and actual practice in the radiological management of acute diverticulitis.

RESULTS

A total of 186 responses were obtained, 72% from radiologists working in departments organized by organ/systems. Protocols for managing acute diverticulitis were in force in 48% of departments. Ultrasonography was the initial imaging technique in 47.5%, and 73% of the respondents considered that ultrasonography should be the first-choice technique; however, in practice, ultrasonography was the initial imaging technique in only 24% of departments. Computed tomography was the first imaging technique in 32.8% of departments, and its use was significantly more common outside normal working hours. The most frequently employed classification was the Hinchey classification (75%). Nearly all (96%) respondents expressed a desire for a consensus within the specialty about using the same classification. Hospitals with >500 beds and those organized by organ/systems had higher rates of protocolization, use of classifications, and belief that ultrasonography is the best first-line imaging technique.

CONCLUSIONS

The radiologic management of acute diverticulitis varies widely, with differences in the protocols used, radiologists' opinions, and actual clinical practice.

Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

Management of diverticular abscess (DA) is still controversial. Antibiotic therapy is indicated in abscesses ≤ 4 cm, while percutaneous drainage/surgery in abscesses > 4 cm. The study aims to assess the role of antibiotics and surgical treatments in patients affected by DA. We retrospectively analyzed 100 consecutive patients with DA between 2013 and 2020, with a minimum follow-up of 12 months. They were divided into two groups depending on abscess size ≤ or > 4 cm (group 1 and group 2, respectively). All patients were initially treated with intravenous antibiotics. Surgery was considered in patients with generalized peritonitis at admission or after the failure of antibiotic therapy. The primary endpoint was to compare recurrence rates for antibiotics and surgery. The secondary endpoint was to assess the failure rate of each antibiotic regimen resulting in surgery. In group 1, 31 (72.1%) patients were conservatively treated and 12 (27.9%) underwent surgery. In group 2, percentages were respectively 50.9% (29 patients) and 49.1% (28 patients). We observed 4 recurrences in group 1 and 6 in group 2. Recurrence required surgery in 3 patients/group. We administered amoxicillin-clavulanic acid to 74 patients, piperacillin-tazobactam to 14 patients and ciprofloxacin + metronidazole to 12 patients. All patients referred to surgery had been previously treated with amoxicillin-Powered by Editorial Manager^® and ProduXion Manager^® from Aries Systems Corporation clavulanic acid. No percutaneous drainage was performed in a hundred consecutive patients. Surgical treatment was associated with a lower risk of recurrence in patients with abscess > 4 cm, compared to antibiotics. Amoxicillin-clavulanic acid was associated with a higher therapeutic failure rate than piperacillin-tazobactam/ciprofloxacin + metronidazole.

Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: Value of current severity classification schemes

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.

The outcomes of right-sided and left-sided colonic diverticulitis following non-operative management: a systematic review and meta-analysis

Background

There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.

Methods

A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.

Results

Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8–13%, I² = 86%, p < 0.01) in right-sided and 20% (95% CI 16–24%, I² = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6–13%, I² = 77%, p < 0.01) in right-sided and 15% (95% CI 8–27%, I² = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2–10%, I² = 84%, p < 0.01) in right-sided and 4% (95% CI 2–7%, I² = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.

Conclusion

Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.

Is There an Impact of the Duration of Antibiotic Therapy on the Outcome of Nonsurgical Treatment of Complicated Diverticulitis?

BACKGROUND

Patients treated nonsurgically for complicated diverticulitis are managed by antibiotics. However, there are no recommendations concerning their duration. We aimed to determine the impact of the duration of antibiotic therapy on the risk of failure of nonsurgical treatment of complicated acute diverticulitis.

PATIENTS AND METHODS

This was a single-center retrospective study of patients with computer tomography (CT)-diagnosed complicated diverticulitis between January 2015 and April 2020. Treatment failure was defined as early recurrence and/or a persistent abscess by control CT.

RESULTS

In total, 148 patients fulfilled the inclusion criteria [87 men (58.8%), mean age 55±15 y]. The diverticulitis was classified as Hinchey I in 41.9%, Hinchey II in 9.5%, and pericolic free air in 48.6% of cases. The median abscess size was 2.9±1.7 cm. The median duration of antibiotic treatment was 10±4.2 days. The median follow-up was 64±60 months. The rate of failure was 12.8%. In univariate analysis, treatment >10 days (P=0.015) and an abscess >3 cm (P=0.032) were associated with a risk of treatment failure. In multivariate analysis, only the diameter of the abscess remained associated with a risk of failure (odds ratio: 1.6, 95% confidence interval: 1.09-2.4, P=0.01).

CONCLUSION

This study suggests that there is no need to extend the duration of antibiotic treatment beyond 10 days in nonsurgically treated complicated acute diverticulitis.

Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review

BACKGROUND

The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof.

METHOD

Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared.

RESULTS

Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%).

CONCLUSION

This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.

Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: value of current severity classification schemes

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.

CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study

Purpose

To perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD).

Methods

Fifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0–3 point scale for each variable.

Results

Of 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors.

Conclusion

DDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.

The Indications for and Timing of Surgery for Diverticular Disease

BACKGROUND

Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease.

METHODS

This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease.

RESULTS

Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails.

CONCLUSION

The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.

A systematic review and meta-analysis of disease severity and risk of recurrence in young versus elderly patients with left-sided acute diverticulitis

Young patients are thought to have a more severe disease course and a higher rate of recurrent diverticulitis. However, these understandings are mainly based on studies with important limitations. This review aimed to clarify the true natural history of acute diverticulitis in young patients compared to elderly patients. PubMed and MEDLINE were searched for studies reporting outcomes on disease severity or recurrences in young and elderly patients with a computed tomography-proven diagnosis of acute diverticulitis. Twenty-seven studies were included. The proportion of complicated diverticulitis at presentation (21 studies) was not different for young patients (age cut-off 40-50 years) compared to elderly patients [risk ratio (RR) 1.19; 95% confidence interval 0.94-1.50]. The need for emergency surgery (11 studies) or percutaneous abscess drainage (two studies) yielded comparable results for both groups with a RR of 0.93 (95% confidence interval 0.70-1.24) and 1.65 (95% confidence interval 0.60-4.57), respectively. Crude data on recurrent diverticulitis rates (12 studies) demonstrated a significantly higher RR of 1.47 (95% confidence interval 1.20-1.80) for young patients. Notably, no association between age and recurrent diverticulitis was found in the studies that used survival analyses, taking length of follow-up per age group into account. In conclusion, young patients do not have a more severe course of acute diverticulitis. Published data on the risk of recurrent diverticulitis in young patients are conflicting, but those with the most robust design do not demonstrate an increased risk. Therefore, young patients should not be treated more aggressively nor have a lower threshold for elective surgery just because of their age.

Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess

PURPOSE

The aim of this systematic review was to determine the rates of failure following nonoperative management for acute sigmoid diverticulitis complicated by abscess.

METHODS

Pubmed and Medline were systematically searched by two independent researchers. Studies reporting outcomes of nonoperative management of diverticulitis with abscess revealed on CT scan were included. The endpoint of the study was failure of nonoperative management which included relapse and recurrence. Relapse was defined as development of additional complications such as peritonitis or obstruction that required urgent surgery during index admission or readmission within 30 days. Recurrence was defined as development of symptoms after an asymptomatic period of 30-90 days following nonoperative management. Nonoperative management included nil per os, intravenous fluids and antibiotics, CT-guided percutaneous drainage, and/or total parenteral nutrition.

RESULTS

Twenty-four of 844 studies yielded by literature search totaling 12,601 patients were eligible for inclusion. Pooled relapse rate was 18.9%. The pooled rate of recurrence of acute diverticulitis was found to be 25.5%. 60.9% of recurrences were complicated diverticulitis. Failure rate appeared to be significantly increased in patients undergoing percutaneous drainage for distant abscess as compared with pericolic abscess (51% vs. 18%; p = 0.0001).

CONCLUSION

The rate of failure of nonoperative management was 44.4%. The rate of relapse at 30 days following nonoperative management was at 18.9%. Distant abscesses were associated with significantly increased rates of relapse compared with pericolic abscesses. The rate of recurrence following nonoperative management was 25.5% at the mean follow-up of 38 months.

Multicentre study of non-surgical management of diverticulitis with abscess formation

This multicentre retrospective cohort study included 447 patients with Hinchey Ib and II diverticular abscesses, who were treated with antibiotics, with or without percutaneous drainage. Abscesses of 3 and 5 cm in size were at higher risk of short‐term treatment failure and emergency surgery respectively. Initial non‐surgical treatment of Hinchey Ib and II diverticular abscesses was comparable between patients treated with antibiotics only and those who underwent percutaneous drainage in combination with antibiotics, with regard to short‐ and long‐term outcomes.

Most do not need drainage

Differences between computed tomoghaphy and surgical findings in acute complicated diverticulitis

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.

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.

Severity of Diverticulitis Does Not Influence Abdominal Complaints during Long-Term Follow-Up

BACKGROUND

Diverticulitis can lead to localized or generalized peritonitis and consequently induce abdominal adhesion formation. If adhesions would lead to abdominal complaints, it might be expected that these would be more prominent after operation for perforated diverticulitis with peritonitis than after elective sigmoid resection.

AIMS

The primary outcome of the study was the incidence of abdominal complaints in the long-term after acute and elective surgery for diverticulitis.

METHODS

During the period 2003 through 2009, 269 patients were operated for diverticular disease. Two hundred eight of them were invited to fill out a questionnaire composed of the gastrointestinal quality of life index and additional questions and finally 109 were suitable for analysis with a mean follow-up of 7.5 years.

RESULTS

Analysis did not reveal any significant differences in the incidence of abdominal complaints or other parameters.

CONCLUSION

This retrospective study on patients after operation for diverticulitis shows that in the long term, the severity of the abdominal complaints is influenced neither by the stage of the disease nor by the fact of whether it was performed in an acute or elective setting.

Impact of CT imaging on predicting the surgical management of acute diverticulitis

Purpose

The incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment.

Methods

Three hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index.

Results

After propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively).

Conclusion

This study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.

Long-term mortality and recurrence in patients treated for colonic diverticulitis with abscess formation: a nationwide register-based cohort study

PURPOSE

The study aimed to investigate long-term mortality, recurrence, and death related to recurrence for patients admitted with acute diverticulitis with abscess formation (Hinchey stage Ib-II).

METHODS

The cohort was identified by linking administrative registers for all Danish citizens in years 2000-2012. Patients were identified from ICD-10 discharge codes and stratified according to treatment (antibiotics, percutaneous abscess drainage, or surgery).

RESULTS

From 6,641,672 persons, 3148 patients were identified with acute diverticulitis with abscess formation. Survival was comparable between treatment groups with a 1-year survival of 81-83% and a 5-year survival of 66-67% (p = 0.66). Glucocorticoid usage prior to admission increased risk of mortality with hazard ratio 1.64 (95%CI 1.39-1.93), 1.77 (1.20-2.63), and 1.92 (1.07-3.44) for the antibiotics, drainage, and operative treatment group, respectively. Drainage treatment increased risk of recurrence with sub-distribution hazard (SDH) of 1.52 (1.19-1.95) and operative treatment decreased risk with a SDH of 0.55 (0.32-0.93), both compared with antibiotic treatment (p = 0.0001). Recurrence occurred in 23.6% (18.5-30.1%) of patients in the drainage group, 15.5% (13.9-17.3%) in the antibiotics group, and 9.1% (5.1-16.1%) in the operative group. Recurrence-related mortality was 2.0% (0.9-4.4%) for the drainage group, 1.1% (0.7-1.8%) for the antibiotics group, and 0.6% (0.1-4.3%) for the operative group (p = 0.24). Most recurrences and recurrence-related mortality occurred within the first year after primary admission.

CONCLUSIONS

This study with complete national data revealed a high mortality and recurrence rate after diverticular abscesses. Survival was comparable between treatment groups, but patients treated with drainage had significantly higher risk of recurrence.

5-aminosalicylic acid agents for prevention of recurrent diverticulitis: A systematic review and meta-analysis

BACKGROUND AND AIM

Prevalence of colonic diverticulosis is increasing worldwide with age, and up to 25% of patients who have colonic diverticulosis might experience diverticulitis. However, a definitive approach of preventing recurrent diverticulitis remains unknown. 5-aminosalicylic acid (5-ASA) agents are anti-inflammatory agents and have been used to prevent recurrent diverticulitis, and there have been some randomized clinical trials (RCTs). However, the efficacy results for secondary prevention in uncomplicated diverticulitis differed across studies. Our aim was to clarify the efficacy and safety of 5-ASA agents in the prevention of recurrent diverticulitis.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and the Cochrane library with no language restrictions. Two reviewers independently assessed and selected RCTs. The data were pooled using a random effect model and were presented in the pooled risk ratio (RR) and 95% confidence interval (CI). Cochrane's Q and I-squared statistics were used to assess heterogeneity. The protocol was registered at PROSPERO.

RESULTS

Seven articles with eight RCTs from 329 potentially relevant articles were included. 5-ASA agents were not superior to controls in preventing recurrent diverticulitis (RR 0.86, 95% CI 0.63 to 1.17, I²  = 60%) and the incidence of adverse events was not different between 5-ASA agents and controls (RR 0.97, 95% CI 0.84 to 1.11, I²  = 45%). However, some included studies were few in number of participants and substantial risk of bias.

CONCLUSIONS

5-aminosalicylic acid agents were not associated with prevention of recurrent diverticulitis.

Conservative Treatment of Acute Colonic Diverticulitis

Purpose of Review

Since the treatment of acute diverticulitis has become more conservative over the last years, knowledge of conservative treatment strategies is increasingly important.

Recent Findings

Several treatment strategies that previously have been imposed as routine treatment are now obsolete. Uncomplicated diverticulitis patients can be treated without antibiotics, without bed rest, and without dietary restrictions; and a selected group of patients can be treated as outpatients. Also, patients with isolated pericolic extraluminal air can be treated conservatively as well. Whereas some patient subgroups have been suggested to suffer from a more virulent disease course or higher recurrence rates, current evidence does not support all traditional understandings. Patients on immunosuppression or non-steroidal anti-inflammatory drugs seem to have a higher risk of complicated diverticulitis, but young patients do not. Data on the risk of recurrent diverticulitis in young patients is conflicting but the risk seems comparable to elderly patients. Besides the traditional treatments, several new treatment strategies have emerged but have failed thus far. Mesalazine does not have any beneficial effect on preventing recurrent diverticulitis based on current literature. Rifaximin and probiotics have been studied insufficiently in acute diverticulitis patients to conclude on their efficacy.

Summary

This review provides an overview of recent developments in conservative treatment strategies of acute diverticulitis and discusses the latest evidence on patient subgroups that have been suggested to suffer from an aberrant disease course.

Impact of diverticular inflammation and complication assessment classification on the burden of medical therapies in preventing diverticular disease complications in Italy

BACKGROUND

Several treatments are currently advised to manage diverticular disease (DD) patients, but their impact on the burden of the disease is unknown. Our aim was to assess the economic analysis of using the recent Diverticular Inflammation and Complication Assessment (DICA) endoscopic classification on the burden of medical therapies prescribed in preventing DD complications occurrence in Italy.

METHODS

We assessed retrospectively the cost/year of treatments in estimated DICA 1, DICA 2 and DICA 3 population. Analysis of diverticulosis prevalence was estimated according to data population provided by Italian Institute of Statistics (ISTAT). Cost of treatments calculated according to data on drugs' consumption collected during the DICA study.

RESULTS

We estimated that >8 million of Italian people >60 years may have diverticulosis, and that about 75% of diverticular population are on DICA 1, about 30% on DICA 2, and about 13% on DICA 3. We estimated that >387 million of euros could be spent in DICA 1 population, >203 million of euros in DICA 2 population, and >88 million of euros in DICA 3 population. Since medical treatments did not show any significant advantage when treating DICA 1 and DICA 3 people in terms of prevention of acute diverticulitis occurrence/recurrence and surgery occurrence, we can estimated that >475 million of euros could be spent in Italy without any significant benefit in preventing DD complications occurrence.

CONCLUSIONS

DICA endoscopic classification may have a significant impact on the burden of DD in Italy, because it helps to select DD people who effectively need treatments in terms of prevention of acute diverticulitis occurrence/recurrence and surgery occurrence.

Risk factors for recurrence after acute colonic diverticulitis: a systematic review

PURPOSE

Several factors may influence the risk of recurrence after an episode of acute colonic diverticulitis. Until now, a comprehensive systematic overview and evaluation of relevant risk factors have not been presented. This review aimed at assembling and evaluating current evidence on risk factors for recurrence after conservatively treated acute colonic diverticulitis.

METHODS

PubMed, Embase, and Cochrane databases were searched for studies evaluating risk factors for recurrence after acute diverticulitis treated non-surgically defined as antibiotic treatment, percutaneous abscess drainage, or by observation. Randomized clinical trials and observational studies were included. Analyzed outcome variables were extracted and grouped. No meta-analysis was performed due to low inter-study comparability. Variables were rated according to their likelihood of causing recurrence (no/low, medium, high).

RESULTS

Of 1153 screened records, 35 studies were included, enrolling 396,676 patients with acute diverticulitis. A total of 50,555 patients experienced recurrences. Primary diverticulitis with abscess formation and young age increased the risk of recurrence. Readmission risk was higher within the first year after remission. In addition, the risk of subsequent diverticulitis more than doubled after two earlier episodes of diverticulitis and the risk increased further for every episode.

CONCLUSIONS

The best treatment strategy for recurrent diverticulitis is undetermined. However, the risk of a new recurrence seemed to increase after each recurrence making elective resection a viable option at some point after multiple recurrences depending on patient risk factors and preferences.

Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review

PURPOSE

This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options.

METHODS

PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence.

RESULTS

Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain.

CONCLUSIONS

Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.

Outcomes of colonic diverticulitis according to the reason of immunosuppression

BACKGROUND

The aims of this study were to analyze the relationship between the different causes of immunosuppression (IMS) and diverticulitis.

METHODS

IMS patients admitted for colonic diverticulitis were included in the study. Patients were divided in 5 groups according to the reasons of IMS: group I, chronic corticosteroid therapy; group II, transplant patients; group III, malignant neoplasm disease; group IV, chronic renal failure; group V, others immunosuppressant treatment. Rate of emergency surgery, outcomes in terms of postoperative mortality, and recurrence rate after nonoperative management were analyzed according to the reason of IMS.

RESULTS

Emergency surgery was performed in 76 patients (39.3%). It was needed more frequently in group I. Overall, postoperative mortality was of 31.6% and recurrence rate after successful nonoperative management occurred in 30 patients (27.8%). No differences were observed among the groups.

CONCLUSIONS

The rate of emergency surgery in IMS patients at the first episode of acute colonic diverticulitis is high. Elective surgery in IMS patients should be individually indicated according to persistence of symptoms or early recurrences.

The role of low CRP values in the prediction of the development of acute diverticulitis

PURPOSE

Computed tomography (CT) is the most appropriate imaging modality for the assessment of acute diverticulitis at the emergency unit. The aim of this study was to determine the clinical outcome of the patients presented first time with symptoms of acute diverticulitis and low CRP values.

METHODS

Two-hundred patients, who presented with the symptoms of acute diverticulitis and had CRP values under 150 mg/L, underwent abdominal CT examination on admission to Oulu University Hospital. The clinical parameters and radiological findings were compared in relation to clinical outcome both by means of univariate and multivariate analyses.

RESULTS

Seventy-one (35.5 %) of the 200 patients presented on admission with complicated diverticulitis. CRP values between 100 and 150 mg/L predicted complicated disease, but the mean values of CRP between uncomplicated disease, 89 mg/L ± 39, and complicated disease, 101 mg/L ± 39, did not differ significantly. Free intra-abdominal fluid in CT was the only independent risk factor of the need for interventional therapy and treatment in the intensive care unit. Longevity of the patients and free fluid in CT predicted significantly prolonged hospitalization. Mortality was 1 % and older patients were significantly affected. The recurrence rate of acute diverticulitis was 24 % (43/177) in the whole group and 18 % (23/129) after uncomplicated diverticulitis.

CONCLUSIONS

Low CRP values do not reliably predict uncomplicated disease in patients presented first time at the emergency unit with acute diverticulitis. We recommend that the need for abdominal CT is carefully evaluated according to the patient's clinical status, always even when the CRP value is under 150 mg/L.

Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography

The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.