Acute diverticulitis in patients 40 years of age and younger

Complicated diverticulitis with colovesical fistula and bladder abscess formation in pregnancy: a case report

Objectives

Diverticulitis, characterized by inflammation or infection of diverticula, is rarely observed during pregnancy due to its association with elderly patients. Limited literature exists regarding its diagnosis and management in pregnant patients, especially in the setting of complications.

Case presentation

This paper presents a case of a 37-year-old multiparous woman diagnosed with complicated diverticulitis, including colovesical fistula and bladder abscess formation.

Conclusions

This paper highlights the importance of considering diverticulitis in pregnant patients with abdominal pain, the need for timely diagnosis, and the significance of multidisciplinary care.

Surgery for young onset diverticulitis: is it curative?

PURPOSE

Previously considered a disease of old age, diverticular disease is increasingly prevalent in younger populations. Guidelines on surgical resection have shifted from recommending resection for all young onset patients to an individualized approach. Therefore, we aim to determine demographics and outcomes including radiographic and surgical recurrence rates in patients < 40 years old undergoing resection for diverticular disease.

METHODS

A retrospective, single center study was performed. All patients ≤ 39 years undergoing operative intervention for left-sided diverticular disease between Jan 2010 and July 2017 were included. Recurrence was determined by individual review of imaging and operative reports.

RESULTS

Overall, 147 (n = 107/72.8% male, mean age = 34.93 ± 4.12 years) patients were included. The majority were ASA 1 or 2 (n = 41/27.9% and n = 82/55.8%). The most common surgical indication was uncomplicated diverticulitis (n = 77, 52.4%) followed by perforation (n = 26/17.7%). The majority (n = 108/73.5%) of cases were elective. Seventy-nine (57.3%) of all cases were performed laparoscopically. Primary anastomosis without diversion was the most common surgical outcome (n = 108/73.5%). Median length of stay was 5 (4, 7) days. There was no mortality. There were three (2.0%) intraoperative and 38 (25.9%) postoperative complications. The most common complication was anastomotic leak (n = 6/4.1%). The majority (n = 5) of leaks occurred after elective surgery. Two neoplastic lesions (1.3% of cohort) were found (1 adenoma with low-grade dysplasia/1 polyp cancer). Over a mean follow-up of 96 (74, 123) months, only 2 (1.3%) patients experienced a surgical or radiological recurrence.

CONCLUSION

Both neoplasia and recurrence after resection for diverticular disease in young onset patients are rare. Leaks after primary anastomosis even in the elective setting warrant careful consideration of a defunctioning ileostomy.

Peanut-Related Perforated Diverticulitis Before the Age of 60

We present a case in which a 55-year-old male with a past medical history of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) presented with sharp, worsening right-sided abdominal pain radiating across the entire abdomen after eating peanuts. Computed tomography (CT) imaging showed evidence of acute sigmoid diverticulitis complicated by a walled-off perforation. The patient’s past medical history suggested previous recurrent episodes of diverticulitis. Our patient underwent exploratory laparotomy, sigmoid colon resection with low anterior anastomosis and proctocolectomy, and loop ileostomy. During treatment, the sigmoid colon was found to be very indurated and abnormally going all the way down to the peritoneal reflection. Appropriate identification of the patient’s condition and timely intervention resulted in a successful outcome.

Intramural diverticulosis and diverticulitis of the colon: Pictorial essay

Diverticulosis of the colon is a gradually progressive disease that usually starts in early adulthood and increases with advancing age in its anatomical extent and the size of diverticula. It is important to recognize the initial stages of diverticular development in young patients in order to properly diagnose and manage the potential complications of this very common intestinal disorder. This article presents the pathological and radiological features of early diverticular formation, when the mucosal outpouchings are very small and contained within the colonic wall as distinct intramural lesions. The subsequent development of intramural diverticulitis and the spectrum of its manifestations on barium enema examination or Computed tomography (CT) are illustrated.

Demographics and trends in the acute presentation of diverticular disease: a national study

BACKGROUND

Diverticular disease (DD) is a major health problem in the Western world. The aim of this study was to describe demographics and trends in acute DD admissions in New Zealand.

METHODS

Information pertaining to acute hospital admissions between January 2000 and June 2012 for a primary diagnosis of large bowel DD was retrieved from a national database.

RESULTS

There were 25,167 admissions for acute DD. Mean age of presentation decreased from 65.9 years in 2000 to 64.1 years in 2012 (P < 0.001). Mean age was lower in men than women (61.4 versus 67.4 years, P < 0.001). Although men comprised 45.2% of the cohort they were over-represented in the 18-44 years stratum (68.6 versus 31.4%; P < 0.001). Europeans accounted for 84.8% of admissions and presented at an older age (65.8 years) than Māori (56.2 years), Pacific Islanders (58.4 years) or Asians (58.9 years) (P < 0.001). Acute DD admissions were higher in more deprived populations (P < 0.001). Mean length of hospital stay (LOS) reduced from 5.8 days in 2000 to 4.1 days in 2012 (P < 0.001). LOS increased with age (P < 0.001) and deprivation (P = 0.013), but did not differ between ethnicities (P = 0.088). Computed tomography scanning of acute admissions doubled from 2000 to 2012 (29.7-59.2%; P < 0.001) with a halving in the use of acute in-patient colonoscopy (26.1-13.2%; P < 0.001) and emergent surgery (14.8-7.2%; P < 0.001). Percutaneous drain use increased from 0.6% in 2000 to 1.1% in 2012 (P = 0.003).

CONCLUSION

Acute DD is a source of considerable morbidity in New Zealand and there have been significant changes in its admission demographics and trends over the last decade.

Younger age and prognosis in diverticulitis: a nationwide retrospective cohort study

BACKGROUND

Traditionally regarded as a disease of the elderly, the incidence of diverticulitis of the colon has been on the rise, especially in younger cohorts. These patients have been found to experience a more aggressive disease course with more frequent hospitalization and greater need for surgical intervention.

OBJECTIVE

To characterize factors that portend a poor prognosis in patients diagnosed with diverticulitis; in particular, to evaluate the role of demographic variables on disease course.

METHODS

Using the Canadian Institute for Health Information Discharge Abstract Databases, readmission rates, length of stay, colectomy rates and mortality rates in patients hospitalized for diverticulitis were examined. Data were stratified according to age, sex and comorbidity (as defined by the Charlson index).

RESULTS

In the cohort ≤30 years of age, a clear male predominance was apparent. Colectomy rate in the index admission, stratified according to age, demonstrated a J-shaped curve, with the highest rate in patients ≤30 years of age (adjusted OR 2.3 [95% CI 1.62 to 3.27]) compared with the 31 to 40 years of age group. In-hospital mortality increased with age. Cumulative rates of readmission at six and 12 months were 6.8% and 8.8%, respectively.

CONCLUSION

In the present nationwide cohort study, younger patients (specifically those ≤30 years of age) were at highest risk for colectomy during their index admission for diverticulitis. It is unclear whether this observation was due to more virulent disease among younger patients, or surgeon and patient preferences.

Impact of age on recurrence and severity of left colonic diverticulitis

AIM

There has been controversy about the presentation and treatment of acute colonic diverticulitis (AD) in young patients. The aim of this observational study was to evaluate the virulence and natural history of AD in three different age groups of patients.

METHOD

The study was performed on 686 patients with the diagnosis of a first episode of AD admitted between January 1998 and December 2008. Patients were classified into three groups: age 45 years or younger (group 1), 45-70 years of age (group 2) and 70 years or more (group 3). The variables studied were gender, American Society of Anesthesiologists status, associated comorbidity, type of treatment, length of hospital stay and recurrence of AD.

RESULTS

Group 1 included 99 (14.4%) patients, group 2 339 (49.4%) and group 3 248 (36.2%). Of these, 144 patients needed emergency operation at the first admission, 25 underwent elective surgery after the first episode of AD and 10 died after medical treatment; 507 patients were followed for recurrence. In all, 104 (20.5%) patients had a recurrence of AD that required hospitalization. Fifty (9.9%) presented with one episode of severe recurrence, without any difference between the groups (P = 0.533). There were no differences in the analysis of cumulative recurrence (Kaplan-Maier) between the three groups.

CONCLUSION

AD does not present a more aggressive clinical course in younger patients and it can be safely managed using the same strategy as in middle aged and older patients.

Acute inflammation of the true cecal diverticulum--case report

In this case report, we describe a rare event: acute inflammation of the true cecal diverticulum. Emergency surgery enabled proper diagnosis and management of this condition. Diagnostic approaches and the management of this disease are described in detail and based on literature review. In conclusion, pathologies of cecal diverticula should be considered in differential diagnosis of pain in the right iliac fossa.

Review article: the pathogenesis of diverticular disease--current perspectives on motility and neurotransmitters

BACKGROUND

Low-fibre diet, structural abnormalities and ageing are traditional aetiological factors implicated in the development of diverticular disease. More recently, motility disorders are implicated in its causation leading to speculation that neurotransmitters play a role in mediating these disturbances.

AIMS

To draw together studies on the role of neurotransmitters in the development of diverticular disease and its symptoms.

METHODS

Medline, GoogleScholar and Pubmed were searched for evidence on this subject using the terms neurotransmitters, motility, diverticular disease and pathogenesis. Articles relevant to the subject were cited and linked references were also reviewed.

RESULTS

Serotonin, which has been found to be an excitatory colonic neurotransmitter, has been found in early studies to be increased in colonic enterochromaffin cells. Acetylcholine, which is thought to be an excitatory neurotransmitter and cholinergic activity, has also seen to be increased in diverticular disease. These findings may suggest that an increase in excitatory neurotransmitters may result in the hypersegmentation thought to cause pulsion diverticula. Similarly, a decrease in nitric oxide which is inhibitory is found.

CONCLUSIONS

There is some evidence that neurotransmitters may play a role in the motility disturbances seen in diverticular disease; however, a clear role is yet to be ascertained.

Epidemiological trends and geographic variation in hospital admissions for diverticulitis in the United States

AIM: To characterize the increasing incidence and geographic variation of acute diverticulitis.

METHODS: Using the nationwide inpatient sample (NIS) we identified a cohort who had been admitted with diverticulitis between 1998 and 2005. We calculated age-, sex-, and region-specific rates of hospitalizations for diverticulitis over time.

RESULTS: The age-adjusted hospitalization rate for diverticulitis increased from 61.8 per 100 000 to 75.5 per 100 000 between 1998 and 2005, and increased similarly in both sexes. Diverticulitis-associated admissions were male-predominant in those younger than age 45 years but were female-predominant thereafter. Admission rates increased the most among those < 45 years, while remaining unchanged for those ≥ 65 years. By 2005, the majority of hospitalized patients were < 65 years. Age-adjusted rates of diverticulitis-associated hospitalizations were lower in the West (50.4/100 000) compared to the Northeast (77.7/100 000), South (73.9/100 000), and Midwest (71.0/100 000).

CONCLUSION: Diverticulitis-associated hospitalizations have steeply risen, especially in young adults. These epidemiological trends vary by geographic region and warrant further investigation into potential dietary and environmental etiologies.

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.

Acute diverticulitis--clinical presentation and differential diagnostics

OBJECTIVE

To describe the clinical presentation of acute diverticulitis in an emergency department and to characterize the natural history of diverticulitis in the short perspective. Comparisons are made with an important differential diagnosis, nonspecific abdominal pain (NSAP).

METHOD

Patients admitted to our hospital with abdominal pain of up to 7 days' duration were registered prospectively using a detailed schedule for history, symptoms and signs, from 1 February 1997 to 1 June 2000. Of 3349 patients initially included, 3073 (92%) were eligible for follow up after 1-3 years.

RESULTS

Acute diverticulitis was the final diagnosis in 145 patients and NSAP in 1142 patients. The incidence of hospitalized patients with diverticulitis was 47 per year and 100 000 population, with a mean hospital stay of 3.3 days. Patients with diverticulitis, more frequently than NSAP, had a longer history and laboratory signs of inflammatory activity. Isolated left abdominal tenderness was more common in diverticulitis, whereas isolated right abdominal tenderness was more common in NSAP. Duration of symptoms on arrival was independent of age and was not correlated to C-reactive protein, leucocytes or body temperature. Sensitivity of diverticulitis as primary diagnosis was 64% and specificity 97%. Corresponding figures for NSAP were 43% and 90% respectively. Age and gender did not influence diagnostic accuracy or risk of surgery.

CONCLUSION

Diverticulitis differs significantly from NSAP in clinical presentation and laboratory parameters. Sensitivity of primary diagnosis for diverticulitis and NSAP was low.

Long-term outcome in 445 patients after diagnosis of diverticular disease

OBJECTIVE

To describe the long-term outcome after primary diagnosis of diverticular disease (DD) with respect to demographics, lifestyle, severity of disease and primary treatment.

METHOD

Retrospective cohort study of all 445 consecutive patients admitted to the department during 1989-1995 with the diagnosis DD with prospective follow up. Follow up was performed on all patients during May 2002 by searching the Danish Patient Register and National Register. Logistic regression analyses were applied for defining risk factors for readmission or death. For defined risk factors Kaplan-Meier survival statistics was performed.

RESULTS

The male/female ratio was 30/70. Median age was 75 years (men being younger than women, P < 0.01). About 73% received conservative treatment primarily. At follow up 35.3% had suffered clinical recurrence of DD, of these 15.9% were subsequently operated. However, 3.6% of the patients died of causes related to diverticulitis. Possible high-risk groups for recurrence were males and their age above 70 years.

CONCLUSION

Age and sex are possible predictors for recurrence of DD. Elective surgery seems not to be justified after just one attack of DD.

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.

Acute colonic diverticulitis in a community-based hospital: CT evaluation in 138 patients

The purpose of this research is to retrospectively analyze computed tomography (CT) findings of patients with acute colonic diverticulitis presented to a community-based hospital. During a 1-year period from May 2004 to April 2005, CT scans of 138 patients [mean age 62.3 years (SD 14.9), range 30-100 years] with clinical diagnosis of diverticulitis were analyzed. Of the 138 patients, 136 CT scans were performed with oral and intravenous contrast administration except in two patients who received only oral contrast. Twenty-eight patients (28/138, 20.3%) had diverticulosis, 77 (77/138, 55.8%) had uncomplicated diverticulitis, and 33 (33/138, 23.9%) had complications. Left-sided diverticulitis predominated (137/138, 99.3%). Colonic diverticula were identified in almost every patient (136/138, 98.6%); the majority had moderate colonic wall thickening (82/110, 74.5%) and moderate pericolonic inflammation (65/110, 59.1%). Isolated extraluminal air bubbles (19/33, 57.6%) were the most commonly seen complication, followed by abscess (15/33, 45.5%). Bowel obstruction (2/33, 6.1%) and pylephlebitis (1/33, 3.0%) were less commonly seen but were observed as significant abnormalities. Complicated diverticulitis was less prevalent in this community hospital setting, in contrast with referral medical centers. Common CT findings of diverticulitis included presence of diverticula, moderate wall thickening, and pericolonic inflammation. Isolated air bubbles were the most commonly seen complication followed by abscess.

A retrospective analysis of medical or surgical therapy in young patients with diverticulitis

BACKGROUND

Acute diverticulitis is increasingly being recognized in younger patients, but its management remains controversial.

AIM

To compare long-term outcomes of young patients treated with surgery vs. medical therapy for their first episode of diverticulitis.

METHODS

A retrospective chart analysis at a university and an affiliated community hospital between 1991 and 2002 revealed 149 patients < or = 40 years of age with confirmed diverticulitis. Forty-nine patients (38 males, 11 females) were contacted at least 1 year after their first episode of diverticulitis. Outcomes were compared based on initial therapy--antibiotics or surgical resection. The groups were compared by outcomes, gender, age, white blood cell count, temperature and diet.

RESULTS

Three (15%) of 20 surgical patients (mean follow-up 6.89 years), and 16 (55%) of 29 medical patients had a recurrence of diverticulitis (mean follow-up 5.72 years; P = 0.01). The treatment groups did not differ in age, white blood cell count, or temperature.

CONCLUSIONS

(i) Surgical treatment is effective initial therapy but disease may recur in a minority of patients; (ii) medical treatment is less effective initial therapy, with recurrence in half of the patients; (iii) initial presentation is not a strong predictor of disease recurrence.

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.

Diverticulosis and Diverticulitis

Diverticulosis and diverticulitis are common disorders in modern society and represent different places on the spectrum of diverticular disease. Often called a problem of western civilization, diverticular disease is rare in developing countries. This article provides an overview of the epidemiology of diverticular disease, risk factors, and clinical presentation in varying phases. Differential diagnostic testing and comprehensive management from the medical, surgical, and wound, ostomy, and continence nursing perspectives are also addressed. Nurses play a key role in supporting people with diverticular disease and referring them for appropriate assessment, treatment, and support.

Diverticular disease in adolescence

Diverticular disease is rare in the adolescent. Acute diverticulitis is almost never considered as a diagnosis for a young patient presenting with abdominal pain. Unfortunately, unrecognized it may be associated with significant morbidity and mortality. Also, when present, diverticulitis in the young adult is considered to be more aggressive compared to diverticulitis in older adults. Therefore, it is important to recognize, diagnose and manage diverticular disease appropriately in this age group. In tis chapter we will review the available literature on diverticula disease in the adolescent and young adult, discuss epidemiology, aetiology and pathogenesis and suggest guidelines for diagnosis and management.