Conservative Treatment of Acute Colonic Diverticulitis

Acute diverticulitis management: evolving trends among Italian surgeons. A survey of the Italian Society of Colorectal Surgery (SICCR)

Acute diverticulitis (AD) is associated with relevant morbidity/mortality and is increasing worldwide, thus becoming a major issue for national health systems. AD may be challenging, as clinical relevance varies widely, ranging from asymptomatic picture to life-threatening conditions, with continuously evolving diagnostic tools, classifications, and management. A 33-item-questionnaire was administered to residents and surgeons to analyze the actual clinical practice and to verify the real spread of recent recommendations, also by stratifying surgeons by experience. CT-scan remains the mainstay of AD assessment, including cases presenting with recurrent mild episodes or women of child-bearing age. Outpatient management of mild AD is slowly gaining acceptance. A conservative management is preferred in non-severe cases with extradigestive air or small/non-radiologically drainable abscesses. In severe cases, a laparoscopic approach is preferred, with a non-negligible number of surgeons confident in performing emergency complex procedures. Surgeons are seemingly aware of several options during emergency surgery for AD, since the rate of Hartmann procedures does not exceed 50% in most environments and damage control surgery is spreading in life-threatening cases. Quality of life and history of complicated AD are the main indications for delayed colectomy, which is mostly performed avoiding the proximal vessel ligation, mobilizing the splenic flexure and performing a colorectal anastomosis. ICG is spreading to check anastomotic stumps' vascularization. Differences between the two experience groups were found about the type of investigation to exclude colon cancer (considering the experience only in terms of number of colectomies performed), the size of the peritoneal abscess to be drained, practice of damage control surgery and the attitude towards colovesical fistula.

Diverticular Disease and Rifaximin: An Evidence-Based Review

There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.

Identifying patients with complicated diverticulitis, is it that complicated?

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Randomized control trial on the efficacy of Limosilactobacillus reuteri ATCC PTA 4659 in reducing inflammatory markers in acute uncomplicated diverticulitis

INTRODUCTION

Recent guidelines suggest treating acute uncomplicated diverticulitis (AUD) without antibiotics. We tested the efficacy of Limosilactobacillus reuteri ATCC PTA 4659 in AUD. Primary outcome was the reduction of abdominal pain and inflammatory markers [C-reactive protein (C-RP) and calprotectin]. Secondary outcome was the reduction of hours of hospitalization.

PATIENTS AND METHODS

A double-blind, randomized controlled trial was conducted in 119 patients with AUD. The probiotic group (61 patients) was treated with fluids, bowel rest and L. reuteri/b.i.d. for 10 days. The placebo group (58 patients) was treated with the same therapy and placebo/b.i.d. for 10 days. All patients completed a daily visual analogue scale (VAS) for abdominal pain.

RESULTS

Both groups showed a mean VAS score of 7 at enrolment and a reduction of 4 points after 3 days. C-RP value, after 72 h, decreased by 58.8% in the probiotic group and by only 40% in the placebo group (P < 0.05). Calprotectin levels, after 72 h, decreased by 17% in the probiotic group and by only 10.6% in the control group (P < 0.05). In the probiotic group, the hospitalization was done for 75.5 h compared to 83.5 in the placebo group.

CONCLUSIONS

The supplementation with L. reuteri 4659 together with bowel rest and fluids significantly reduced both blood and faecal inflammatory markers compared to the placebo group.

Management and long-term outcomes of acute right colonic diverticulitis and risk factors of recurrence

Background

Acute right-sided colonic diverticulitis (RCD) is a common disease in Asian populations for which the optimal treatment remains controversial. The aim of this study was to investigate management and evaluate long-term outcomes of treatment in patients with acute RCD.

Methods

We retrospectively collected and analyzed clinical data for patients with acute RCD admitted to the Tongren Hospital, Shanghai Jiao Tong University School of Medicine from December 2015 to December 2020. The patients were divided into two groups, according to primary treatment strategy, which was either conservative treatment or surgical treatment.

Results

A total of 162 consecutive patients with acute RCD were enrolled in the study. There was no significant difference in age, sex, history of abdominal surgery, medical co-morbidities, fever, previous history of RCD, treatment success rate and incidence of complications between the conservative and surgery groups. However, the recurrence rate in conservative groups was significantly higher than in surgery groups (16.53% vs 2.44%, P = 0.020). And more frequent bowel movements and previous history of RCD increased the risk of recurrence of acute RCD. Moreover, there was no significant difference in either treatment success rate or the overall recurrence rate between the patients with uncomplicated diverticulitis and patients with complicated diverticulitis.

Conclusions

Surgical treatment is also safe and effective for acute RCD. Surgical treatment should mainly be considered for patients with acute RCD with recurrence risk factors (more frequent bowel movements and previous history of RCD) or with complicated acute RCD.

Acute Diverticulitis in Young Patients: A Review of the Changing Epidemiology and Etiology

Acute diverticulitis is one of the leading gastrointestinal causes for hospitalization. The incidence of acute diverticulitis has been increasing in recent years, especially in patients under 50 years old. Historically, acute diverticulitis in younger patients was felt to represent a separate entity, being more virulent and associated with a higher rate of recurrence. Accordingly, young patients were often managed differently to older counterparts. Our understanding of the natural history of this condition has evolved, and current clinical practice guidelines suggest age should not alter management. The purpose of this review is to evaluate the changing epidemiology of acute diverticulitis, consider potential explanations for the observed increased incidence in younger patients, as well as review the natural history of acute diverticulitis in the younger population.

Accuracy of specific free air distributions in predicting the localization of gastrointestinal perforations

PURPOSE

To evaluate the role of specific distributions of free air in predicting the location of gastrointestinal (GI) tract perforation.

MATERIALS AND METHODS

One hundred and fifteen patients with surgically proven GI tract perforation between January 2015 and June 2019 were included in the study. The site of perforation was based on surgical findings in all cases. Two radiologists retrospectively interpreted the computed tomography (CT) images of these patients for extraluminal free air distribution. Perforation sites were demonstrated intraoperatively in all cases and were categorized as follows: stomach and duodenum, jejunum and ileum, proximal colon (cecum, ascending colon, and transverse colon), distal colon (descending colon and sigmoid colon), rectum, and appendix.

RESULTS

There were 79 male and 36 female patients with a mean age of 56.4 years. Periportal, perihepatic, and perigastric free air were statistically significant in predicting gastroduodenal perforation. Mesenteric free air was significant in predicting both small bowel and distal colon perforations. Pelvic free air was statistically significant in distal colon perforations. Periappendiceal free air was found to be a strong predictor of acute perforated appendicitis.

CONCLUSION

Specific free air distributions may help to predict the site of gastrointestinal perforation, which would change the treatment plan.

Drains, Germs, or Steel: Multidisciplinary Management of Acute Colonic Diverticulitis

The medical and surgical management of uncomplicated diverticulitis has changed over the last several years. Although immunocompetent patients or those without comorbidities can be treated with antibiotics as an outpatient, the efficacy of high-fiber intake or drugs such as mesalamine or rifaximin is not yet clearly established in the treatment of acute episodes and in the prevention of recurrences. On the other hand, the choice between antibiotic treatment and percutaneous drainage is not always obvious in diverticulitis complicated by abscess formation, especially for larger abscesses; although the results of studies comparing the two approaches remain controversial, surgery must be pursued for abscesses > 8 cm. For emergency surgery, the debate is still ongoing regarding laparoscopic lavage and surgical resection followed by primary anastomosis, since for both approaches the published reports are not in agreement regarding possible benefits. Therefore, these approaches are recommended only for selected patients under the care of experienced surgeons. Also, the contribution of elective surgery toward the overall approach has been revised; currently, it is reserved primarily for patients with a high risk of recurrence and whenever more conservative treatments were not effective.

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.

Recent advances in understanding and managing diverticulitis

In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single 'causa prima' will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies.