[Applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis]

Update on the management of uncomplicated acute diverticulitis at our centre. Equally effective, more efficient

GOALS

The current trend in the treatment of non-complicated diverticulitis is the outpatient management with antibiotic or even anti-inflammatory regimens in selected cases. We present a comparison of the results in our hospital with different protocols applied in 2016 and 2017.

MATERIAL AND METHODS

All patients selected for this study were diagnosed with diverticulitis grade Ia of Hinchey's classification according to radiological findings on abdominal CT. We have analyzed two retrospective cohorts: 100 patients treated in 2016 according to the old protocol and 104 patients treated in 2017 with a new protocol. In 2016, the candidates for ambulatory treatment remained under observation for 24 hours before being discharged. The treatment consisted of 14 days of ciprofloxacin and metronidazole. In 2017, only patients with more acute symptoms were observed 24 hours and amoxicillin-clavulanic acid was prescribed for only 5 days.

RESULTS

The persistence of the disease in 2016 was 6% and in 2017 was only 5.77% (p = 0.944). Recurrence during the first year was 13% in the first group, while in the second it was 5.7%, although this difference was not statistically significant. Likewise, a significant reduction in health costs was achieved.

CONCLUSIONS

Outpatient treatment of acute uncomplicated diverticulitis with oral treatment seems to be a safe and effective therapeutic strategy in selected patients with low comorbidity.

Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis

BACKGROUND

In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting.

METHODS

A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment.

RESULTS

This systematic review included 21 studies including 1781 patients who had outpatient management of AD  including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data.

CONCLUSIONS

The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.

The use of the modified Neff classification in the management of acute diverticulitis

INTRODUCTION

Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management.

OBJECTIVE

To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD.

MATERIAL AND METHODS

Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery.

RESULTS

The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage.

CONCLUSIONS

The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

BACKGROUND

The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.

PURPOSE

Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.

METHODS

PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.

RESULTS

A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I² 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.

CONCLUSION

Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.

Outpatient treatment of uncomplicated diverticulitis: a systematic review

Acute diverticulitis occurs in up to 25% of patients with diverticulosis. The majority of cases are mild or uncomplicated and it has become a frequent reason for consultation in the emergency department. On the basis of the National Inpatient Sample database from the USA, 86% of patients admitted with diverticulitis were treated with medical therapy. However, several recent studies have shown that outpatient treatment with antibiotics is safe and effective. The aim of this systematic review is to update the evidence published in the outpatient treatment of uncomplicated acute diverticulitis. We performed a systematic review according to the PRISMA guidelines and searched in MEDLINE and Cochrane databases all English-language articles on the management of acute diverticulitis using the following search terms: 'diverticulitis', 'outpatient', and 'uncomplicated'. Data were extracted independently by two investigators. A total of 11 articles for full review were yielded: one randomized controlled trial, eight prospective cohort studies, and two retrospective cohort studies. Treatment successful rate on an outpatient basis, which means that no further complications were reported, ranged from 91.5 to 100%. Fewer than 8% of patients were readmitted in the hospital. Intolerance to oral intake and lack of family or social support are common exclusion criteria used for this approach, whereas severe comorbidities are not definitive exclusion criteria in all the studies. Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and economically efficient when applying an appropriate selection in most reviewed studies.

Systematic review: outpatient management of acute uncomplicated diverticulitis

PURPOSE OF REVIEW

Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach.

METHODS

Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion.

RESULTS

Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %.

CONCLUSION

Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.

Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial)

OBJECTIVE

We compare the results of 2 different strategies for the management of patients with uncomplicated left colonic diverticulitis and to analyze differences in quality of life and economic costs.

BACKGROUND

The most frequent standard management of acute uncomplicated diverticulitis still is hospital admission both in Europe and United States.

METHODS

This multicenter, randomized controlled trial included patients older than 18 years with acute uncomplicated diverticulitis. All the patients underwent abdominal computed tomography. There were 2 strategies of management: hospitalization (group 1) and outpatient (group 2). The first dose of antibiotic was given intravenously to all patients in the emergency department and then group 1 patients were hospitalized whereas patients in group 2 were discharged. The primary end point was the treatment failure rate of the outpatient protocol and need for hospital admission. The secondary end points included quality-of-life assessment and evaluation of costs.

RESULTS

A total of 132 patients were randomized: 4 patients in group 1 and 3 patients in group 2 presented treatment failure without differences between the groups (P=0.619). The overall health care cost per episode was 3 times lower in group 2, with savings of €1124.70 per patient. No differences were observed between the groups in terms of quality of life.

CONCLUSIONS

Outpatient treatment is safe and effective in selected patients with uncomplicated acute diverticulitis. Outpatient treatment allows important costs saving to the health systems without negative influence on the quality of life of patients with uncomplicated diverticulitis. Trial registration ID: EudraCT number 2008-008452-17.

Home treatment of uncomplicated acute diverticulitis

Diverticular disease of the colon is a common disease, mainly in the population over 50 years of age. In acute forms of presentation, we considered home treatment in those patients that were classified as having uncomplicated forms by means of clinical presentation and a computed tomography of the abdomen. According to these criteria, we treated 38 patients at home and admitted 18 patients to the hospital during the same period of time. No severe complications developed in the home-treatment patients. Home treatment is an effective alternative treatment for patients with uncomplicated acute diverticulitis. In uncomplicated acute diverticulitis, home treatment benefits the patient, over hospitalization, by allowing better management of resources and by keeping the patient in a familiar environment where there is no risk of a nosocomial infection.

Treatment of elderly patients with uncomplicated diverticulitis, even with comorbidity, at home

BACKGROUND

Elderly patients with uncomplicated diverticulitis are usually hospitalized. The aim of this study is to compare the outcomes of elderly patients with uncomplicated diverticulitis who were treated at home versus traditional Hospitalization.

METHODS

Prospective study from March 2011 to September 2012 including patients over 70 years with uncomplicated diverticulitis admitted to Hospital at Home Unit and to Conventional Hospitalization from the Emergency Department. Patients with β-lactam allergy or who required admission to Conventional Hospitalization for other pathology were excluded. All patients were given intravenous antibiotic. Patients transferred to Hospital at Home stayed 24h in the Observation Ward within the Emergency Department prior to discharge. Characteristics and outcomes of patients are analyzed.

RESULTS

34 patients were treated at home and 18 in hospital. Mean age was similar in both groups (77 vs 79). The oldest patient treated at home was 90 years old. 64% of patients treated in Hospital at Home had comorbidity vs 68% in Conventional Hospitalization. 11% of patients treated at home were diabetic. Thickening colonic wall was present in 100% of patients. 38% of patients treated at home had free fluid vs 42% treated in Hospital. All patients had a good clinical evolution. None of the patients treated at home was transferred to Hospital. Home treatment was associated with a cost reduction of 1368 euros per patient.

CONCLUSIONS

Treatment at home of elderly patients with uncomplicated diverticulitis is as safe and effective as treatment in Hospital, even if patient has comorbidity.

Patients with uncomplicated diverticulitis and comorbidity can be treated at home

BACKGROUND

Patients with uncomplicated diverticulitis and comorbidity are usually hospitalized. We analyze the efficacy and safety of treating these patients in Hospital at Home.

METHODS

Prospective study since January 2007 to December 2009. Patients were transferred to the Hospital at Home after 12-24h at Emergency Department Observation Ward. All patients were treated with intravenous antibiotic until clinical condition improved.

RESULTS

176 patients were diagnosed with uncomplicated diverticulitis at the Emergency Department. 18% of them (33) had comorbidity. Twenty four patients were transferred to the Hospital at Home (seventeen patients had cardiopathy, four diabetes mellitus and three chronic renal failure). Mean age was 73.4 years. All patients had abdominal pain and 29.1% fever; 45.8% presented with leucocytosis. 20.8% had a previous history of diverticulitis. Mean stay of patients was 9 days. All patients had a favorable course. The home treatment was successfully completed in 100% of patients. 95% of the patients expressed their satisfaction with this type of treatment.

CONCLUSIONS

Treatment of patients with uncomplicated diverticulitis and comorbidity at home after a short period of observation in Hospital is safe and effective.

[Safety and efficiency of ambulatory treatment of acute diverticulitis]

INTRODUCTION

The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management.

OBJECTIVE

To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients.

METHODS

We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7-10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month.

RESULTS

The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery.

CONCLUSIONS

In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs.