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Schena CA, Covino M, Laterza V, Quero G, La Greca A, Cina C, de'Angelis N, Marchegiani F, Sganga G, Gasbarrini A, Franceschi F, Longo F, Alfieri S, Rosa F. The role of procalcitonin as a risk stratification tool of severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis. Surgery 2024; 176:162-171. [PMID: 38594101 DOI: 10.1016/j.surg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Imaging-based classifications do not always reflect the clinical severity and prognosis of acute left-sided colonic diverticulitis. This study aims to investigate the role of an early procalcitonin assessment in the emergency department as a risk stratification tool for severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis. METHODS In this retrospective cohort study, all adult patients consecutively admitted from January 2015 to September 2020 for acute left-sided colonic diverticulitis and having a procalcitonin determination at admission were enrolled. The following data were collected: age, sex, comorbidities, laboratory parameters, level of urgency, clinical presentation, type of treatment, complications, and post-management outcomes. The association between the procalcitonin value at admission and the following endpoints was analyzed: type of treatment, classification of acute left-sided colonic diverticulitis, mortality, and type of surgery. RESULTS A total of 503 consecutive patients were enrolled. Procalcitonin >0.5 ng/mL emerged as an independent risk factor for complicated acute left-sided colonic diverticulitis (P = .007). Procalcitonin >0.5 ng/mL (P = .033), together with a history of complicated acute left-sided colonic diverticulitis (P < .001), abdominal pain (P = .04), bowel perforation (P < .001), and peritonitis (P < .001), was a significant risk factor for surgery. Procalcitonin >0.5 ng/mL (P = .007) and peritonitis (P = .03) emerged as independent risk factors for sigmoidectomy without colorectal anastomosis. Procalcitonin >0.5 ng/mL (P = .004), a higher level of urgency at admission (P = .005), Hartmann's procedure (P = .002), and the necessity of mechanical ventilation (P = .004) emerged as independent risk factors for mortality. CONCLUSION Procalcitonin >0.05 ng/mL at emergency department admission is a useful risk stratification tool for severity, prognosis, and need for surgical treatment in patients with acute left-sided colonic diverticulitis.
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Affiliation(s)
- Carlo Alberto Schena
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marcello Covino
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Vito Laterza
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, France.
| | - Giuseppe Quero
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio La Greca
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Caterina Cina
- Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Gabriele Sganga
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Franceschi
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Fabio Longo
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Sergio Alfieri
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fausto Rosa
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
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Schmidbauer M, Levers A, Wacker FK, Ringe KI. Classification of Diverticular Disease (CDD) - assessment of the intra- and interobserver agreement in abdominal CT scans. ROFO-FORTSCHR RONTG 2024; 196:591-599. [PMID: 38065539 DOI: 10.1055/a-2203-3144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
PURPOSE Along with ultrasound, computed tomography (CT) is one of the imaging modalities of choice in patients with suspected diverticular disease (DD). Recently, a newer Classification of Diverticular Disease (CDD) has been proposed. However, its reliability in daily radiological practice has never been proven. Therefore, our aim was to evaluate the intra- and interobserver agreement of the CDD in abdominal CT scans. METHODS In this retrospective study, 481 CT scans of patients with suspected DD were included. Two readers (one board-certified radiologist with 6 years of experience, one 3 rd year radiology resident) individually evaluated all CTs in two reading sessions using the CDD. A composite endpoint of a prior consensus reading, follow-up, and intraoperative findings served as the reference. Intra- and interobserver agreement were calculated using Cohen-k statistic. RESULTS DD was present in 317 cases (66 %), mostly classified as CDD stage 0, 1b, and 2a (28 %, 30 %, und 14 %). Intraobserver agreement was almost perfect for both readers (kappa 0.93 and 0.88). Interobserver agreement was high and improved from substantial (kappa 0.77) in the first reading session to almost perfect (kappa 0.84) in the second reading session. The interobserver agreement was best for CDD types 0 (diverticulosis) and 2c (free perforated diverticulitis) (mean kappa 0.83 and 0.86) and poorest for CDD types 1a (diverticulitis without phlegmon) and 2b (covered diverticulitis with macroabscess) (mean kappa 0.17 and 0.38). Intra- and interobserver agreement of acute uncomplicated (CDD type 1) and acute complicated diverticulitis (CDD type 2) were substantial to almost perfect (mean kappa 0.63-0.86). Agreement with the reference was almost perfect for both observers (mean kappa 0.86 and 0.82). Administration of rectal contrast did not significantly improve the diagnosis. CONCLUSION The CDD is a classification based on relatively clear imaging characteristics, which can be readily applied by radiologists with different expertise. In our study, the CDD had a high intra- and interobserver agreement, enabling a reliable therapy-related categorization of DD. KEY POINTS · The Classification of Diverticular Disease (CDD) is an easy-to-use classification for diverticular disease based on relatively clear image features.. · The CDD can be applied equally by radiologists with different levels of experience in the clinical routine.. · The high intra- and interobserver agreement indicates high reliability in the therapy-relevant classification of diverticulitis on CT.. CITATION FORMAT · Schmidbauer M, Levers A, Wacker FK et al. Classification of Diverticular Disease (CDD) - assessment of the intra- and interobserver agreement in abdominal CT scans. Fortschr Röntgenstr 2024; 196: 591 - 599.
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Affiliation(s)
- Martina Schmidbauer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Alena Levers
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Frank K Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Kristina Imeen Ringe
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Taha M, Fakieh AT, Alhazmi AM, Khiami AJ, Alasmari EA, Alharbi SS, Almajnoni MH. The Assessment of Knowledge, Awareness and Practice Regarding Diverticulitis and Its Risk Factors Among the Population of Saudi Arabia. Cureus 2024; 16:e60124. [PMID: 38864053 PMCID: PMC11165291 DOI: 10.7759/cureus.60124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2024] [Indexed: 06/13/2024] Open
Abstract
Background The term "diverticula" refers to the existence of diverticula in the gastrointestinal tract but is mainly located in the sigmoid colon and is used to describe colonic diverticulosis. Diverticula, which are sac-like protrusions in the wall of the large bowel, are becoming more prevalent globally, in both developed and developing nations. This increase in occurrence is primarily attributed to changes in dietary and lifestyle patterns. Raising public awareness can potentially contribute to a decrease in the incidence of the disease and its associated complications. Aim This study aims to assess knowledge and awareness levels among the Saudi Arabian population regarding diverticulitis and its risk factors. Methods A descriptive cross-sectional study was conducted in Saudi Arabia between 1st January 2024 to 1st April 2024 using an online questionnaire for data collection. The target population consists of individuals who are between 18 years and 45, in Saudi Arabia without a history of diverticulitis. The study questionnaire covered participants' demographic (Western, Central, Southern, Eastern, Northern) regions, knowledge, awareness and practice of diverticulitis. Results A total of 548 eligible participants completed the study questionnaire, most of them (80.3%; 395) were from the Western region including Mecca, Medina and Jeddah. Participants' ages ranged from 18 to more than 40 years with a mean age of 30.5 ± 11.9 years old. A greater percentage (72.3%) of the participants were males compared to the percentage of females, which was 27.7%. The vast majority of the study participants had an inadequate knowledge level about diverticulitis (85.9%; 471) while only 31 (5.7%) had adequate knowledge and awareness about the disease. The most reported sources of information included study courses (6.4%), media (5.3%), and physicians (4.7%) while most respondents (83.6%) had no source. Conclusion In conclusion, aside from preventive strategies, the current study found that the public knew very little about diverticulitis, including its risk factors, clinical presentation, and diagnostic process. The two significant predictors of public awareness level were age and doctors as information sources.
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Affiliation(s)
- Medhat Taha
- Department of Anatomy, Umm Al-Qura University, Al-Qunfudhah, SAU
| | - Anas T Fakieh
- College of Medicine, Umm Al-Qura University, Al-Qunfudhah, SAU
| | | | | | - Emad A Alasmari
- College of Medicine, Umm Al-Qura University, Al-Qunfudhah, SAU
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Gunby SA, Strate LL. Acute Colonic Diverticulitis. Ann Intern Med 2024; 177:ITC33-ITC48. [PMID: 38466995 DOI: 10.7326/aitc202403190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Acute colonic diverticulitis is a gastrointestinal condition that is frequently encountered by primary care and emergency department practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It is often diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, the presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.
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Affiliation(s)
- Sarah A Gunby
- University of Washington School of Medicine, Seattle, Washington (S.A.G., L.L.S.)
| | - Lisa L Strate
- University of Washington School of Medicine, Seattle, Washington (S.A.G., L.L.S.)
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Libman H, Nee JW, Lembo AJ, Burns RB. How Would You Manage This Patient With Recurrent Diverticulitis? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:836-843. [PMID: 37307586 DOI: 10.7326/m23-0669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Acute diverticulitis, which refers to inflammation or infection, or both, of a colonic diverticulum, is a common medical condition that may occur repeatedly in some persons. It most often manifests with left-sided abdominal pain, which may be associated with low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction. The American College of Physicians recently published practice guidelines on the diagnosis and management of acute diverticulitis, the role of colonoscopy after resolution, and interventions to prevent recurrence of this condition. Among the recommendations were the use of abdominal computed tomography (CT) scanning in cases where there was diagnostic uncertainty, initial management of uncomplicated cases in the outpatient setting without antibiotics, referral for colonoscopy after an initial episode if not performed recently, and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. Here, 2 gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease.
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Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
| | - Judy W Nee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
| | - Anthony J Lembo
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH (A.J.L.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
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Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
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7
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Naycı AE, Çakır E. A Retrospective Study of Patients with Diverticulitis: Does Neutrophil-to-Lymphocyte Ratio Predict Chronic Diverticulitis Disease Progression? ISTANBUL MEDICAL JOURNAL 2022. [DOI: 10.4274/imj.galenos.2022.36518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Fugazzola P, Ceresoli M, Coccolini F, Gabrielli F, Puzziello A, Monzani F, Amato B, Sganga G, Sartelli M, Menichetti F, Puglisi GA, Tartaglia D, Carcoforo P, Avenia N, Kluger Y, Paolillo C, Zago M, Leppäniemi A, Tomasoni M, Cobianchi L, Dal Mas F, Improta M, Moore EE, Peitzman AB, Sugrue M, Agnoletti V, Fraga GP, Weber DG, Damaskos D, Abu-Zidan FM, Wani I, Kirkpatrick AW, Pikoulis M, Pararas N, Tan E, Broek RT, Maier RV, Davies RJ, Kashuk J, Shelat VG, Mefire AC, Augustin G, Magnone S, Poiasina E, De Simone B, Chiarugi M, Biffl W, Baiocchi GL, Catena F, Ansaloni L. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg 2022; 17:5. [PMID: 35063008 PMCID: PMC8781436 DOI: 10.1186/s13017-022-00408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/27/2021] [Indexed: 02/08/2023] Open
Abstract
Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.
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Affiliation(s)
- Paola Fugazzola
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy.
| | - Marco Ceresoli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Francesco Gabrielli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alessandro Puzziello
- Department of Surgery and Transplants, AOU San Giovanni di Dio and Ruggi d'Aragona, University of Salerno, Fisciano, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Francesco Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Dario Tartaglia
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Paolo Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Nicola Avenia
- Medical School, General Surgery and Surgical Specialties Unit, S. Maria University Hospital University of Perugia, Terni, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ciro Paolillo
- Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Mauro Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matteo Tomasoni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Lorenzo Cobianchi
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Lincoln International Business School, University of Lincoln, Lincoln, UK
| | | | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Michael Sugrue
- Donegal Clinical Research Academy, Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | | | - Gustavo P Fraga
- Surgery Department, Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Imtiaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Sringar, Kashmir, India
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attiko Hospital, MSc "Global Health-Disaster Medicine", National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Nikolaos Pararas
- General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Edward Tan
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Goran Augustin
- Department of Surgery, University Hospital Centre, Zagreb, Croatia
| | - Stefano Magnone
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Elia Poiasina
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Gian Luca Baiocchi
- Department of General Surgery, ASST Cremona, University of Brescia, Cremona, Italy
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luca Ansaloni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
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9
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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10
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Abstract
Objective
Diverticulosis is extremely common in western society. A recent study has shown that outpatient, nonantibiotic management of acute uncomplicated diverticulitis may be a feasible and safe option. However, the ability to identify these patients is still difficult. This study explores the ability of white cell count, C-reactive protein, and bilirubin in differentiating patients with complicated and uncomplicated diverticulitis, as well as progression to surgical intervention.
Methods
This is a retrospective study of patients admitted with acute diverticulitis over a 5-year period (2009–2014) at a single institution in Australia. Patients were classified into 3 groups; uncomplicated diverticulitis, complicated diverticulitis without surgery, and complicated diverticulitis with surgery. Analysis of variance (ANOVA) and Bonferroni's post hoc analyses were used to compare markers across the groups.
Results
A total of 541 patients met the inclusion criteria for this study. One-way ANOVA showed a significant difference in white cell count (P < 0.0001), C-reactive protein (P < 0.0001), and bilirubin (P = 0.0006) between all 3 groups. Post hoc analyses showed a significant difference in white cell count, C-reactive protein, and bilirubin when comparing uncomplicated diverticulitis against complicated diverticulitis without surgery (P < 0.05) and complicated diverticulitis with surgery (P < 0.05). White cell count also showed a significant difference when comparing complicated diverticulitis without surgery and complicated diverticulitis with surgery (P < 0.05).
Conclusions
White cell count, C-reactive protein, and bilirubin can distinguish between uncomplicated and complicated diverticulitis.
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The Effects of Diverticulum Localization and Hinchey Classification on Recurrence and Complications in Acute Colonic Diverticulitis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:451-456. [PMID: 33364886 PMCID: PMC7751249 DOI: 10.14744/semb.2020.03453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/16/2020] [Indexed: 02/07/2023]
Abstract
Objectives: Diverticular disease of the colon is a pathology that arises from outward ballooning of the mucosa due to some weakness in the muscle layer. Diverticular disease may range from symptomatic uncomplicated diverticular disease to symptomatic disease with complications, such as acute diverticulitis or diverticular bleeding. Acute colonic diverticulitis occurs in about 10- 25% of patients. Methods: In this study, 134 patients who were admitted to our emergency clinic with complaints of abdominal pain between 2016-2019 and hospitalized with the diagnosis of acute diverticulitis were included. Patients’ sex, age, presence of additional disease, increase in leukocyte and C-reactive protein (CRP), localization of diverticulitis, Hinchey classification, mean length of hospital stay and treatment were evaluated. The effects of these parameters on complications and recurrence were statistically analyzed. Results: The length of hospital stay was statistically significantly associated positively with the Hinchey classification (p<0.001). While 18 patients who were medically treated developed recurrence later, and this rate was statistically significant (p<0.001). When one of the factors, localization, which may play a role in the severity of the disease and recurrence are examined, was evaluated concerning its results in our study, we found that rectosigmoid location is an important factor for recurrence. We found that the localization in the colon and the severity of the disease were effective in the prognosis of acute diverticulitis. Conclusion: We believe that localization and the severity of the disease should be taken into consideration when planning surgery in these patients.
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Zafar A, Neerukonda T, Zafar Y. Complicated Colonic Diverticulitis Presenting as Vaginal Bleeding: An Unusual Presentation. Cureus 2020; 12:e10595. [PMID: 33110730 PMCID: PMC7581223 DOI: 10.7759/cureus.10595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Cohen A, Li T, Stankard B, Nelson M. A Prospective Evaluation of Point-of-Care Ultrasonographic Diagnosis of Diverticulitis in the Emergency Department. Ann Emerg Med 2020; 76:757-766. [PMID: 32653332 DOI: 10.1016/j.annemergmed.2020.05.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We evaluate the sensitivity and specificity of point-of-care ultrasonography, performed by ultrasonographic fellowship-trained emergency physicians and physician assistants, compared with computed tomography (CT) scan in diagnosing acute diverticulitis in the emergency department (ED). METHODS This was a prospective observational study of a convenience sample of patients with suspected diverticulitis who were treated at an academic ED between 2017 and 2020. Sonographers were blinded to clinical data, laboratory results, and CT scan findings. A total of 19 ultrasonographic fellowship-trained emergency physicians and physician assistants performed the ultrasonographic examinations. Point-of-care ultrasonographic diagnosis of acute diverticulitis was defined as the presence of bowel wall thickening, greater than 5 mm, surrounding a diverticulum, enhancement of the surrounding pericolonic fat, and sonographic tenderness to palpation. The primary outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value of point-of-care ultrasonography in the diagnosis of diverticulitis compared with CT, which was considered the criterion standard. RESULTS Data from 452 patients were analyzed. Median age was 60 years, 54% were women, and 36% had a diagnosis of diverticulitis based on CT scan. Of the 452 patients, there were 13 false-positive (3%) and 10 false-negative (2%) point-of-care ultrasonographic examinations. Overall, compared with CT, point-of-care ultrasonography had a sensitivity of 92% (95% confidence interval 88% to 96%), specificity of 97% (95% confidence interval 94% to 99%), positive predictive value of 94% (95% confidence interval 90% to 97%), and negative predictive value of 96% (93% to 98%) in the diagnosis of diverticulitis. CONCLUSION In a convenience sample of ED patients with suspected diverticulitis, point-of-care ultrasonography performed by ultrasonographic fellowship-trained emergency physicians and physician assistants could be used as an imaging modality for diagnosing acute diverticulitis, with high sensitivity and specificity compared with CT scan.
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Affiliation(s)
- Allison Cohen
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY.
| | - Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Brendon Stankard
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY
| | - Mathew Nelson
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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MDCT in the Setting of Suspected Colonic Diverticulitis: Prevalence and Diagnostic Yield for Diverticulitis and Alternative Diagnoses. AJR Am J Roentgenol 2020; 215:39-49. [DOI: 10.2214/ajr.19.21852] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Sugi MD, Sun DC, Menias CO, Prabhu V, Choi HH. Acute diverticulitis: Key features for guiding clinical management. Eur J Radiol 2020; 128:109026. [PMID: 32422553 DOI: 10.1016/j.ejrad.2020.109026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023]
Abstract
Diverticular disease of the colon and small bowel is an important cause of pathology leading to emergency department visits and urgent gastrointestinal surgery. CT is a highly sensitive and specific modality for the diagnosis of acute diverticulitis and its complications as well as for the exclusion of alternate causes of pathology. Ultrasound, MRI and virtual CT colonoscopy have important adjunct roles for screening and workup of complications in specific patient populations. While diverticular disease most commonly involves the descending and sigmoid colon, it can also affect the proximal colon and small bowel. Acute diverticulitis may be categorized as uncomplicated or complicated according to the degree of inflammatory changes and related complications it induces, although some degree of overlap exists in clinical practice. Uncomplicated diverticulitis is classically characterized by localized inflammation surrounding a diverticulum ranging from wall thickening and phlegmonous change to the development of small, localized pericolic abscesses. Complicated forms of disease manifest with larger pericolic and distant abscesses, fistulae to adjacent organs, perforation, and peritonitis. Recurrent episodes of diverticulitis may lead to muscular hypertrophy of the bowel wall and luminal narrowing, potentially leading to bowel obstruction. Several imaging features may help to differentiate diverticulitis from colonic malignancy, however this remains a diagnostic imaging challenge that often requires further evaluation with colonoscopy. In this review, we discuss the pathophysiology and key imaging features of acute diverticulitis and its complications. We explore both common and uncommon presentations of the disease involving the colon and small bowel, acute and chronic manifestations of disease, and pitfalls to recognize when imaging alone may be insufficient to distinguish benign from malignant.
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Affiliation(s)
- Mark D Sugi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, United States.
| | - Derek C Sun
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, United States
| | - Christine O Menias
- Department of Radiology, Division of Abdominal Imaging, Mayo Clinic, Scottsdale, AZ, United States
| | - Vinay Prabhu
- Department of Radiology, New York University Langone Health, New York, NY, United States
| | - Hailey H Choi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, United States
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Sköldberg F, Granlund J, Discacciati A, Hjern F, Schmidt PT, Olén O. Incidence and lifetime risk of hospitalization and surgery for diverticular disease. Br J Surg 2019; 106:930-939. [PMID: 31012495 DOI: 10.1002/bjs.11143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/06/2018] [Accepted: 01/24/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Studies on incidence rates of first-time colonic diverticular disease are few, and population-based estimates of lifetime risk are lacking. In this observational study, the incidence, admission rates and lifetime risks of hospitalization and surgery for diverticular disease were investigated. METHODS Considering the entire Swedish population as an open cohort, incidence and admission rates, and lifetime risk estimates (considering death as a competing risk) of hospitalization and surgery for diverticular disease were calculated using data from cross-linked national registers and population statistics from 1987 to 2010. RESULTS In total, there were 144 107 hospital admissions for diverticular disease in 95 049 individual patients. Of these, 17 599 were admissions with bowel resection or stoma formation in 16 824 patients. The total number of person-years in the population during the study period was 213 949 897. Age-standardized incidence rates were 47·4 (95 per cent c.i. 47·1 to 47·7) for first-time hospitalization with diverticular disease and 8·4 (8·2 to 8·5) per 100 000 person-years for diverticular disease surgery. The corresponding admission rates (including readmissions) were 70·8 (70·4 to 71·2) and 8·7 (8·6 to 8·9) per 100 000 person-years. Following an increase in 1990-1994, rates stabilized. Based on incidence and mortality rates from 2000 to 2010, the estimated remaining lifetime risk of hospitalization from 30 years of age was 3·1 per cent in men and 5·0 per cent in women. The corresponding risk of surgery was 0·5 per cent in men and 0·8 per cent in women. CONCLUSION Diverticular disease is a common reason for hospital admission, particularly in women, but rates are stable and the lifetime risk of surgery is low.
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Affiliation(s)
- F Sköldberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J Granlund
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - A Discacciati
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - F Hjern
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - P T Schmidt
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - O Olén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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18
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Abstract
Acute colonic diverticulitis is a gastrointestinal condition frequently encountered by primary care practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It can often be diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.
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Affiliation(s)
- Sophia M Swanson
- From the University of Washington School of Medicine, Seattle, Washington. (S.M.S., L.L.S.)
| | - Lisa L Strate
- From the University of Washington School of Medicine, Seattle, Washington. (S.M.S., L.L.S.)
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Boermeester MA, Humes DJ, Velmahos GC, Søreide K. Contemporary Review of Risk-Stratified Management in Acute Uncomplicated and Complicated Diverticulitis. World J Surg 2017; 40:2537-45. [PMID: 27206400 DOI: 10.1007/s00268-016-3560-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute colonic diverticulitis is a common clinical condition. Severity of the disease is based on clinical, laboratory, and radiological investigations and dictates the need for medical or surgical intervention. Recent clinical trials have improved the understanding of the natural history of the disease resulting in new approaches to and better evidence for the management of acute diverticulitis. METHODS We searched the Cochrane Library (years 2004-2015), MEDLINE (years 2004-2015), and EMBASE (years 2004-2015) databases. We used the search terms "diverticulitis, colonic" or "acute diverticulitis" or "divertic*" in combination with the terms "management," "antibiotics," "non-operative," or "surgery." Registers for clinical trials (such as the WHO registry and the https://clinicaltrials.gov/ ) were searched for ongoing, recruiting, or closed trials not yet published. RESULTS Antibiotic treatment can be avoided in simple, non-complicated diverticulitis and outpatient management is safe. The management of complicated disease, ranging from a localized abscess to perforation with diffuse peritonitis, has changed towards either percutaneous or minimally invasive approaches in selected cases. The role of laparoscopic lavage without resection in perforated non-fecal diverticulitis is still debated; however, recent evidence from two randomised controlled trials has found a higher re-intervention in this group of patients. CONCLUSIONS A shift in management has occurred towards conservative management in acute uncomplicated disease. Those with uncomplicated acute diverticulitis may be treated without antibiotics. For complicated diverticulitis with purulent peritonitis, the use of peritoneal lavage appears to be non-superior to resection.
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Affiliation(s)
| | - David J Humes
- Division of Epidemiology and Public Health, School of Community Health Sciences, City Hospital, University of Nottingham, Clinical Sciences Building 2, Nottingham, UK. .,Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals, University of Nottingham, Nottingham, NG7 2UH, UK.
| | - George C Velmahos
- Division of Trauma Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, P. O. Box 8100, 4068, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Jamal Talabani A, Endreseth BH, Lydersen S, Edna TH. Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis. Int J Colorectal Dis 2017; 32:41-47. [PMID: 27613727 PMCID: PMC5219887 DOI: 10.1007/s00384-016-2644-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The study investigated the capability of clinical findings, temperature, C-reactive protein (CRP), and white blood cell (WBC) count to discern patients with acute colonic diverticulitis from all other patients admitted with acute abdominal pain. METHODS The probability of acute diverticulitis was assessed by the examining doctor, using a scale from 0 (zero probability) to 10 (100 % probability). Receiver operating characteristic (ROC) curves were used to assess the clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain. RESULTS Of 833 patients admitted with acute abdominal pain, 95 had acute colonic diverticulitis. ROC curve analysis gave an area under the ROC curve (AUC) of 0.95 (CI 0.92 to 0.97) for ages <65 years, AUC = 0.86 (CI 0.78 to 0.93) in older patients. Separate analysis showed an AUC = 0.83 (CI 0.80 to 0.86) of CRP alone. White blood cell count and temperature were almost useless to discriminate acute colonic diverticulitis from other types of acute abdominal pain, AUC = 0.59 (CI 0.53 to 0.65) for white blood cell count and AUC = 0.57 (0.50 to 0.63) for temperature, respectively. CONCLUSION This prospective study demonstrates that standard clinical evaluation by non-specialist doctors based on history, physical examination, and initial blood tests on admission provides a high degree of diagnostic precision in patients with acute colonic diverticulitis.
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Affiliation(s)
- A Jamal Talabani
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7602, Levanger, Norway
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - B H Endreseth
- Clinic of Surgery, St Olavs Hospital, University of Trondheim, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - S Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare - Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - T-H Edna
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7602, Levanger, Norway.
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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The Current Role of Radiologic and Endoscopic Imaging in the Diagnosis and Follow-Up of Colonic Diverticular Disease. AJR Am J Roentgenol 2016; 207:15-24. [PMID: 27082846 DOI: 10.2214/ajr.16.16138] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Colonic diverticular disease is among the most prevalent conditions in Western society and is a common cause for outpatient visits and hospitalizations. The role of imaging is in evolution, but it has proven useful in confirming clinically suspected disease, assessing severity and complications, and directing patient management. CONCLUSION This review focuses on the current role of radiologic and endoscopic imaging in distinct clinical scenarios of diverticular disease, with emphasis on diverticulitis and its follow-up.
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Clinically Diagnosed Acute Diverticulitis in Outpatients: Misdiagnosis in Patients with Irritable Bowel Syndrome. Dig Dis Sci 2016; 61:578-88. [PMID: 26441278 DOI: 10.1007/s10620-015-3892-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/17/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Physicians often diagnose diverticulitis and prescribe antibiotics in outpatients with abdominal pain and tenderness without other evidence. AIM We investigated the misattribution of irritable bowel syndrome (IBS) symptoms to diverticulitis in outpatients. METHODS In patients diagnosed with diverticulitis and dispensed antibiotics in an integrated healthcare system, we retrospectively compared 15,846 outpatients managed without computed tomography (CT) versus 3750 emergency department/inpatients who had CT. We assessed demographics and past history, including 17 symptom-based somatic and 11 mental disorders and three somatic-mental comorbidity pairs (dyads) coded over 3 years and seven drug classes dispensed over 1 year before diagnosis. RESULTS Univariate analysis showed small intergroup demographic differences. Outpatients had increases in prior diverticulitis, including outpatient-managed episodes, total somatic diagnoses (p < .0001), eight somatic and three mental disorders (p ≤ .015), all three dyads (p ≤ .05), and dispensing of three drug classes (p ≤ .016). IBS had been diagnosed in 2399 (15.1 %) outpatients versus 361 (9.6 %) emergency department/inpatients (p < .0001), the greatest increase in any comorbidity. Emergency department/inpatients had no somatic comorbidity more often but more alcohol dependence, non-dependent drug abuse, and opioid dispensing (p ≤ .05). Regression analysis revealed outpatient care was independently positively associated with younger age, non-Hispanic white race/ethnicity, less Charlson comorbidity, diverticulitis history, IBS, chest pain, dyspepsia, fibromyalgia, low back pain, migraine, acute reaction to stress, and antispasmodic and anxiolytic dispensing and negatively associated with non-dependent drug abuse and opioid dispensing (p ≤ .0226). CONCLUSIONS Multiple types of indirect and concordant evidence suggest misattribution of IBS pain to diverticulitis and unnecessary antibiotic therapy in outpatients.
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Ambrosetti P. Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography. Clin Exp Gastroenterol 2016; 9:249-57. [PMID: 27574459 PMCID: PMC4993273 DOI: 10.2147/ceg.s110428] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.
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Affiliation(s)
- Patrick Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Geneva, Switzerland
- Correspondence: Patrick Ambrosetti, Department of Surgery, Clinique Générale Beaulieu, Ch Beau-Soleil, 1205 Geneva, Switzerland, Tel +41 22 830 0520, Fax +41 22 830 2343, Email
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Lembcke B. Diagnosis, Differential Diagnoses, and Classification of Diverticular Disease. VISZERALMEDIZIN 2015; 31:95-102. [PMID: 26989378 PMCID: PMC4789974 DOI: 10.1159/000380833] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background While detailed history, physical examination, and laboratory tests are of great importance when examining a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging (ultrasonography (US), computed tomography (CT)). Methods Qualified US has diagnostic value equipotent to qualified CT, follows relevant legislation for radiation exposure protection, and is frequently effectual for diagnosis. Furthermore, its unsurpassed resolution allows detailed investigation down to the histological level. Subsequently, US is considered the first choice of imaging in diverticular disease. Vice versa, CT has definite indications in unclear/discrepant situations or insufficient US performance. Results Endoscopy is not required for the diagnosis of diverticulitis and shall not be performed in the acute attack. Colonoscopy, however, is warranted after healing of acute diverticulitis, prior to elective surgery, and in atypical cases suggesting other diagnoses. Perforation/abscess must be excluded before colonoscopy. Conclusion Reliable diagnosis is fundamental for surgical, interventional, and conservative treatment of the different presentations of diverticular disease. Not only complications of acute diverticulitis but also a number of differential diagnoses must be considered. For an adequate surgical strategy, correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV) has passed a new classification of diverticulitis displaying the different facets of diverticular disease. This classification addresses different types (not stages) of the condition, and includes symptomatic diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding.
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Affiliation(s)
- Bernhard Lembcke
- c/o Department of Medicine I, ZIM, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany
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Pietrzak A, Bartnik W, Szczepkowski M, Krokowicz P, Dziki A, Reguła J, Wallner G. Polish interdisciplinary consensus on diagnostics and treatment of colonic diverticulosis (2015). POLISH JOURNAL OF SURGERY 2015; 87:203-20. [DOI: 10.1515/pjs-2015-0045] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Indexed: 11/15/2022]
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Fuchs HF, Broderick RC, Harnsberger CR, Chang DC, Mclemore EC, Ramamoorthy S, Horgan S. Variation of outcome and charges in operative management for diverticulitis. Surg Endosc 2014; 29:3090-6. [PMID: 25539698 DOI: 10.1007/s00464-014-4046-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 12/11/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States. METHODS A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis. RESULTS 148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95 % CI 1.13-1.55; P < 0.05) and Mississippi (OR 2.84; 95 % CI 1.24-6.51, P < 0.02). Wisconsin had a significant lower mortality rate (OR 0.74; 95 % CI 0.59-0.94, P < 0.01). LOS was 1.4 days longer in New York and 0.54 days shorter in Wisconsin than in California (P < 0.01). Patients with age >40 years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah. CONCLUSIONS Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices.
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Affiliation(s)
- Hans F Fuchs
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA. .,Department of General Surgery, University of Cologne, Cologne, Germany.
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA
| | - Cristina R Harnsberger
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA
| | - David C Chang
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Elisabeth C Mclemore
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA
| | - Sonia Ramamoorthy
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0740, La Jolla, CA, 92093-0740, USA
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Bugiantella W, Rondelli F, Longaroni M, Mariani E, Sanguinetti A, Avenia N. Left colon acute diverticulitis: an update on diagnosis, treatment and prevention. Int J Surg 2014; 13:157-164. [PMID: 25497007 DOI: 10.1016/j.ijsu.2014.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy.
| | - Maurizio Longaroni
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
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Kawatkar A, Chu LH, Iyer R, Yen L, Chen W, Erder MH, Hodgkins P, Longstreth G. Development and validation of algorithms to identify acute diverticulitis. Pharmacoepidemiol Drug Saf 2014; 24:27-37. [PMID: 25257514 DOI: 10.1002/pds.3708] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 07/23/2014] [Accepted: 08/11/2014] [Indexed: 11/06/2022]
Abstract
PURPOSE The objectives of this study were to develop and validate algorithms to accurately identify patients with diverticulitis using electronic medical records (EMRs). METHODS Using Kaiser Permanente Southern California's EMRs of adults (≥18 years) with International Classification of Diseases, Clinical Modifications, Ninth Revision diagnosis codes of diverticulitis (562.11, 562.13) between 1 January 2008 and 31 August 2009, we generated random samples for pilot (N = 692) and validation (N = 1502) respectively. Both samples were stratified by inpatient (IP), emergency department (ED), and outpatient (OP) care settings. We developed and validated several algorithms using EMR data on diverticulitis diagnosis code, antibiotics, computed tomography, diverticulosis history, pain medication and/or pain diagnosis, and excluding patients with infections and/or conditions that could mimic diverticulitis. Evidence of diverticulitis was confirmed through manual chart review. Agreement between EMR algorithm and manual chart confirmation was evaluated using sensitivity and positive predictive value (PPV). RESULTS Both samples were similar in socio-demographics and clinical symptoms. An algorithm based on diverticulitis diagnosis code with antibiotic prescription dispensed within 7 days of diagnosis date, performed well overall. In the validation sample, sensitivity and PPV were (84.6, 98.2%), (95.8, 98.1%), and (91.8, 82.6%) for OP, ED, and IP, respectively. CONCLUSION Using antibiotic prescriptions to supplement diagnostic codes improved the accuracy of case identification for diverticulitis, but results varied by care setting.
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Affiliation(s)
- Aniket Kawatkar
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Broderick RC, Fuchs HF, Harnsberger CR, Chang DC, McLemore E, Ramamoorthy S, Horgan S. The price of decreased mortality in the operative management of diverticulitis. Surg Endosc 2014; 29:1185-91. [PMID: 25159639 DOI: 10.1007/s00464-014-3791-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 07/18/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Healthcare costs in the United States are increasing. It is thought that as cost increases, outcomes should improve. The aim of this study was to analyze patient charges and mortality in the operative management of diverticulitis over time. METHODS A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open partial colectomy were identified by ICD-9 codes. Multivariate analyses examined in-hospital mortality and total charges. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open vs. laparoscopic), and insurance status. RESULTS From 1998 to 2010, 148,348 patients had a partial colectomy for diverticulitis. After adjusting for other covariates and inflation, the average charge of hospitalization per admission increased by $34,057 from 1998 to 2010. In the same observation period, adjusted in-hospital mortality decreased significantly by 2005 compared to 1998 (p < 0.001, OR 0.77, 95% CI 0.68-0.88) and remained unchanged for the remainder of the study period. Additionally, laparoscopic management was associated with lower rate of charge increase compared to open management (p < 0.001), such that charges are currently higher for open management than laparoscopic. CONCLUSION In-hospital mortality following partial colectomy for diverticulitis has improved over time, most dramatically after 2005. With decreasing mortality, an increase in hospital charges is observed on an annual basis. However, while mortality reached a plateau after 2005, overall charges continue to rise.
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Affiliation(s)
- Ryan C Broderick
- Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, CA, USA,
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Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP. Toward an evidence-based step-up approach in diagnosing diverticulitis. Scand J Gastroenterol 2014; 49:775-84. [PMID: 24874087 DOI: 10.3109/00365521.2014.908475] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The lack of pathognomonic findings and the chance of complicated disease have resulted in the widespread use of additional imaging to diagnose acute colonic diverticulitis (ACD). The added value of additional imaging in the diagnostic workup of patients suspected of ACD is not well defined. AIMS The aim of this study was to systematically review the literature of the accuracy of the clinical evaluation and diagnostic modalities for patients with suspected ACD, to come to an evidence-based approach to diagnose ACD. METHODS A systematic review and meta-analysis of studies that reported diagnostic accuracy of the clinical diagnosis and diagnostic modalities in patients with suspected diverticulitis were performed. Study quality was assessed with the STARD checklist. True-positive, true-negative, false-positive, and false-negative findings were extracted and pooled estimates of sensitivity and specificity per diagnostic test were calculated, if applicable. RESULTS The overall quality of the studies reporting the diagnostic accuracy of the clinical diagnosis, contrast enema and magnetic resonance imaging (MRI) were moderate to poor and not suitable for meta-analysis. Sensitivity of the clinical diagnosis varied between 64% and 68%. Ultrasound (US) and computed tomography (CT) studies were eligible for meta-analysis. Summary sensitivity estimates for US were 90% (95% CI: 76-98%) versus 95% (95% CI: 91-97%) for CT (p = 0.86). Summary specificity estimates for US were 90% (95% CI: 86-94%) versus 96% (95% CI: 90-100%) for CT (p = 0.04). Sensitivity for MRI was 98% and specificity varied between 70% and 78%. Sensitivity of contrast enema studies varied between 80% and 83%. CONCLUSION In two-thirds of the patients, the diagnosis of ACD can be made based on clinical evaluation alone. In one-third of the patients, additional imaging is a necessity to establish the diagnosis. US and CT are comparable in diagnosing diverticulitis and superior to other modalities. CT has the advantage of higher specificity and the ability to identify alternative diagnoses. The role of MRI is not yet clear in diagnosing ACD. Contrast enema is considered an obsolete imaging technique to diagnose ACD based on lower sensitivity and specificity than US and CT. A step-up approach with CT performed after an inconclusive or negative US, seems a logical and safe approach for patients suspected of ACD.
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Affiliation(s)
- Caroline S Andeweg
- Department of Surgery, Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
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31
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Abstract
A reliable diagnosis is fundamental for operative, interventional and conservative treatment of the different facets of diverticular disease. Not only differential diagnoses but also overlap or coincidence with other entities sharing similar symptoms must be considered. Furthermore, an adequate surgical strategy and correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV) has released a new classification of diverticulitis displaying the different facets of diverticular disease. This classification also comprises symptomatic uncomplicated diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding. While detailed history, physical examination and laboratory testing are of great importance for exploring a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging using ultrasonography (US) or computed tomography (CT). The diagnostic value of qualified US is equipotent to qualified CT, complies with relevant legislation for radiation exposure protection and is frequently effective for diagnosis. Therefore, US is considered to be the first choice for imaging in diverticular disease. In contrast, CT has definite indications in unclear, discrepant situations or insufficient US performance. Strengths and weaknesses of both methods are discussed. Endoscopy is not required for the diagnosis of diverticulitis and should not be performed in an acute attack. Colonoscopy, however, is warranted after healing of diverticulitis, prior to elective surgery and in cases of an atypical course. Prior exclusion of perforation is considered mandatory. An unequivocal indication for colonoscopy is diverticular bleeding and the rapid performance (within 12-24 h) allows better identification of sites of bleeding and endoscopic interventions.
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Kiewiet JJS, Andeweg CS, Laurell H, Daniels L, Laméris W, Reitsma JB, Hendriks JCM, Bleichrodt RP, van Goor H, Boermeester MA. External validation of two tools for the clinical diagnosis of acute diverticulitis without imaging. Dig Liver Dis 2014; 46:119-24. [PMID: 24252579 DOI: 10.1016/j.dld.2013.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 08/13/2013] [Accepted: 09/17/2013] [Indexed: 12/11/2022]
Abstract
AIM External validation and comparison of the diagnostic accuracy of two predictive tools, the emergency department triad and the clinical scoring tool in diagnosing acute diverticulitis. METHODS Two derivation datasets were used crosswise for external validation. In addition, both tools were validated in a third independent cohort. Predictive values were reassessed and the Area Under the Curve expressed discriminatory capacity. Performance was compared by calculating positive predictive values of the emergency department triad in the validation cohorts and with a cut-off analysis for the clinical scoring tool at a positive predictive value of 90%. RESULTS Predictive value of the emergency department triad was comparable to the clinical scoring tool. The positive predictive value of the emergency department triad (97%) decreased in the clinical scoring tool cohort (81%) and was excellent in the independent cohort (100%), identifying 24%, 20% and 14% of the patients. A smaller proportion of patients with diverticulitis could be identified with the clinical scoring tool (6%, 19% and 9%). CONCLUSION The emergency department triad as well as the clinical scoring tool have significant predictive value in external cohorts of patients suspected of diverticulitis. These tools can be used to select patients in whom additional imaging to diagnose acute diverticulitis may be omitted.
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Affiliation(s)
- Jordy J S Kiewiet
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
| | - Caroline S Andeweg
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Lidewine Daniels
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Wytze Laméris
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Johannes B Reitsma
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan C M Hendriks
- Department of Epidemiology, Biostatistics and HTA, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Robert P Bleichrodt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Abstract
PURPOSE Hospitalization for acute colonic diverticulitis has become more and more frequent. We studied the changes in the rate of admission and incidence of the disease during the last 25 years. METHODS We performed a retrospective analysis of all cases treated for acute diverticulitis during 1988-2012 at one hospital serving a defined population in Mid-Norway. The study made a distinction between admission rates and incidence rates. The admission rates defined the total number of cases admitted, while the incidence rates defined the number of new patients hospitalized for acute diverticulitis (first admission). Poisson regression was used to analyse factors associated with diverticulitis incidence rates. RESULTS A total of 851 admissions in 650 different patients were identified, with an overall admission rate of 38.5 (CI 35.9 to 41.1) per 100,000 person-years. The admission rate increased from 17.9 (CI 14.1 to 22.3)/100,000 during 1988-1992 to 51.1 (CI 44.8 to 58.0)/100,000 during 2008-2012. Poisson regression analysis showed a significant increase in admission rates with a factor of 2.8 (C.I. 2.2 to 3.5) during 25 years. The overall incidence rate (IRR) of new patients was 29.4 (CI 27.1 to 31.7)/100,000 person-years. IRR increased significantly with a factor of 2.6 (CI 1.96 to 3.34) during 25 years, while IRR for perforations increased even more, by a factor of 3.3 (CI 1.24 to 8.58). CONCLUSION The hospital admission rates as well as incidence rates for acute colonic diverticulitis increased significantly during the 25-year time span.
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[Unusual differential diagnosis of posttraumatic back pain]. Unfallchirurg 2013; 117:1057-60. [PMID: 24202064 DOI: 10.1007/s00113-013-2503-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The differential diagnosis of lumbar back pain includes a broad spectrum of vertebral and extravertebral pathologies. Even in cases of a traumatic event physicians should keep an extravertebral cause in mind. This is a case report on the coincidence of perforated sigma diverticulitis and traumatic spine compression fracture in an 85-year-old woman with acute back pain. The presence of free retroperitoneal gas in the computed tomography (CT) scan was of significant diagnostic importance.
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Helou N, Abdalkader M, Abu-Rustum RS. Sonography: first-line modality in the diagnosis of acute colonic diverticulitis? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1689-1694. [PMID: 24065248 DOI: 10.7863/ultra.32.10.1689] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Nabil Helou
- Center for Advanced Fetal Care, Najah Center, First Floor, Aasheer Al Dayeh Street, Tripoli, Lebanon.,
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36
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Andeweg CS, Mulder IM, Felt-Bersma RJF, Verbon A, van der Wilt GJ, van Goor H, Lange JF, Stoker J, Boermeester MA, Bleichrodt RP. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 2013; 30:278-92. [PMID: 23969324 DOI: 10.1159/000354035] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 06/25/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed. METHODS A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities. RESULTS The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy. CONCLUSION Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.
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Reply to Letter. Ann Surg 2013; 258:e15. [DOI: 10.1097/sla.0b013e31829c7af2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Complicated intra-abdominal infections such as acute appendicitis and complicated diverticulitis represent both diagnostic and therapeutic challenges. Both diseases, although different in many ways, are caused by the obstruction of a blind pouch leading to inflammation, abscesses, and perforation of surrounding tissues. For many decades, acute appendicitis was managed through a conventional surgical incision in the right iliac fossa. As for other diseases, there is a significant tendency to propose less invasive treatments. For many teams, laparoscopy, which leads to less postoperative pain, a shorter hospital stay, and a quicker recovery, represents the standard of care for appendectomy. For selected cases, a medical approach can be proposed with satisfactory outcomes. Additionally, the management of complicated diverticulitis is also quickly moving towards less invasive procedures than the deleterious '3-phase surgery', which is Hartmann's procedure, followed by reversal protected with a stoma, and finally stoma closure. Benefiting from the evolution of antimicrobial therapy and interventional radiology, many complicated cases classified as Hinchey stage I and Hinchey stage II complicated diverticulitis are now treated medically. CT images allow the identification of patients requiring radiological drainage of localized abscesses or collections over 5 cm in size. Patients with Hinchey stage III sigmoiditis may benefit from an initial laparoscopic exploration allowing, in some cases, a conservative nonresective approach that will prevent laparotomy and stoma. Major resection leading to temporary or definitive stoma is usually indicated for stage IV complications and is required only in exceptional cases. Although a surgical intervention can be the definitive treatment for complicated intra-abdominal infections, multidisciplinary management including radiology, medical treatment, and laparoscopic surgery may limit the severe consequences of an acute surgical approach in patients suffering from complicated appendicitis and diverticulitis. Today, the ultimate goal of acutely infected abdomen management is to reduce hospital stay, disability, and numerous operations for these patients.
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Affiliation(s)
- D Mutter
- IRCAD-EITS, IHU, University Hospital of Strasbourg, Strasbourg, France.
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Minimal-invasive chirurgische Behandlung der Sigmadivertikulitis. COLOPROCTOLOGY 2013. [DOI: 10.1007/s00053-012-0334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Longstreth GF, Iyer RL, Chu LHX, Chen W, Yen LS, Hodgkins P, Kawatkar AA. Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients. Aliment Pharmacol Ther 2012; 36:886-94. [PMID: 22967027 DOI: 10.1111/apt.12047] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Computed tomography (CT) demonstrates diverticulitis severity. AIM To assess demographic, clinical and leucocyte features in association with severity. METHODS We reviewed medical records of 741 emergency department cases and in-patients with diverticulitis. CT findings were: (i) nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe (abscess and/or extra-luminal gas and/or contrast). RESULTS Patients with severe vs. nondiagnostic/moderate findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P = .002), fever (52.2% vs. 27.0%, P < .0001), leucocytosis (81.5% vs. 55.2%, P < .0001), neutrophilia (86.2% vs. 59.0%, P < .0001), ‘bandemia’ (18.5% vs. 5.5%, P < .0001) and the triad of abdominal pain, fever and leucocytosis (46.7% vs. 19.9%, P < .0001) respectively. Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P < .0001). The former group (odds ratio [95% CI]) included females less often (0.45 [0.26-0.76]) and had less lower abdominal pain only (0.54 [0.29-0.99]) and more constipation (2.32 [1.27-4.23]), fever (2.13 [1.27-3.57]) and leucocytosis (2.67 [1.43-4.99]). CONCLUSIONS Less than 50% of severe cases have the clinical/laboratory triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who lack fever and leucocytosis have severe diverticulitis. Male gender, pain not limited to the lower abdomen, constipation, fever and leucocytosis are independently associated with severe diverticulitis.
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Affiliation(s)
- G F Longstreth
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA 91101, USA.
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Barry BD, Leroy J, Mutter D, Wu HS, Marescaux J. Minimally invasive surgical treatment of sigmoid diverticulitis. Langenbecks Arch Surg 2012; 397:1035-41. [PMID: 22644602 DOI: 10.1007/s00423-012-0965-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 05/20/2012] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Diverticular disease is very common in Western societies. However, there is a trend towards reducing indications for the surgical management of diverticulitis. Minimally invasive surgery offers many potential advantages to patients in the treatment of diverticulitis and may optimise surgical indications. METHODS A systematic literature review of minimally invasive techniques was carried out for the treatment of diverticulitis. The following techniques were reviewed: laparoscopic, single-port, natural orifice specimen extraction, natural orifice transluminal endoscopic surgery and laparoscopic lavage for the treatment of diverticulitis. RESULTS In total, 2,050 minimally invasive cases were reviewed. Of all the different minimally invasive techniques published regarding the management of diverticular disease, laparoscopic surgery is the only technique that has undergone the rigours of randomised controlled trials. The documented benefits are less blood loss, less pain and analgesic requirements, a reduction in major complications, a reduction in the frequency of drain usage, a reduction in the duration of postoperative ileus and shorter hospital stay. However, operative time does appear to be longer. It has also been demonstrated that elective laparoscopic surgery results in improved quality of life and social functioning. CONCLUSION Minimally invasive surgery for the treatment of diverticular disease appears feasible and safe. The result of future randomised trials will more clearly define the role each minimally invasive technique will play in the future.
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Affiliation(s)
- B D Barry
- Department of General, Digestive and Endocrine Surgery, IRCAD/EITS, University Hospital of Strasbourg, 1 Place de l'Hôpital, 67091 Strasbourg, France
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Abstract
The traditional view that recurrent episodes of diverticulitis lead to progressively complicated disease resulting in a disadvantageous course, more difficult, complicated operations and lethal outcomes did not stand the test of evidence. Only a minority of patients with acute diverticulitis will ever require surgery, and if so, this occurs during or early after the first episode. Complications and recurrence of disease after surgery are enumerable. Strong indicators favoring sigmoid colectomy are major abscess, free air, and fistula, i.e. perforating disease. This occurs predominantly at the initial presentation, frequently in younger or immunosuppressed patients. Important differential diagnoses must be considered both for initial diagnosis of diverticulitis and for recurrent episodes. Conservative management of recurrent diverticulitis is safe and best guided by gastroenterological expertise. Sophisticated ultrasound experience as a part of this competence allows detailed evaluation of the local status and the best evidence in the literature for diagnosing diverticulitis is on US. In practice, however, the question of perforating diverticulitis is adequately answered by subtle CT scan. Medical therapy is usually the treatment of choice for recurrent diverticulitis. Avoidance of drugs bearing the hazard of perforation (e.g. NSAIDs) is emphasized, and smoking is strongly discouraged. A mathematical model based on published data shows that patients with recurrent diverticulitis overall (only) profit from surgery if they are hit by four episodes during the course of disease. This is where theory and reality (should) meet.
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Affiliation(s)
- Bernhard Lembcke
- Department of Internal Medicine and Gastroenterology, KKEL, St. Barbara-Hospital Gladbeck, Gladbeck, Germany.
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Berger M, de Wit N, Vogelenzang R, Wetzels R, Kortenhof NVRV, Opstelten W. NHG-Standaard Diverticulitis. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s12445-011-0238-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. Ann Surg 2011; 253:940-6. [PMID: 21346548 DOI: 10.1097/sla.0b013e3182113614] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to assess and compare the diagnostic value of elements of the disease history, physical examination, and routine laboratory tests in patients with suspected acute left-sided colonic diverticulitis (ALCD). BACKGROUND Misdiagnosis rates for diverticulitis vary in literature between 34% and 68% which needs improvement. Because of the frequent misdiagnosis, liberal use of imaging has been recommended. Before making a plea for routine imaging, the diagnostic accuracy of different variables of disease history, physical examination, and routine laboratory tests needs to be specified. METHODS All patients seen on the emergency department because of acute abdominal pain suspected of ALCD in whom an abdominal computed tomography was performed, between January 2002 and March 2006, were studied. Univariate logistic regression was used to study differences in patients' characteristics and symptoms, findings at physical examination and routine laboratory tests between patients with and without ALCD. Independent predictors to the risk of ALCD were identified using multivariate logistic regression and used to create a clinical scoring system. RESULTS Of 1290 patients with acute abdominal pain, 287 patients were eligible for analysis. Acute left-sided colonic diverticulitis was the final diagnosis in 124 patients (43%). Age, 1 or more previous episodes, localization of symptoms in the lower left abdomen, aggravation of pain on movement, the absence of vomiting, localization of abdominal tenderness in the lower left abdomen, and C-reactive protein 50 or more were found to be independent predictors of ALCD. A nomogram was constructed based on these independent predictors with a diagnostic accuracy of 86%. CONCLUSIONS This study showed that the clinical diagnosis of diverticulitis is difficult to make but can be improved using a clinical scoring system. In case of a high chance of ALCD based on the nomogram, additional imaging may not be needed.
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Lopez DE, Brown CVR. Diverticulitis: the most common colon emergency for the acute care surgeon. Scand J Surg 2010; 99:86-9. [PMID: 20679043 DOI: 10.1177/145749691009900208] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- D E Lopez
- Department of Surgery, University of Texas Southwestern - Austin, University Medical Center Brackenridge, Austin, TX 78701, USA
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Laméris W, van Randen A, van Gulik TM, Busch ORC, Winkelhagen J, Bossuyt PMM, Stoker J, Boermeester MA. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum 2010; 53:896-904. [PMID: 20485003 DOI: 10.1007/dcr.0b013e3181d98d86] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to identify patients in whom the clinical diagnosis of diverticulitis can be made with a high certainty, distinguishing them from patients requiring imaging. METHODS We prospectively recorded clinical features in patients with acute abdominal pain presenting at the emergency department, before they underwent imaging. We identified features significantly associated with a final diagnosis of acute diverticulitis using multivariate logistic regression analysis and developed a decision rule based on these features. We evaluated the performance of the rule in identifying patients with a high probability of having diverticulitis. RESULTS In total, 112 of the 1021 patients (11%) had a final diagnosis of diverticulitis. Of the 126 patients with clinically suspected diverticulitis, 80 had a final diagnosis of diverticulitis. In 32 patients with diverticulitis as their final diagnosis, another clinical diagnosis was made. A decision rule was based on the 3 strongest clinical features: direct tenderness only in the left lower quadrant, the absence of vomiting, and a C-reactive protein >50 mg/L. Of the 126 clinically suspected patients, 30 patients had all 3 features (24%), of whom 29 had a final diagnosis of acute diverticulitis (97%; 95% CI: 83%-99%). Of the 96 patients without all 3 features, 45 (47%) did not have diverticulitis. CONCLUSION In a quarter of patients with suspected diverticulitis, the diagnosis can be made clinically based on a combination of direct tenderness only in the left lower quadrant, the absence of vomiting, and an elevated C-reactive protein. In patients without these features, imaging is required to reach adequate diagnostic accuracy.
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Affiliation(s)
- Wytze Laméris
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Schildberg CW, Skibbe J, Croner R, Schellerer V, Hohenberger W, Horbach T. [Rational diagnostics of acute abdomen]. Chirurg 2010; 81:1013-9. [PMID: 20464353 DOI: 10.1007/s00104-010-1938-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. MATERIAL AND METHODS A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. RESULTS Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. CONCLUSION Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.
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Affiliation(s)
- C W Schildberg
- Viszeral- und Allgemeinchirurgie, Universität Erlangen/Nürnberg, Deutschland.
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Abstract
OBJECTIVE To evaluate the diagnostic accuracy of clinical evaluation and cross-sectional imaging modalities such as ultrasound and computed tomography for patients with suspected colonic diverticulitis and to determine the value of these examinations in clinical decision-making. METHOD A prospective analysis was conducted of 802 consecutive patients that presented with abdominal pain at the emergency department. Initial clinical diagnoses and management proposals were compared to the final diagnoses and therapeutic strategies for all patients. RESULTS Fifty-seven patients were identified with colonic diverticulitis as the final diagnosis. The positive and negative predictive values for the clinical diagnosis of colonic diverticulitis were 0.65 and 0.98 respectively. Additional cross-sectional imaging had a positive and negative predictive value of respectively 0.95 and 0.99 or higher. These additional examinations led to a correct change of the initial clinical diagnosis in 37% of the patients, and a change in management in only 7%. CONCLUSION The accuracy of the clinical diagnosis for colonic diverticulitis is low. Ultrasound and computed tomography have superior diagnostic accuracy but these examinations rarely change the initial management proposal.
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Stoker J, van Randen A, Laméris W, Boermeester MA. Imaging patients with acute abdominal pain. Radiology 2009; 253:31-46. [PMID: 19789254 DOI: 10.1148/radiol.2531090302] [Citation(s) in RCA: 206] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
UNLABELLED Acute abdominal pain may be caused by a myriad of diagnoses, including acute appendicitis, diverticulitis, and cholecystitis. Imaging plays an important role in the treatment management of patients because clinical evaluation results can be inaccurate. Performing computed tomography (CT) is most important because it facilitates an accurate and reproducible diagnosis in urgent conditions. Also, CT findings have been demonstrated to have a marked effect on the management of acute abdominal pain. The cost-effectiveness of CT in the setting of acute appendicitis was studied, and CT proved to be cost-effective. CT can therefore be considered the primary technique for the diagnosis of acute abdominal pain, except in patients clinically suspected of having acute cholecystitis. In these patients, ultrasonography (US) is the primary imaging technique of choice. When costs and ionizing radiation exposure are primary concerns, a possible strategy is to perform US as the initial technique in all patients with acute abdominal pain, with CT performed in all cases of nondiagnostic US. The use of conventional radiography has been surpassed; this examination has only a possible role in the setting of bowel obstruction. However, CT is more accurate and more informative in this setting as well. In cases of bowel perforation, CT is the most sensitive technique for depicting free intraperitoneal air and is valuable for determining the cause of the perforation. Imaging is less useful in cases of bowel ischemia, although some CT signs are highly specific. Magnetic resonance (MR) imaging is a promising alternative to CT in the evaluation of acute abdominal pain and does not involve the use of ionizing radiation exposure. However, data on the use of MR imaging for this indication are still sparse. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/content/253/1/31/suppl/DC1.
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Affiliation(s)
- Jaap Stoker
- Departments of Radiology and Surgery, Academic Medical Center, University of Amsterdam, 1105 AZ Amsterdam, the Netherlands.
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Abstract
OBJECTIVE The purpose of our study is to present a series of 14 patients with chronic diverticulitis on barium enema examinations and to correlate the radiographic findings with the clinical and pathologic findings in these patients. CONCLUSION Chronic diverticulitis is a distinct pathologic entity characterized by the frequent development of chronic obstructive symptoms and abdominal pain rather than the classic clinical findings of acute sigmoid diverticulitis. Barium enema examinations usually reveal a relatively long segment of circumferential narrowing in the sigmoid colon with a spiculated contour and tapered margins, sometimes associated with retrograde obstruction. Our experience suggests that chronic diverticulitis can often be diagnosed on the basis of the characteristic clinical and radiographic findings in these patients.
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