Diverticulitis in the younger patient

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.

Risk factors for complicated diverticulitis: systematic review and meta-analysis

PURPOSE

The aim of this systematic review is to identify risk factors that can predict complicated diverticulitis. Uncomplicated diverticulitis is a self-limiting and mild disease, but 10% of patients with diverticulitis develop complications requiring further treatment. It is important to estimate the risk of developing complicated diverticulitis at an early stage to set the right treatment at initial presentation.

METHODS

Embase, MEDLINE, and Cochrane databases were searched for studies reporting on risk factors for complicated diverticulitis. Complicated diverticulitis was defined as Hinchey ≥Ib or severe diverticulitis according to the Ambrosetti criteria. Meta-analyses were performed when at least four studies reported on the outcome of interest. This study was conducted according to the PRISMA guidelines.

RESULTS

A total of 12 studies were included with a total of 4619 patients. Most were of reasonable quality. Only the risk factors "age" and "sex" were eligible for meta-analysis, but none showed a significant effect on the risk for complicated diverticulitis. There was reasonable quality of evidence suggesting that high C-reactive protein; white blood cell count; clinical signs including generalized abdominal pain, constipation and vomiting; steroid usage; a primary episode; and comorbidity are risk factors for complicated diverticulitis.

CONCLUSION

Although high-level evidence is lacking, this study identified several risk factors associated with complicated diverticulitis. Individually, these risk factors have little value in predicting the course of diverticulitis. The authors propose a prognostic model combining these risk factors which might be the next step to aid the physician in predicting the course of diverticulitis and setting the right treatment at initial presentation.

Trends in Hospital Admission and Surgical Procedures Following ED visits for Diverticulitis

Introduction

Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission.

Methods

: We performed a cross-sectional descriptive analysis using data on ED visits from 2006–2011 to determine change in admission and surgical patterns over time. The Nationwide Emergency Department Sample database, a nationally representative administrative claims dataset, was used to analyze ED visits for diverticulitis. We included patients with a principal diagnosis of diverticulitis (ICD-9 codes 562.11, 562.13). We analyzed the rate of admission and surgery in all admitted patients and in low-risk patients, defined as age <50 with no comorbidities (Elixhauser). We used hierarchical multivariate logistic regression to identify patient characteristics associated with admission for diverticulitis.

Results

Fryom 2006 to 2011 ED visits for diverticulitis increased by 21.3% from 238,248 to 302,612, while the admission rate decreased from 55.7% to 48.5% (−7.2%, 95% CI [−7.78 to −6.62]; p<0.001 for trend). The admission rate among low-risk patients decreased from 35.2% in 2006 to 26.8% in 2011 (−8.4%, 95% CI [−9.6 to −7.2]; p<0.001 for trend). Admission for diverticulitis was independently associated with male gender, comorbid illnesses, higher income and commercial health insurance. The surgical rate decreased from 6.5% in 2006 to 4.7% in 2011 (−1.8%, 95% CI [−2.1 to −1.5]; p<0.001 for trend), and among low-risk patients decreased from 4.0% to 2.2% (−1.8%, 95% CI [−4.5 to −1.7]; p<0.001 for trend).

Conclusion

From 2006 to 2011 ED visits for diverticulitis increased, while ED admission rates and surgical rates declined, with comorbidity, sociodemographic factors predicting hospitalization. Future work should focus on determining if these differences reflect increased disease prevalence, increased diagnosis, or changes in management.

Israeli Arabs develop diverticulitis at a younger age and are more likely to require surgery than Jews

BACKGROUND

Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis.

AIM

To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery.

METHODS

Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012.

RESULTS

Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis.

CONCLUSIONS

Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis.

Diverticular disease in younger patients--is it clinically more complicated and related to obesity?

AIM

The aims of this systematic review were to determine the presentations of diverticular disease in patients under 40 years of age and to assess whether obesity is an important factor.

METHOD

The PubMed and EMBASE databases and the Cochrane Library were searched to identify all original articles published between 1990 and 2011 on diverticular disease severity in obese patients (body mass index of ≥ 30 kg/m(2) ) under 40 years of age.

RESULTS

Twenty-three clinical case series (two of which were prospective) were identified plus two large aetiological population-based studies. These reported that young patients with diverticular disease were presenting more frequently, that diverticular disease in this age group was less likely to be complicated but that emergency operation rates were higher. The majority (63.1-96.5%) of patients under 40 years of age with diverticular disease were obese.

CONCLUSION

The studies suggest that in the young, obese patient with lower abdominal pain, diverticulitis and appendicitis are included in the differential diagnosis. CT and/or laparoscopy should be considered where the diagnosis is in doubt.

Diverticulitis in the Young

Background: Colonic diverticulitis is relatively uncommon in young patients, especially those younger than 40 years. We compared demographic data, clinical presentation, management, and clinical course of diverticulitis in patients ≤40 years old compared with patients >40 years old. Methods: This study included all patients who presented to the emergency department with a diagnosis of diverticulitis between October 1, 2009 and September 30, 2010. Patients were divided into 2 groups: group 1 (≤40 years old) and group 2 (>40 years old). Demographic characteristics, clinical presentation and management, and short-term outcomes were compared. Results: Ninety-four patients were included in the study (37 patients in group 1 and 57 patients in group 2). A higher percentage of obese and Hispanic men was found in group 1 ( P > .05). The rate of discharge from the emergency department was significantly higher in group 1 (56.8% in group 1 vs 7.0% in group 2, P < .01). Group 2 patients had a shorter median length of stay than group 1 patients (3.1 vs 5.7 days, P = .16). There were no differences in vital signs, laboratory data (including complete blood count and basic metabolic panel), and in-hospital mortality rates between the 2 groups. Conclusions: This study demonstrates that young Hispanic men develop diverticulitis and that this diagnosis needs to be considered when they present to emergency rooms with abdominal symptoms. A longitudinal study is needed to determine the long-term outcomes in these patients and to investigate the pathogenesis.

Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy

BACKGROUND & AIMS

Colonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10% to 25% lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. We measured the long-term risk of acute diverticulitis among patients with confirmed diverticulosis discovered incidentally on colonoscopy.

METHODS

We performed a retrospective study using administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, collecting data on patients who underwent colonoscopies from January 1996 through January 2011. We identified patients diagnosed with diverticulosis, determined incidence rates per 1000 patient-years, and analyzed a subgroup of patients with rigorously defined events confirmed by imaging or surgery. We used a Cox proportional hazards model to identify factors associated with the development of diverticulitis.

RESULTS

We identified 2222 patients with baseline diverticulosis. Over an 11-year follow-up period, 95 patients developed diverticulitis (4.3%; 6 per 1000 patient-years); of these, 23 met the rigorous definition of diverticulitis (1%; 1.5 per 1000 patient-years). The median time-to-event was 7.1 years. Each additional decade of age at time of diagnosis reduced the risk for diverticulitis by 24% (hazard ratio, 0.76; 95% confidence interval, 0.6-0.9).

CONCLUSIONS

Based on a study of the Veterans Affairs Greater Los Angeles Healthcare System, only about 4% of patients with diverticulosis develop acute diverticulitis, contradicting the common belief that diverticulosis has a high rate of progression. We also found that younger patients have a higher risk of diverticulitis, with risk increasing per year of life. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.

Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis

BACKGROUND AND AIM

For years, the natural course of diverticulitis in the young has been debatable in terms of its severity and recurrence rate, and no consensus has been reached regarding its treatment and timing of surgery. Thus, the study aims to evaluate by meta-analysis the natural course of acute diverticulitis in the young.

METHODS

Data were obtained from electronic databases and manual search of studies comparing the course of diverticulitis in young versus elderly patients. The age cut-off was selected to be 40-50 years, and only studies using computed tomography as the sole modality for diagnosis were included. Primary outcomes were surgery during hospitalization and disease recurrence. Relative risks (RRs) with 95% confidence intervals (CIs) are reported.

RESULTS

One thousand eighty publications were found, 12 of which were included. The total number of patients was 4982. Most young patients were males (RR 1.70, 95% CI 1.31-2.21), without tendency toward a more complicated disease at admission (RR 0.95, 95% CI 0.46-1.97). While there was no significant difference in the rate of surgery during hospitalization (RR 0.69, 95% CI 0.46-1.06), young patients underwent more elective surgeries (RR 2.39, 95% CI 1.82-3.15). No mortality was recorded among young patients. The disease recurrence rate was significantly higher than that of elderly patients (RR 1.70, 95% CI 1.31-2.21); however, no study specified the mean follow-up period for each group.

CONCLUSIONS

The course of diverticulitis in the young is not more severe than that in elderly patients; however, the disease tends to recur more often. Therefore, while choosing a therapeutic regimen, factors other than age should also be considered.

Acute diverticulitis: a decade of prospective follow-up

BACKGROUND

Acute diverticulitis (AD) is the most common complication of diverticular disease and affects 10% to 25% of patients. Data regarding the natural history of AD are lacking.

GOALS

Our aim was to prospectively assess the occurrence of recurrent attacks, surgeries, and accompanying symptoms in patients who were hospitalized with AD.

STUDY

All patients hospitalized with first episode of AD between January 2000 and November 2006 were enrolled. Patients were followed up both during hospitalization and after discharge. Data regarding operations and complications were collected. Special attention was paid to patients younger than 45 years of age and compared with older patients.

RESULTS

A total of 261 patients were identified-of them 103 were men. Thirty patients (11.5%) were 45 years old or younger. The mean follow-up period was 88±22 months (range, 52 to 184 mo). Younger patients experienced significantly more complications during hospitalization (37% vs. 12.5%, P=0.001) and underwent more often a sigmoidectomy in the follow-up period (42.3% vs. 18.3%, P=0.01). Older patients tended to be more often asymptomatic after discharge (P=0.053). The average time from index hospitalization to the sigmoidectomy was 18.17±23.35 months (range, 1 to 120 mo). The odds ratio for sigmoidectomy after complicated AD is 16.2 (95% confidence interval, 13.4 to 19.6). Age did not affect the risk for surgery.

CONCLUSIONS

Younger patients with AD experience more complications during hospitalization and undergo surgery after discharge more frequently. Complicated AD at index hospitalization is a risk factor for sigmoidectomy. Our data can help predict the outcome of patients suffering from AD and enable tailoring an individual treatment.

[Perforation risk and patient age. Risk analysis in acute sigmoid diverticulitis]

INTRODUCTION

It is often postulated that younger patients with acute sigmoid diverticulitis (SD) have an increased risk of perforation which constitutes an indication for early surgery. The aim of this study was to correlate the severity of sigmoid diverticulitis with patient age in order to check the surgical indication in younger patients.

PATIENTS AND METHODS

Patients with acute SD from January 1998 to June 2009 were included. Two age groups were distinguished: group I (GI) ≤40 years in age and group II (GII) >40 years. The perforation risk associated with first episode SD was determined by multivariate analysis. SD was classified according to Hansen and Stock (H/S).

RESULTS

In the total cohort of 959 patients, including 86 in GI (8.9%) and 873 in GII (91.1%) 468 had a first episode, with 64 in GI (13.7%) and 404 in GII (86.3%). The proportion of first episodes was 74.4% in GI and 46.3% in GII (p<0.001). The perforation risk did not differ (H/S IIb: 29.7% in GI vs. 29.2% in GII, p=0.938; H/S IIc: 25% in GI vs. 25% in GII, p=1). Treatment regimes were (GI vs. GII) emergency operations 25% vs. 25% (p=1), elective operations 17.2% vs. 10% (p=0.096) and conservative treatment 57.8% vs. 64.9% (p=0.276).

CONCLUSION

First episodes of SD were more frequent in younger patients (≤40) and did not involve a higher risk of perforation. The indication for treatment of acute SD should not be based on age but on the severity of inflammation and the individual situation of patients.

Sigmoid diverticulitis in young patients--a more aggressive disease than in older patients?

INTRODUCTION

There is controversy over whether sigmoid diverticulitis (SD) is more aggressive with a higher risk of perforation in younger than in older patients. The aim of this study was to assess the clinical presentation and outcome of patients ≤40 and >40 years old with acute diverticulitis.

PATIENTS AND METHODS

Consecutive admissions of all patients with acute SD were prospectively recruited from January 1998 to June 2010.

RESULTS

A total of 1,019 patients were included: 513 (69 ≤40 years and 444 >40 years) presented with their first episode, while 506 (20 ≤40 years, 486 >40 years) had a prior history of SD. The percentage of patients with severe SD did not differ between the two age groups either for the first (covered perforation, 30.4% vs. 29.5%, p = 0.875; free perforation, 26.1% vs. 23.9%, p = 0.69) or for the recurrent episode (covered perforation, 15% vs. 8.2%, p = 0.287; free perforation, 5% vs. 4.1%, p = 0.846). Furthermore, the rate of emergency surgery did not differ between both age groups either for the first (26.1% vs. 23.9%, p = 0.690) or the recurrent episode (5% vs. 4.1%, p = 0.846). No differences in the rate of Hartmann's procedure (52.6% vs. 68.3%, p = 0.180) and failure of conservative treatment (3.4% vs. 4.9%, p = 0.607) were observed between younger and older patients.

CONCLUSION

Acute SD in younger patients is not more aggressive and has no higher risk of perforation or need for emergency surgery compared to older patients.

Acute diverticulitis in younger patients: Any rationale for a different approach?

AIM: To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently.

METHODS: This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B > 50 years (n = 126). Mean patient follow-up was 15 mo.

RESULTS: The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence.

CONCLUSION: Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.

Elective surgical treatment of diverticulitis

Elective surgical resection in cases of diverticulitis should be offered to patients who have experienced two episodes. High-risk patients such as immunocompromised individuals or transplant patients may warrant resection after one episode. It is controversial whether young patients or patients with right-sided diverticulitis need to be treated differently. Chronic diverticulitis can be successfully treated surgically in selected cases. Adequate surgical resection margins should include the top of the true rectum and the proximal extent of thickened inflamed colon to minimize the risk of recurrence. Careful operative planning and the use of proximal diversion if unsuspected significant inflammatory changes are encountered will improve surgical outcomes.

Presentation and treatment outcome of diverticulitis in younger adults: a different disease than in older patients?

PURPOSE

The severity and most appropriate treatment of diverticulitis in young patients are still controversial. The aim of this study is to compare young patients (<or=50 years) with older patients (>50 years) regarding clinical and radiologic parameters of acute left colonic diverticulitis and to determine whether differences exist in presentation and treatment.

METHODS

We reviewed medical records of 271 consecutive patients with left colonic acute diverticulitis admitted to our institution from 2001 through 2004: 71 patients were aged 50 years or younger and 200 patients were older than 50. Clinical and radiologic parameters were analyzed. Conservative treatment was standardized, and included antibiotic therapy and bowel rest. Criteria for emergency surgical treatment were diffuse peritonitis, pneumoperitoneum, and septic shock.

RESULTS

Conservative treatment alone was successful in 64 patients (90.1%) in the younger group and in 152 patients (76%) in the older group (P = .017). The percentage of patients requiring surgery at admission or during the hospital stay was significantly lower in younger than in older patients (5.6% vs 20.5%, P = .007), and the percentage of patients requiring emergency end colostomy was higher (although not significantly) in the older group (1.4% vs 9.0%, P = .059). No differences in rate of successful conservative treatment were observed between patients with a first episode and those with recurrence in either age group (P = .941 in the younger group; P = .227 in the older group).

CONCLUSION

Young age is not a predictive factor of poor outcome in the management of first or recurrent episodes of acute diverticulitis. Patients older than 50 years more frequently need emergency surgical treatment.

The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature

Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age <or= 50 years). Much of the older literature suggests that young patients experience a more virulent course with diverticulitis. Previous studies have shown misclassification and selection bias. As a result leading to a bias for more severe cases to be recognized mild cases may not be included. Young patients appear more likely to undergo operations to resolve an uncertain diagnosis. Recent studies have raised doubts about a virulent course with diverticulitis suggesting that recurrence may be associated with disease severity on CT scan, and supporting a conservative approach to diverticular disease. The diagnosis of diverticulitis is often delayed in younger patients because it is not considered, resulting in presenting cases being found at surgery or appearing more severe and more likely to be complicated. There is a lack of evidence to support the hypothesis that elective surgery should follow a single attack of diverticulitis. Any increased risk appears be a chronologic rather than pathologic phenomenon. Most patients will not have further episodes of diverticulitis.

Elective resection for diverticular disease: an evidence-based review

Controversy exists as to the most appropriate management of patients following two episodes of diverticulitis. Despite a growing body of new evidence challenging the concept of elective sigmoid resection after a patient experiences two attacks of diverticulitis, we continue to base our practice on outdated studies carried out more than 30 years ago. The recommendation that patients undergo elective sigmoid resection after two attacks of acute diverticulitis should be re-evaluated as it is generally inappropriate and is not cost effective. Elective resection for uncomplicated diverticulitis does not alter outcome, nor does it decrease mortality or prevent complications of the disease. In fact, based on current literature, 18 patients would have to undergo elective operation to prevent one emergency surgery. This article aims to review the current evidence for elective resection following episodes of diverticular disease and addresses emerging controversies in the management of this disease.

Recurrent diverticulitis

The term "diverticulitis" indicates the inflammation of a diverticulum or diverticula, which is accompanied by detectable or microscopical perforation. Diverticulitis is a common condition with an estimated incidence of 25%. At present, elective sigmoid resection is recommended after 2 episodes of uncomplicated diverticulitis to prevent the serious complications of recurrent colonic diverticulitis. This guideline has been based on the assumption that recurrent episodes (2 or more) of diverticulitis will lead to complicated diverticulitis and higher mortality. The data to support this assumption are based on only a few small studies. Advances in diagnostic modalities, medical therapy, and surgical techniques over the past 2 decades have changed both the management and outcomes of diverticulitis. Many authors have shown that patients treated nonoperatively have a low risk of recurrent disease and would be expected to do well without elective colectomy.

Outcome of younger patients with acute diverticulitis

BACKGROUND

There is controversy over whether patients presenting with a primary attack of acute diverticulitis at a younger age are more prone to complications and recurrence than older patients.

METHODS

A review, including postal questionnaires, was undertaken of 234 patients who had a primary episode of acute diverticulitis. The diagnosis was confirmed by computed tomography (CT) and/or pathology report. The mean length of follow-up was 30 (range 16-45) months.

RESULTS

In 58 patients aged 50 years or less no differences in fever or white blood cell count were found in comparison with findings in 176 patients aged above 50 years. The rate of severe diverticulitis observed with CT was lower in the younger patients (2 versus 11.9 per cent; P = 0.025). Surgical management during the first admission was undertaken less commonly in younger patients (2 versus 6.8 per cent; P = 0.271). Rates of subsequent events (recurrent diverticulitis and/or further surgery) during follow-up were higher in younger patients (25 versus 19.5 per cent), but this was not significant (P = 0.423). A type II error cannot be excluded.

CONCLUSION

First episodes of acute diverticulitis were not more aggressive in patients aged 50 years or less. Recurrence rates were slightly higher than in older patients.

Review article: Management of diverticulitis

BACKGROUND AND AIM

The incidence and therefore complications of (sigmoid) diverticular disease are increasing.

METHODS

Review of current literature.

RESULTS

From all patients, 15% will develop diverticulitis, 5% complications and 5% diverticular bleeding. Diagnosis is established with computerised tomography. Colonoscopy is needed to rule out malignancy. NSAIDs increase the risk of perforation; steroids, diabetes, collagen vascular disease and immune compromised are associated with complicated disease and death. In mild diverticulitis, antibiotics are recommended. In complicated disease with abscesses, <5 cm antibiotics are sufficient. Larger abscesses are drained under computerised tomography-guidance. Peritonitis forms an indication for surgery. Diverticulitis recurrence rate is around 30%, most are uncomplicated. Recurrence after surgery is around 10%. Elective surgery is reserved for fistula closure and obstruction. The need for elective surgery to prevent recurrence has diminished because of new insights. Important is to identify risk groups. New issues are the possible relationship between diverticulitis and cancer, segmental colitis associated with diverticulitis, and treatment of diverticulitis with mesalazine and probiotics.

CONCLUSIONS

Uncomplicated diverticulitis is treated medically. Complicated diverticulitis with small abscesses is treated with antibiotics while larger abscesses are drained with computerised tomography-guided puncture. Emergency surgery is reserved for peritonitis, elective surgery for fistula/stenosis. Surgery to prevent recurrence is indicated only in selected cases (e.g. immune compromised).

Acute diverticulitis in very young patients: a frequent surgical management

PURPOSE

The natural history of sigmoid diverticulitis in terms of the virulence and management in young patients is an ongoing controversy. This retrospective study was designed to assess the severity and early management of acute diverticulitis according to age.

METHODS

From 2000 to 2004, 284 patients were admitted for acute diverticulitis. Fifty-two patients (18 percent) were aged 50 years or younger and were divided in two groups: aged 40 years or younger (Group 1, n = 20), and patients older than aged 40 years (Group 2, n = 32). The diagnosis was confirmed by computed tomography in 49 patients (94 percent).

RESULTS

Radiologic findings showed that the rate of complicated lesions (i.e., diverticular perforation and/or abscess) was significantly higher for patients younger than aged 40 years than patients older, respectively 72 and 35 percent (P = 0.02). The risk of requiring immediate surgical treatment was significantly more frequent in Group 1 than Group 2 (40 vs.13 percent; P = 0.04). There was a trend toward a higher risk of "major surgery" (i.e., Hartmann's procedure) in Group 1 than Group 2 (15 vs. 0 percent; P = 0.05).

CONCLUSIONS

Diverticulitis in patients younger than aged 40 years seems to have a particularly aggressive and fulminant course and requires early surgical procedures for complications (associated abscess, colonic perforation) in 40 percent of cases. The use of "major procedure" (i.e., stoma) is more frequent in these patients.

CT and clinical features of acute diverticulitis in an urban U.S. population: rising frequency in young, obese adults

OBJECTIVE

On the basis of our experience in recent years, we hypothesized that acute diverticulitis occurs more frequently in young adult patients (age, < or = 50 years) now than previously recognized. We reviewed the CT findings, clinical features, and demographic data of a cohort of patients who presented with acute diverticulitis at an urban U.S. academic medical center.

MATERIALS AND METHODS

We used our hospital and radiology databases to identify 104 adult patients with both CT and clinical diagnoses of acute diverticulitis. Clinical parameters recorded included age, sex, ethnicity, in- or outpatient management, and therapy (medical treatment, percutaneous drainage, or surgery). CT studies were evaluated for the site of diverticulitis; associated complications; and the presence of abdominal obesity, as determined by measurement of sagittal abdominal diameter.

RESULTS

The study group was composed of 55 men and 49 women (age range, 22-88 years; mean age, 52.2 years; median age, 49.0 years). Fifty-six (53.8%) were 50 years old or younger, and 22 were 40 years old or younger. Forty-one complications were noted in 38 patients (36%). There was no significant age difference between the < or = 50 and > 50 years old age groups for hospital admission (90 patients, 86.5%), medical therapy (76, 73.1%), or surgery or percutaneous abscess drainage (28, 26.9%). Abdominal obesity measured by sagittal abdominal diameter was present in 48 (85.7%) and 37 (77%) of the < or = 50 and > 50 years old age groups, respectively. The mean sagittal abdominal diameter for patients < or = 50 years old (27.0 cm) was greater than that for patients > 50 years old (25.6 cm) (p = 0.05).

CONCLUSION

In this urban population, acute diverticulitis occurred more frequently in patients 20-50 years old than previously recognized. This group had significantly greater abdominal obesity than the older group. Severe disease requiring hospital admission, surgery, or percutaneous drainage (or both surgery and percutaneous drainage) was common in all age groups.

Management of diverticulitis in younger patients

PURPOSE

This study was designed to evaluate the clinical course of sigmoid diverticulitis patients younger than aged 50 years examined by abdominal CT during the first episode of disease to elucidate whether the criteria used for older patients can safely be followed in their younger counterparts.

METHODS

Retrospective review of patients with sigmoid diverticulitis treated from 1990 to 2003 was performed.

INCLUSION CRITERIA

patients younger than aged 50 years with sigmoid diverticulitis documented by CT scan. Severity of disease was classified according to radiographic findings. Age, gender, treatment, recurrent disease, and need for colostomy were documented.

RESULTS

A total of 5,499 patients were identified with sigmoid diverticulitis: 962 patients were younger than aged 50 years, and 411 had a CT scan on their first episode of disease. Of the 411 patients, 335 were classified as uncomplicated and 76 were complicated. Of the uncomplicated patients, 101 underwent an elective operation and 234 were followed nonoperatively. Of those followed, 67 had a recurrent uncomplicated episode, 10 had a recurrent complicated episode, of whom 5 required emergent operation and colostomy. Of the 76 patients with complicated disease, 23 had an emergent operation with colostomy, and 38 had an elective operation. Fifteen patients were followed without an operation and seven had a recurrent uncomplicated episode. None required emergent operation or colostomy.

CONCLUSIONS

Younger patients with uncomplicated diverticulitis by CT criteria respond well to medical management and seldom required an emergent operation and colostomy. Young patients with diverticulitis should be treated according to the same criteria used for older patients.

A diverticular 'pain in the bottom'

This is the case of a 40-year-old man with a gluteal abscess as the first presentation of diverticular disease. As well as the unusual site, imaging revealed the lack of a connective tract between the abscess and the abdominal cavity or retroperitoneum. In addition, a lack of gastrointestinal symptoms made this case very unusual. Hence, this highlights the need for a high index of clinical suspicion when the usual clinical pointers that guide to the diagnosis of diverticulitis are absent.

Diagnosis and management of diverticulitis and appendicitis

Diverticulitis and appendicitis are common infections of the gastrointestinal tract that require urgent medical and surgical attention. Successful management of these conditions requires a multidisciplinary approach among primary care providers, gastroenterologists, surgeons, and radiologists. The diagnosis of appendicitis, in particular, can be difficult. Advances in radiographic imaging have improved the diagnostic accuracy in these infections. Minimally invasive surgical techniques have improved the patient's postoperative recovery when surgery is necessary in the management of these conditions.

Diverticulitis in the young patient-Is it different

AIM: To prospectively study the incidence and the natural history of acute diverticulitis in young patients.

METHODS: A total of 207 patients hospitalized at our hospital between January 2000 to February 2005 with the diagnosis of acute diverticulitis were included. Their demographic characteristics, medical history, physical, radiographic and endoscopic findings as well as therapy were recorded. Patients were followed every 6 mo for the first year and later annually.

RESULTS: The mean patients’ age was 61 (range 27-92) years. Twenty- five patients (12%) were younger than 45 years. Acute diverticulitis was significantly more prevalent among male in the young age group as compared to the older age group (19/25, 76% vs 61/182, 33%, respectively, P = 0.0001). Complications occurred more often in the young age group; 32% vs 13%, (P = 0.002). During follow-up, 6 patients (28%) remained asymptomatic in the young age group as compared to 87 patients (55%) in the older age group (P = 0.024). As a result, sigmoidectomies were performed twice as often in the young age group (38% vs 13%, P = 0.002).

CONCLUSION: Diverticulitis in young patients has a male predominance, a more aggressive course with a higher rate of complications and a higher recurrence rate. An earlier surgical approach might be considered in young patients with acute diverticulitis.

Elective surgery after acute diverticulitis

BACKGROUND

Diverticulitis is a common condition. Practice guidelines from many organizations recommend bowel resection after two attacks. The evidence for such a recommendation is reviewed.

METHODS

A Medline literature search was performed to locate English language articles on surgery for diverticular disease. Further articles were obtained from the references cited in the literature initially reviewed.

RESULTS

Most people with diverticulosis are asymptomatic. Diverticular disease occurs in over 25 per cent of the population, increasing with age. After one episode of diverticulitis one-third of patients have recurrent symptoms; after a second episode a further third have a subsequent episode. Perforation is commonest during the first episode of acute diverticulitis. After recovering from an episode of diverticulitis the risk of an individual requiring an urgent Hartmann's procedure is one in 2000 patient-years of follow-up. Surgery for diverticular disease has a high complication rate and 25 per cent of patients have ongoing symptoms after bowel resection.

CONCLUSION

There is no evidence to support the idea that elective surgery should follow two attacks of diverticulitis. Further prospective trials are required.