Changes in the approach to acute diverticulitis

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.

Multifocal Versus Conventional Unifocal Diverticulitis: A Comparison of Clinical and Transcriptomic Characteristics

BACKGROUND

The management of diverticulitis is compromised by difficulty in identifying patients who require surgery for recurrent or persistent disease. Here, we introduce the concept of multifocal diverticulitis (MFD), characterized by multiple episodes of diverticulitis occurring at different locations within the colon.

AIMS

To compare clinical characteristics, success of surgical management, and colonic transcriptomes of MFD patients to patients with conventional unifocal diverticulitis (UFD).

METHODS

This retrospective study included 404 patients with CT-confirmed diverticulitis episodes. Patients with diverticulitis seen in at least two different colonic locations were classified as the MFD group and compared to the UFD group based on number of episodes, sites of disease, family history, surgeries performed, and postoperative recurrence. RNA-seq was conducted on full-thickness colonic tissues of ten MFD and 11 UFD patients.

RESULTS

Twenty-eight patients (6.9%) with MFD were identified. MFD patients had more diverticulitis episodes and were more likely to have positive family history, have right-sided disease, require surgery, and have recurrence after surgery. All MFD patients treated with segmental resection had recurrence, while recurrence was less common in patients undergoing more extensive surgery (P < 0.001). Using RNA-seq, we identified 69 genes that were differentially expressed between MFD and UFD patients. Significantly down-regulated genes were associated with immune response pathways.

CONCLUSIONS

MFD appears to be a more severe subset of diverticulitis with a possible genetic component. Transcriptomic data suggest that MFD may be associated with alteration of the immune response.

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.

Antibiotics versus no antibiotics in the treatment of acute uncomplicated diverticulitis - a systematic review and meta-analysis

BACKGROUND

Acute uncomplicated diverticulitis (AUD) is common and antibiotics are the cornerstone of traditional conservative management. This approach lacks clear evidence base and studies have recently suggested that avoidance of antibiotics is a safe and efficacious way to manage AUD. The aim of this systematic review is to determine the safety and efficacy of treating AUD without antibiotics.

METHODS

A systematic search of Embase, Cochrane library, MEDLINE, Science Citation Index Expanded, and ClinicalTrials. gov was performed. Studies comparing antibiotics versus no antibiotics in the treatment of AUD were included. Meta-analysis was performed using the random effects model with the primary outcome measure being diverticulitis-associated complications. Secondary outcomes were readmission rate, diverticulitis recurrence, mean hospital stay, requirement for surgery and requirement for percutaneous drainage.

RESULTS

Eight studies were included involving 2469 patients; 1626 in the non-antibiotic group (NAb) and 843 in the antibiotic group (Ab). There was a higher complication rate in the Ab group however this was not significant (1.9% versus 2.6%) with a combined risk ratio (RR) of 0.63 (95% CI, 0.25 to 1.57, p=0.32). There was a shorter mean length of hospital stay in the Nab group (standard mean difference of -1.18 (95% CI, -2.34 to -0.03 p= 0.04). There was no significant difference in readmission, recurrence and surgical intervention rate or requirement for percutaneous drainage.

CONCLUSION

Treatment of AUD without antibiotics may be feasible with outcomes that are comparable to antibiotic treatment and with potential benefits for patients and the NHS. Large scale randomised multicentre studies are needed. This article is protected by copyright. All rights reserved.