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Galgano SJ, McNamara MM, Peterson CM, Kim DH, Fowler KJ, Camacho MA, Cash BD, Chang KJ, Feig BW, Gage KL, Garcia EM, Kambadakone AR, Levy AD, Liu PS, Marin D, Moreno C, Pietryga JA, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria ® Left Lower Quadrant Pain-Suspected Diverticulitis. J Am Coll Radiol 2020; 16:S141-S149. [PMID: 31054740 DOI: 10.1016/j.jacr.2019.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 12/18/2022]
Abstract
This review summarizes the relevant literature regarding imaging of suspected diverticulitis as an etiology for left lower quadrant pain, and imaging of complications of acute diverticulitis. The most common cause of left lower quadrant pain in adults is acute sigmoid or descending colonic diverticulitis. Appropriate imaging triage for patients with suspected diverticulitis should address the differential diagnostic possibilities and what information is necessary to make a definitive management decision. Patients with diverticulitis may require surgery or interventional radiology procedures because of associated complications, including abscesses, fistulas, obstruction, or perforation. As a result, there has been a trend toward greater use of imaging to confirm the diagnosis of diverticulitis, evaluate the extent of disease, and detect complications before deciding on appropriate treatment. Additionally, in the era of bundled payments and minimizing health care costs, patients with acute diverticulitis are being managed on an outpatient basis and rapid diagnostic imaging at the time of initial symptoms helps to streamline and triage patients to the appropriate treatment pathway. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Samuel J Galgano
- Research Author, University of Alabama at Birmingham, Birmingham, Alabama.
| | | | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | - Kenneth L Gage
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | | | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | | | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | - Jason A Pietryga
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Sohn M, Agha A, Iesalnieks I, Bremer S, Trum S, Di Cerbo F, Nerlich A, Lotz N, Klieser E, Hochrein A, Schredl P, Kalcheva D, Emmanuel K, Presl J. PREDICtors for health-related quality of life after elective sigmoidectomy for DIVerticular disease: the PREDIC-DIV study protocol of a prospective multicentric transnational observational study. BMJ Open 2020; 10:e034385. [PMID: 32209628 PMCID: PMC7202696 DOI: 10.1136/bmjopen-2019-034385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Diverticulitis is among the most common abdominal disorders. The best treatment strategy for this complicated disease as well as for recurrent stages is still under debate. Moreover, little knowledge exists regarding the effect of different therapeutic strategies on the health-related quality of life (HrQoL). Therefore, the PREDIC-DIV (PREDICtors for health-related quality of life after elective sigmoidectomy for DIVerticular disease) study aims to assess predictors of a change in HrQoL in patients after elective sigmoidectomy for diverticular disease. METHODS AND ANALYSIS A prospective multicentre transnational observational study was started in November 2017. Patients undergoing elective sigmoid resection for diverticular disease were included. Primary outcome includes HrQoL 6 months postoperatively, staged by the Gastrointestinal Quality of Life Index (GIQLI). Secondary outcomes include HrQoL 6 months after sigmoidectomy, assessed using the Short Form 36 Questionnaire and a custom-made Visual Analogue Scale-based inventory; HrQoL after 12 and 24 months; postoperative morbidity; mortality; influence of surgical technique (conventional laparoscopic multiport operation vs robotic approach); histological grading of inflammation and morphological characteristics of the bowel wall in the resected specimen; postoperative functional changes (faecal incontinence, faecal urge, completeness of emptying, urinary incontinence, sexual function); disease-specific healthcare costs; and changes in economic productivity, measured by the iMTA Productivity Cost Questionnaire. The total follow-up will be 2 years. ETHICS AND DISSEMINATION The protocol was approved by the medical ethical committee of the Bavarian Medical Council (report identification number: 2017-177). The study was conducted in accordance with the Declaration of Helsinki. The findings of this study will be submitted to a peer-reviewed journal (BMJ Open, Annals of Surgery, British Journal of Surgery, Diseases of the Colon and the Rectum). Abstracts will be submitted to relevant national and international conferences. TRIAL REGISTRATION NUMBER The study is registered with the ClinicalTrials.gov register as NCT03527706; Pre-results.
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Affiliation(s)
| | - Ayman Agha
- München Klinik Bogenhausen, Munich, Bayern, Germany
| | | | | | | | | | | | - Natalie Lotz
- München Klinik Bogenhausen, Munich, Bayern, Germany
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Coble JL, Sheldon KE, Yue F, Salameh TJ, Harris LR, Deiling S, Ruggiero FM, Eshelman MA, Yochum GS, Koltun WA, Gerhard GS, Broach JR. Identification of a rare LAMB4 variant associated with familial diverticulitis through exome sequencing. Hum Mol Genet 2018; 26:3212-3220. [PMID: 28595269 DOI: 10.1093/hmg/ddx204] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/23/2017] [Indexed: 12/13/2022] Open
Abstract
Diverticulitis is a chronic disease of the colon in which diverticuli, or outpouching through the colonic wall, become inflamed. Although recent observations suggest that genetic factors may play a significant role in diverticulitis, few genes have yet been implicated in disease pathogenesis and familial cases are uncommon. Here, we report results of whole exome sequencing performed on members from a single multi-generational family with early onset diverticulitis in order to identify a genetic component of the disease. We identified a rare single nucleotide variant in the laminin β 4 gene (LAMB4) that segregated with disease in a dominant pattern and causes a damaging missense substitution (D435N). Targeted sequencing of LAMB4 in 148 non-familial and unrelated sporadic diverticulitis patients identified two additional rare variants in the gene. Immunohistochemistry indicated that LAMB4 localizes to the myenteric plexus of colonic tissue and patients harboring LAMB4 variants exhibited reduced LAMB4 protein levels relative to controls. Laminins are constituents of the extracellular matrix and play a major role in regulating the development and function of the enteric nervous system. Reduced LAMB4 levels may therefore alter innervation and morphology of the enteric nervous system, which may contribute to colonic dysmotility associated with diverticulitis.
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Affiliation(s)
- Joel L Coble
- Department of Biochemistry and Molecular Biology
| | | | - Feng Yue
- Department of Biochemistry and Molecular Biology
| | | | | | - Sue Deiling
- Department of Surgery, Division of Colon and Rectal Surgery
| | - Francesca M Ruggiero
- Division of Anatomical Pathology, The Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | | | - Gregory S Yochum
- Department of Biochemistry and Molecular Biology.,Department of Surgery, Division of Colon and Rectal Surgery
| | | | - Glenn S Gerhard
- Department of Medical Genetics and Molecular Biochemistry, Temple University College of Medicine, Philadelphia, PA 19140, USA
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Horesh N, Shwaartz C, Amiel I, Nevler A, Shabtai E, Lebedeyev A, Nadler R, Rosin D, Gutman M, Zmora O. Diverticulitis: does age matter? J Dig Dis 2016; 17:313-8. [PMID: 27106275 DOI: 10.1111/1751-2980.12350] [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: 01/17/2016] [Revised: 03/01/2016] [Accepted: 04/18/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Acute diverticulitis has been traditionally associated with worse outcome in young patients, indicating a more aggressive surgical approach is required for them. The aim of this study was to assess whether acute diverticulitis was more virulent in young patients. METHODS A retrospective, cross-sectional study included all patients who were admitted for a first episode of acute diverticulitis between January 2004 and December 2013. The patients were divided into two groups (≤50 years and >50 years) based on their age. Patients' characteristics, clinical and surgical data were recorded and analyzed. RESULTS Overall, 636 patients were included in the database, including 177 (27.8%) in the younger group and 459 in the elder group. There were no significant differences between the groups in disease complexity, peritonitis, laboratory work-up, vital signs on presentation, bowel obstruction or the presence of fistula and abscess in need of drainage. Younger patients had more free extra-luminal air on computed tomography (CT) scan (P = 0.03). Surgical data, including the intra-operative modified Hinchey score and the need for emergency and additional surgery did not significantly differ between the two groups. Young patients had more readmissions (P = 0.01) due to acute diverticulitis, diverticular complications and elective surgery. Length of hospital stay (P = 0.0001) was longer and postoperative complications were more common in the elder patients. CONCLUSIONS The clinical presentation of acute diverticulitis does not seem to be worse in the young population. Younger patients tend to have a more severe presentation on CT scan and more readmissions, but this did not translate to a more severe disease course.
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Affiliation(s)
- Nir Horesh
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Chaya Shwaartz
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Imri Amiel
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Avinoam Nevler
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Esther Shabtai
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Alexander Lebedeyev
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Roi Nadler
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Danny Rosin
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Mordechai Gutman
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Oded Zmora
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel
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Levchenko SV, Komissarenko IA, Lazebnik LB. Prevention of complications of colonic diverticular disease in outpatient practice. TERAPEVT ARKH 2016; 88:96-100. [DOI: 10.17116/terarkh201688196-100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Buchs NC, Mortensen NJ, Ris F, Morel P, Gervaz P. Natural history of uncomplicated sigmoid diverticulitis. World J Gastrointest Surg 2015; 7:313-318. [PMID: 26649154 PMCID: PMC4663385 DOI: 10.4240/wjgs.v7.i11.313] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 07/31/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
While diverticular disease is extremely common, the natural history (NH) of its most frequent presentation (i.e., sigmoid diverticulitis) is poorly investigated. Relevant information is mostly restricted to population-based or retrospective studies. This comprehensive review aimed to evaluate the NH of simple sigmoid diverticulitis. While there is a clear lack of uniformity in terminology, which results in difficulties interpreting and comparing findings between studies, this review demonstrates the benign nature of simple sigmoid diverticulitis. The overall recurrence rate is relatively low, ranging from 13% to 47%, depending on the definition used by the authors. Among different risk factors for recurrence, patients with C-reactive protein > 240 mg/L are three times more likely to recur. Other risk factors include: Young age, a history of several episodes of acute diverticulitis, medical vs surgical management, male patients, radiological signs of complicated first episode, higher comorbidity index, family history of diverticulitis, and length of involved colon > 5 cm. The risk of developing a complicated second episode (and its corollary to require an emergency operation) is less than 2%-5%. In fact, the old rationale for elective surgery as a preventive treatment, based mainly on concerns that recurrence would result in a progressively increased risk of sepsis or the need for a colostomy, is not upheld by the current evidence.
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Daniels M, Merkel S, Agaimy A, Hohenberger W. Treatment of perforated colon carcinomas-outcomes of radical surgery. Int J Colorectal Dis 2015; 30:1505-13. [PMID: 26248792 DOI: 10.1007/s00384-015-2336-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE When patients present with a perforation of a colon cancer (CC), this situation increases the challenge to treat them properly. The question arises how to deal with these patients adequately, more restrictively or the same way as with elective cases. METHODS Between January 1995 and December 2009, 52 patients with perforated CC and 1206 nonperforated CC were documented in the Erlangen Registry of Colorectal Carcinomas (ERCRC). All these patients underwent radical resection of the primary including systematic lymph node dissection with CME. The median follow-up period was 68 months. RESULTS The median age of the patients in the perforated CC group was significantly higher than in the nonperforated CC group (p = 0.010). Significantly, more patients with perforated CC were classified in ASA categories 3 and 4 (p = 0.014). Hartmann procedures were performed significantly more frequently with perforation than with the nonperforated ones (p < 0.001). If an anastomosis was performed, the leakage rate of primary anastomoses did not differ (p = 1.0). Cancer-related survival was significantly lower with perforated cancer (difference 12.8 percentage points) and by 9.6 percentage points for observed survival, if postoperative mortality was excluded. CONCLUSIONS Perforated CC patients should be treated basically following the same oncologic demands, which are CME for colonic cancer including multivisceral resections, if needed. This strategy can only be performed if high-quality surgery is available, permanently.
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Affiliation(s)
- M Daniels
- Universitätsklinikum Erlangen, Chirurgische Klinik, Krankenhausstraße 12, 91054, Erlangen, Germany.
| | - S Merkel
- Universitätsklinikum Erlangen, Chirurgische Klinik, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - A Agaimy
- Universitätsklinikum Erlangen, Pathologisches Institut, Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - W Hohenberger
- Universitätsklinikum Erlangen, Chirurgische Klinik, Krankenhausstraße 12, 91054, Erlangen, Germany
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Itai G, Slijper N, Sroka G, Matter I. Israeli Arabs develop diverticulitis at a younger age and are more likely to require surgery than Jews. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2015; 28:102-4. [PMID: 26176244 PMCID: PMC4737329 DOI: 10.1590/s0102-67202015000200004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/20/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis. AIM To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery. METHODS Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012. RESULTS Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis. CONCLUSIONS Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis.
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Affiliation(s)
- Ghersin Itai
- Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa, Israel
| | - Nadav Slijper
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
| | - Gideon Sroka
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
| | - Ibrahim Matter
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
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Management of acute diverticulitis and its complications. Indian J Surg 2014; 76:429-35. [PMID: 25614717 DOI: 10.1007/s12262-014-1086-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.
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Zdichavsky M, Kratt T, Stüker D, Meile T, Feilitzsch MV, Wichmann D, Königsrainer A. Acute and elective laparoscopic resection for complicated sigmoid diverticulitis: clinical and histological outcome. J Gastrointest Surg 2013; 17:1966-71. [PMID: 23918084 DOI: 10.1007/s11605-013-2296-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 07/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis. METHODS A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results. RESULTS Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified. CONCLUSIONS Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.
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Affiliation(s)
- Marty Zdichavsky
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany,
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Ünlü Ç, van de Wall BJ, Gerhards MF, Wiezer M, Draaisma WA, Consten EC, Boermeester MA, Vrouenraets BC. Influence of age on clinical outcome of acute diverticulitis. J Gastrointest Surg 2013; 17:1651-6. [PMID: 23733363 DOI: 10.1007/s11605-013-2240-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/22/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The controversy about the treatment of acute colonic diverticulitis in young patients continues. The discussion is focused on whether younger age is a risk factor for recurrence or a complicated course, thereby subject to different treatment choices. AIM In this study, we investigated whether an episode of acute diverticulitis at a younger age (≤50 years) has a higher recurrence rate or a more severe outcome. MATERIAL AND METHODS A retrospective cohort study was conducted in four teaching hospitals using hospital registry codes for diverticulitis. All patients diagnosed with acute diverticulitis between January 2004 and January 2012, confirmed by imaging, were included. RESULTS A total of 1,441 consecutive patients were identified as having primary acute diverticulitis of the sigmoid colon. Four hundred and sixty-three patients (32.1%) were ≤50 years (group 1) and 978 patients (67.9%) were older than 50 years (group 2). Twenty patients (4.3%) needed emergency surgery, due to perforated diverticulitis, within 72 h at first presentation in group 1 compared to 77 patients (7.8%) in group 2 (p = 0.029). Surgery within 30 days was needed for 29 of 463 patient (6.2%) in group 1 and 104 of 978 patients (10.6%) in group 2 (p = 0.02). Recurrence rate after a median follow-up of 22 months was comparable among groups (25.6% (111 patients) in group 1 versus 23.8% (208 patients) in group 2; p = 0.278). Also, cumulative recurrence was comparable among groups. CONCLUSION Younger age is neither associated with a more severe presentation of diverticulitis nor with a higher incidence in recurrence.
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Affiliation(s)
- Ç Ünlü
- Department of Surgery, Sint Lucas Andreas Hospital, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Mazzei MA, Cioffi Squitieri N, Guerrini S, Stabile Ianora AA, Cagini L, Macarini L, Giganti M, Volterrani L. Sigmoid diverticulitis: US findings. Crit Ultrasound J 2013; 5 Suppl 1:S5. [PMID: 23902791 PMCID: PMC3711739 DOI: 10.1186/2036-7902-5-s1-s5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute diverticulitis (AD) results from inflammation of a colonic diverticulum. It is the most common cause of acute left lower-quadrant pain in adults and represents a common reason for acute hospitalization, as it affects over half of the population over 65 years with a prevalence that increases with age. Although 85% of colonic diverticulitis will recover with a nonoperative treatment, some patients may have complications such as abscesses, fistulas, obstruction, and /or perforation at presentation. For these reasons, different classifications were introduced through times to help clinicians to develop a correct diagnosis and guide the treatment and for the same reasons imaging is used in most cases both to realise a differential diagnosis and to guide the therapeutic management. US and CT are both usefull in diagnosis of diverticolitis, and their sensibility and specificity are similar. However CT scanning is essential for investigating complicated diverticular disease especially where there are diffuse signs and clinical suspicion of secondary peritonitis; instead in most uncomplicated cases the experienced sonographer may quickly confirm a diagnosis guided by the clinical signs. US is to be recommended in premenopausal women, and in young people to reduce dose exposure.
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Affiliation(s)
- Maria Antonietta Mazzei
- Department of Medical, Surgical and Neuro Sciences, Section of Radiological Sciences, Siena, Italy.
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Park NS, Jeen YT, Choi HS, Kim ES, Kim YJ, Keum B, Seo YS, Chun HJ, Lee HS, Um SH, Kim CD, Ryu HS. Risk factors for severe diverticulitis in computed tomography-confirmed acute diverticulitis in Korea. Gut Liver 2013; 7:443-9. [PMID: 23898385 PMCID: PMC3724033 DOI: 10.5009/gnl.2013.7.4.443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 02/14/2013] [Accepted: 03/11/2013] [Indexed: 01/05/2023] Open
Abstract
Background/Aims Acute complicated diverticulitis can be subdivided into moderate diverticulitis and severe diverticulitis. Although there have been numerous studies on the risk factors for complicated diverticulitis, little research has focused on severe diverticulitis. This study was designed to identify the risk factors for severe diverticulitis in an acute diverticulitis attack using the modified Hinchey classification. Methods Patients were included if they had any evidence of acute diverticulitis detected by computed tomography. The patients were subdivided into severe diverticulitis (Hinchey class ≥Ib; abscesses or peritonitis) and moderate diverticulitis (Hinchey class Ia; pericolic inflammation) groups. Results Of the 128 patients, 25 exhibited severe diverticulitis, and 103 exhibited moderate diverticulitis. In a multivariate analysis, age >50 years (odds ratio [OR], 5.27; p=0.017), smoking (OR, 3.61; p=0.044), comorbidity (OR, 4.98; p=0.045), leukocytosis (OR, 7.70; p=0.003), recurrence (OR, 4.95; p=0.032), and left-sided diverticulitis (OR, 6.92; p=0.006) were significantly associated with severe diverticulitis. Conclusions This study suggests that the risk factors for severe diverticulitis are age >50 years, smoking, comorbidity, leukocytosis, recurrent episodes, and left-sided diverticulitis.
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Affiliation(s)
- Nark-Soon Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University College of Medicine, Seoul, Korea
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Flor N, Rigamonti P, Pisani Ceretti A, Romagnoli S, Balestra F, Sardanelli F, Cornalba G, Pickhardt PJ. Diverticular disease severity score based on CT colonography. Eur Radiol 2013; 23:2723-9. [PMID: 23660775 DOI: 10.1007/s00330-013-2882-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/21/2013] [Accepted: 04/13/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We propose a diverticular disease severity score (DDSS) based on CT colonography (CTC) findings. METHODS Seventy-nine patients (62 ± 14.5 years) underwent CTC after recovering from an episode of acute diverticulitis. Two independent readers classified each case using a four-point scale (DDSS), based on maximum sigmoid colon wall thickness (MSCWT) and minimum lumen diameter at CTC: 1 = MSCWT <3 mm, lumen diameter ≥15 mm; 2 = MSCWT 3-8 mm, lumen diameter ≥5 mm; 3 = MSCWT ≥8 mm, lumen diameter ≥5 mm; 4 = MSCWT ≥8 mm, lumen diameter <5 mm. Intra- and interobserver reproducibility was evaluated. Of 79 patients, 32 (40 %) underwent surgery after CTC; MSCWT was directly measured on the pathological specimen. RESULTS Intra- and interobserver reproducibility of DDSS were almost perfect (k = 0.90-0.84). DDSS significantly correlated with the probability of surgery (P = 0.001). After surgery, histopathology revealed acute/chronic diverticular inflammation only in 29 cases, and superimposed sigmoid cancer (n = 2) or Crohn's disease (n = 1) in 3 patients with a DDSS of 4. MSCWT at histopathology correlated with DDSS (P = 0.008). CONCLUSION DDSS is highly reproducible and correlates with pathological MSCWT. Nearly 1 in 3 patients with a DDSS of 4 had significant superimposed histopathology. CTC with DDSS can provide colorectal surgeons with valuable information. KEY POINTS • A diverticular disease severity score (DDSS) based on CT colonography is proposed. • This DDSS is based on sigmoid colon wall thickness and lumen diameter. • High scores may be associated with relevant coexisting lesions. • A CTC-based DDSS may influence therapeutic decision-making.
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Affiliation(s)
- Nicola Flor
- Unità Operativa Radiologia Diagnostica e Interventistica, Azienda Ospedaliera San Paolo, via A di Rudinì 8, 20142, Milano, Italy,
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Biondo S. Age and immunocompromised status in acute diverticulitis. Colorectal Dis 2012; 14:1553-4; author reply 1554-5. [PMID: 22958750 DOI: 10.1111/codi.12017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 08/03/2012] [Accepted: 09/07/2012] [Indexed: 02/08/2023]
Affiliation(s)
- S. Biondo
- Department of General and Digestive Surgery, Colorectal Unit; Bellvitge University Hospital, University of Barcelona and IDIBELL, C/Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907 Barcelona; Spain
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