The role of procalcitonin as a risk stratification tool of severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis

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.

Emergency medicine updates: Acute diverticulitis

INTRODUCTION

Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician.

DISCUSSION

Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients with acute diverticulitis.

Biochemical predictors of complicated diverticulitis: A case-control study evaluating white cell count and C-reactive protein in the assessment of acute diverticulitis

Background/Aim: Acute diverticulitis represents a common surgical condition and one of the leading gastrointestinal causes of surgical admissions in Western societies. Complicated diverticulitis increases the length of the hospital stay and the risk of requiring surgical intervention. In areas of limited availability or long waiting times for CT scanning, biochemical predictors of complicated diverticulitis might be valuable. In the available literature, there is no consensus on cut-off values of C-reactive protein or the value of a white cell count in the diagnosis of complicated diverticulitis. Additional studies among different populations are required to add to the existing literature to reach a consensus on diagnostic cut-off levels of inflammatory markers to diagnose complicated diverticulitis. The aim of the present study is to evaluate the predictive value of a white cell count and C-reactive protein, and their sensitivity and specificity in differentiating complicated from uncomplicated diverticulitis. Methods: This case-control study was performed for patients with acute diverticulitis in Lyell McEwin Hospital in Adelaide, South Australia. Data were collected for consecutive patients admitted from January 2015 to December 2017. Patients with acute diverticulitis confirmed by computed tomography were included in the study. Data of patients with complicated diverticulitis were compared to those of patients with uncomplicated diverticulitis as a control group. Patient characteristics, symptoms, number of attacks of diverticulitis, presence of immunosuppression, past history of complicated diverticulitis, inflammatory markers (white cell count and C-reactive protein), and computed tomography findings were collected and compared. Results: A total of 106 consecutive cases were recruited for the period from 2015 to 2017. There were 44 cases of complicated diverticulitis and 62 cases with uncomplicated diverticulitis (control group). A white cell count (WCC) and C-reactive protein (CRP) were collected at the time of presentation from the clinical records and pathology reports. A receiver operating characteristic (ROC) analysis was performed and multiple cut-off values for both WCC and CRP were reported. For WCC, the area under curve (AUC) was 0.69 (0.582-0.797) with a P-value of 0.001. At a cut-off of 14, sensitivity was found to be 56.8% and specificity of 80.7%. The sensitivity gradually decreased and specificity gradually increased as the cut-off value increased. At 18 the sensitivity was 25% and specificity was 79%. The positive predictive value for the study sample at WCC of 18 × 109/L or above is 79.5%. For CRP, the AUC was 0.828 (0.729-0.927) with a P-value of <0.001. At a cut-off value of 100 mg/L, the sensitivity was 72.7% and specificity was 80.6%. Sensitivity gradually decreased and specificity increased as the cut-off increased in value. At 160 mg/L, sensitivity was 36.36% and specificity was 97.22% with a positive predictive value of 76%. Conclusion: Contrary to what has been previously reported in the literature, we found that WCC remains a significant test in diagnosing complicated diverticulitis. A high cut-off value of 18 × 109/L is useful in predicting complicated diverticulitis with high positive predictive value. When compared to WCC, CRP is a more sensitive test in detecting complicated diverticulitis. We recognized a cut-off value of 160 mg/L to be a significant value to rule in complicated diverticulitis with a significant positive predictive value. WCC and CRP are very specific predictors of complicated diverticulitis with high positive predictive value at high cut-off values of 18 × 109/L and 160 mg/L, respectively.

Evaluation of a treatment pathway for the management of uncomplicated diverticulitis

INTRODUCTION

Recent clinical practice recommendations have radically modified the management of colonic diverticulitis. The goal of our study was to evaluate a treatment pathway for uncomplicated diverticulitis and to analyze the outcome (patient compliance, treatment failure and complications).

PATIENTS AND METHODS

All patients who presented to the emergency department with the diagnosis of uncomplicated diverticulitis were prospectively included in this study. The treatment pathway included an outpatient clinical re-assessment by a gastrointestinal surgeon. In case of symptomatic treatment failure, oral antibiotics were prescribed. If developed clinical signs of severity developed, the patient was referred to the emergency department for new laboratory and imaging workup.

RESULTS

Eighty-seven patients were included. The mean interval before re-assessment was 2.8 days. Fifty-nine patients (67.8%) had symptomatic treatment upon discharge from the emergency department and were reassessed as outpatients by the surgical team. Patient evolution was satisfactory for 45 (76.3%); 10 (16.9%) required oral antibiotics. One (1.7%) patient developed complicated diverticulitis. Thirty-four (39.1%) patients did not comply with the current recommendations.

CONCLUSION

In our experience, uncomplicated diverticulitis can be treated effectively in an ambulatory setting followed by early re-assessment by a surgeon.

Development of a prediction model for clinically important outcomes of acute diverticulitis

OBJECTIVE

Acute diverticulitis (AD) is a common disease with various outcomes. When AD is diagnosed in the emergency department (ED), the ED clinician must determine the patient's treatment strategy whether the patient can be discharged, needs to be admitted to the general ward, ICU, or needs surgical consultation. This study aimed to identify potential risk factors for clinically important outcomes (CIOs) and to develop a prediction model for CIOs in AD to aid clinical decision making in the ED.

METHODS

Retrospective data from between 2013 and 2017 in an ED in an urban setting were reviewed for adult AD. Potential risk factors were age, sex, past medical history, symptoms, physical exams, laboratory results, and imaging results. A CIO was defined as a case with one of the following outcomes: hospital death, ICU admission, surgery or invasive intervention, and admission for 7 or more days. The prediction model for CIOs was developed using potential risk factors. Model discrimination and calibration were assessed using the area under the curve (AUC) and 95% confidence intervals (CIs) and the Hosmer-Lemeshow (HL) test, respectively. Model validation was conducted using 500 random bootstrap samples.

RESULTS

Of the final 337 AD patients, 63 patients had CIOs. Six potential factors (age, abdominal pain (≥ 3 days), anorexia, rebound tenderness, white blood cell count (> 15,000/μl), C-reactive protein (> 10 mg/dL), and CT findings of a complication) were used for the final model. The AUC (95% CI) for CIOs was 0.875 (0.826-0.923), and χ² was 2.969 (p-value = 0.936) with the HL test. Validation using bootstrap samples resulted in an optimism-corrected AUC of 0.858 (0.856-0.861).

CONCLUSION

A prediction model for clinically important outcomes of AD visiting a single ED showed good discrimination and calibration power with an acceptable range.

Evaluation of molecular and genetic predisposing parameters at diverticular disease of the colon

BACKGROUND

Diverticular disease (DD) refers to the presence of diverticula throughout the gastrointestinal (GI) tract, mainly along colon. DD might evolve into diverticulitis that is accompanied by severe clinical presentation, which includes abscess formation, perforation, stricture, obstruction and/or fistula.

AIM

The aim of the present review is to summarize the role of molecular and genetic factors in DD development, as well as their possible contribution towards new prognostic indicators, diagnostic algorithms and new therapeutic approaches.

METHODS AND RESULTS

Except from common predisposing parameters, several genetic mutations, immune factors, neurotransmitters, hormones and protein dysfunctions have been associated to the early onset of DD symptoms, pathogenesis and prognosis of the disease. Specific structural changes in the colonic wall, altered matrix composition and compromised motility have been verified as possible pathogenic factors for the development of DD. Dysregulation in peristaltic activity and reduced ability of the longitudinal muscle to relax following contraction has been also associated with DD evolution. In addition, it has been suspected that genetic defects combined with alterations in intestinal microbiota might play an important role in diverticulitis presentation.

The Use of Biochemical Markers in Complicated and Uncomplicated Acute Diverticulitis

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 &lt; 0.0001), C-reactive protein (P &lt; 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 &lt; 0.05) and complicated diverticulitis with surgery (P &lt; 0.05). White cell count also showed a significant difference when comparing complicated diverticulitis without surgery and complicated diverticulitis with surgery (P &lt; 0.05).

Conclusions

White cell count, C-reactive protein, and bilirubin can distinguish between uncomplicated and complicated diverticulitis.

C-reactive protein trajectory in the first 48 hours predicts the need for intervention in conservative management of acute diverticulitis

BACKGROUND

C-reactive protein (CRP) is a useful marker for monitoring response to treatment in sepsis. The aim of this study was to examine the use of CRP trajectory in predicting the need for intervention in conservatively managed patients with acute diverticulitis (AD).

METHODS

A retrospective review of patients with AD who were managed conservatively was performed. They were divided into four groups based on CRP relative to the median at day 0 and 2: 'Low rise' (levels below median at day 0 and 2), 'High rise' (levels above median at day 0 and 2), 'Rapid rise' (levels below median at day 0 but above median at day 2) and 'Decline' (levels above median at day 0 but below median at day 2).

RESULTS

Intervention was required in 64 of 456 (14%) with 30 (48%) of these performed after day 2 of admission. There were 150 patients (54%) in the 'Low rise', 76 (27%) in the 'Decline', 26 patients (9%) in the 'Rapid rise' and 25 patients (9%) in the 'High rise' groups. Within these groups 5%, 8%, 19% and 32% of patients required intervention (P = 0.001). On multivariate analysis, patients with a pelvic abscess were more likely to need intervention (odds ratio 19.1 (confidence interval 6.2-59.4), P < 0.0001).

CONCLUSION

The CRP trajectory during the initial 48 h of admission can predict the need for intervention in AD patients being managed conservatively. Patients with a 'Rapid rise' or 'High rise' in CRP from day 0 to 2 are more likely to need intervention.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

BACKGROUND

Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

METHODS

The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

RESULTS

The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

CONCLUSIONS

The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Are Correlated with Complicated Diverticulitis and Hinchey Classification: A Simple Tool to Assess Disease Severity in the Emergency Department

Background and Aim

Rapid identification of patients with complications related to acute diverticulitis who require urgent intervention in the emergency department (ED) is essential. The aim of our study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting severity of diverticulitis as assessed by Hinchey classification.

Patients and Methods

We performed a single retrospective study in EMMS Nazareth Hospital from 4/2014 to 4/2018. Patients were categorized into two groups: group A with mild to moderate complicated diverticulitis (Hinchey 1-2) and group B with severe complicated diverticulitis (Hinchey 3-4).

Results

Two hundred twenty-five patients were included. Two hundred seven patients were in group A, and 18 patients were in group B. On univariate analysis, age, NLR, and PLR correlated with advanced Hinchey classification and disease severity (stages 3-4) (OR 1.038, 95% CI 1.001–1.076, P=0.0416; OR 1.192, 95% CI 1.093–1.300, P < 0.0001; and OR 1.011, 95% CI 1.005–1.017, P=0.0005, respectively). On multivariate logistic regression analysis, the NLR and PLR remain significantly correlated with Hinchey 3-4 (OR 1.174, 95% CI 1.071–1.286, P=0.0006, and OR 1.008, 95% CI 1.001–1.015, P=0.0209, respectively). The area under the curve (AUC) for the NLR and PLR on univariate analysis was 0.7526 and 0.6748, respectively, and 0.7760 and 0.7391 on multivariate logistic regression analysis, respectively, and receiver-operating characteristic (ROC) curves were drawn.

Conclusion

The NLR and PLR independently associated with diverticulitis severity and positively correlated with advanced Hinchey classification. This simple available laboratory tool can be implemented into clinical practice to optimize patient management.

Long-term follow-up of a multicentre cohort study on laparoscopic peritoneal lavage for perforated diverticulitis

AIM

Laparoscopic peritoneal lavage has increasingly been investigated as a promising alternative to sigmoidectomy for perforated diverticulitis with purulent peritonitis. Most studies only reported outcomes up to 12 months. Therefore, the objective of this study was to evaluate long-term outcomes of patients treated with laparoscopic lavage.

METHODS

Between 2008 and 2010, 38 patients treated with laparoscopic lavage for perforated diverticulitis in 10 Dutch teaching hospitals were included. Long-term follow-up data on patient outcomes, e.g. diverticulitis recurrence, reoperations and readmissions, were collected retrospectively. The characteristics of patients with recurrent diverticulitis or complications requiring surgery or leading to death, categorized as 'overall complicated outcome', were compared with patients who developed no complications or complications not requiring surgery.

RESULTS

The median follow-up was 46 months (interquartile range 7-77), during which 17 episodes of recurrent diverticulitis (seven complicated) in 12 patients (32%) occurred. Twelve patients (32%) required additional surgery with a total of 29 procedures. Fifteen patients (39%) had a total of 50 readmissions. Of initially successfully treated patients (n = 31), 12 (31%) had recurrent diverticulitis or other complications. At 90 days, 32 (84%) patients were alive without undergoing a sigmoidectomy. However, seven (22%) of these patients eventually had a sigmoidectomy after 90 days. Diverticulitis-related events occurred up to 6 years after the index procedure.

CONCLUSION

Long-term diverticulitis recurrence, re-intervention and readmission rates after laparoscopic lavage were high. A complicated outcome was also seen in patients who had initially been treated successfully with laparoscopic lavage with relevant events occurring up to 6 years after initial surgery.

Delta neutrophil index as a promising prognostic marker of emergent surgical intervention for acute diverticulitis in the emergency department

BACKGROUND

Early identification of patients with acute diverticulitis who require emergent surgical intervention in the emergency department (ED) is important to the physician. Although computed tomography (CT) has an important role in evaluating the severity of diverticulitis, its findings alone may not predict the need for emergent surgical intervention in all patients with acute diverticulitis in the ED. Serum inflammation markers may help to differentiate severity of acute diverticulitis and predict the need for surgical intervention in clinical practice. No information is currently available on the clinical usefulness of the delta neutrophil index (DNI), with respect to the prediction of emergent surgical intervention in patients with acute diverticulitis at the ED.

METHODS

This was a retrospective observational study of consecutive adult patients with acute diverticulitis confirmed by CT in the ED, between January 2014 and December 2016. Recruited patients were divided into two groups: emergent surgical intervention and no surgical intervention. The following laboratory serum parameters were examined in the ED: DNI value, C-reactive protein (CRP) levels, white blood cell count, neutrophil count, and neutrophil-to-lymphocyte ratio (NLR). The patients were also examined for the presence or absence of complications by CT.

RESULTS

A total of 132 patients were finally included in the study, with the emergent surgical intervention group constituting 52 patients. The median DNI value, CRP levels, neutrophil count, and NLR were significantly higher in the emergent surgical intervention group than in the no surgical intervention group. The area under the curve for predicting emergent surgical intervention, using the DNI was significantly higher than that of CRP levels, neutrophil count, or NLR. Moreover, the combination of initial DNI and CT was most powerful diagnostic modality.

CONCLUSIONS

DNI values measured at the ED combined with CT were good predictors for emergent surgical intervention in acute diverticulitis. If the DNI value is greater than 0.7% and complications in CT are suspected in patients suspected to have acute diverticulitis, the need for emergent surgical intervention should be considered carefully in the ED.

Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis

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.

The Role of Biomarkers in Diverticular Disease

Diverticulosis of the colon is a common condition in western countries. Acute diverticulitis may occur in 10% to 25% of the patients, sometimes associated with the presence of complications such as abscess, fistula, and perforation. Early diagnosis and accurate assessment of acute diverticulitis are necessary to start an efficacious treatment promptly, either conservatively or by surgery. The clinical picture may mimic other abdominal conditions; therefore, imaging techniques such as ultrasound or computed tomography are usually recommended, although they are expensive, examiner dependent, and potentially harmful. Recently, there has been increasing interest about the role of biological markers in diverticular disease as noninvasive, reliable, and inexpensive tools, conceivably able to support physicians in the diagnosis, the assessment of activity, and the monitoring of acute diverticulitis. By a MEDLINE search, most of the relevant data derived from C-reactive protein showed that it strongly supported the diagnosis of acute diverticulitis at values of >50 mg/L. It also represents a stronger marker compared with other serum biomarkers, able to correlate with the histologic severity in acute diverticulitis, the risk of perforation, and the response to therapy. Regarding fecal biomarkers, an interesting role has been reported for fecal calprotectin. It significantly correlates with inflammatory infiltrate. More relevantly, it correlates with the response to therapy and may predict the recurrence of colonic diverticulitis, as it is reliable in detecting subclinical intestinal inflammation, as reported already for inflammatory bowel disease. These represent encouraging results, but need to be confirmed in further larger studies.

Predictors of acute diverticulitis severity: A systematic review

BACKGROUND

Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring systems exist for predicting prognosis associated with severe complications of diverticulitis such as peritonitis. However, predicting disease severity has not received as much attention. Therefore, the aim of this review was to identify the factors that are predictive of severe acute diverticulitis.

METHODS

A systematic literature search was performed using Medline, PubMed, EMBASE, and the Cochrane Library to identify papers that evaluated factors predictive of severe diverticulitis. Severe diverticulitis was defined as complicated diverticulitis (associated with haemorrhage, abscess, phlegmon, perforation, purulent/faecal peritonitis, stricture, fistula, or small-bowel obstruction) or diverticulitis that resulted in prolonged hospital admission, surgical intervention or death.

RESULTS

Twenty one articles were included. Studies were categorised into those that identified patient characteristics (n = 12), medications (n = 5), biochemical markers (n = 8) or imaging (n = 3) as predictors. Predictors for severe diverticulitis included first episode of diverticulitis, co-morbidities (Charlson score ≥ 3), non-steroidal anti-inflammatory drug use, steroid use, a high CRP on admission and severe disease on radiological imaging. Age and gender were not associated with disease severity.

CONCLUSION

A number of predictors exist for identifying severe diverticulitis, and CT remains the gold standard for diagnosing complicated disease. Patients who present with identified risk factors for severe disease warrant early imaging, closer in-patient observation and a lower threshold for early surgical intervention. Patients without these factors may be suitable for outpatient-based treatment.

WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting

Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.

The role of C-reactive protein in prediction of the severity of acute diverticulitis in an emergency unit

OBJECTIVE

Computed tomography (CT) is the most appropriate initial imaging modality for the assessment of acute diverticulitis. The aim here was to determine the usefulness of C-reactive protein (CRP) in predicting the severity of the diverticulitis process and the need for a CT examination.

METHODS

The CRP values of 350 patients who presented first time with symptoms of acute diverticulitis and underwent CT imaging on admission to Oulu University Hospital were compared with the CT findings and clinical parameters by means of both univariate and multivariate analyses.

RESULTS

The receiver operating characteristic curve showed that a CRP cut-off value of 149.5 mg/l significantly discriminated acute uncomplicated diverticulitis from complicated diverticulitis (specificity 65%, sensitivity 85%, area under the curve 0.811, p = 0.0001). In multivariate analysis, a CRP value over 150 mg/l and old age were independent risk factors for acute complicated diverticulitis. The mean CRP value was significantly higher in the patients who died, 207 (84 SD), than in those who survived, 139 (SD 83). In addition, a CRP value over 150 mg/l and free abdominal fluid in CT were independent variables predicting postoperative mortality.

CONCLUSIONS

CRP is useful for the predicting the severity of acute diverticulitis on admission. Patients with a CRP value higher than 150 mg/l have an in increased risk of complicated diverticulitis and a CT examination should always be carried out.