International Consensus on Diverticulosis and Diverticular Disease. Statements from the 3rd International Symposium on Diverticular Disease

Predicting complicated acute diverticulitis with the HALP score: A retrospective study

OBJECTIVE

HALP score is a scoring system consisting of hemoglobin, albumin, lymphocyte and platelet. It is different from other prognostic markers because it provides information about both inflammation and immunonutrition status. This study aims to evaluate the severity of the disease and the level of prognosis in patients diagnosed with acute diverticulitis.

MATERIAL METHODS

190 patients diagnosed with acute diverticulitis between January 2017 and June 2023 were included in the study. The patients were divided into two separate groups according to the Hinchey classification. The prognostic effect of inflammatory markers and HALP score was examined.

RESULT

The median values of C-reactive protein, white blood cell count, neutrophil count, HALP score, and hospitalization duration were significantly higher in patients diagnosed with complicated diverticulitis than in those diagnosed with uncomplicated diverticulitis. (p < 0.001, p = 0.045, p = 0.004, p < 0.001 and p < 0.001, respectively). The distinguishing feature of the HALP score in predicting the complexity of the diagnosis of diverticulitis was evaluated using ROC analysis. Area Under Curve (AUC) value was found to be 0.723 (p < 0.001). According to the ROC curve, the sensitivity and specificity for the cut-off value of HALP score ≤44.1 were 66.7 % and 75.0 %, respectively.

CONCLUSION

HALP score is an inexpensive parameter that can be used safely to determine the severity and prognosis of acute diverticulitis.

Canadian Association of Radiologists Gastrointestinal Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Gastrointestinal Expert Panel consists of radiologists, a gastroenterologist, a general surgeon, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 58 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 85 recommendation statements specific to the adult population across the 20 scenarios. This guideline presents the methods of development and the referral recommendations for dysphagia/dyspepsia, acute nonlocalized abdominal pain, chronic abdominal pain, inflammatory bowel disease, acute gastrointestinal bleeding, chronic gastrointestinal bleeding/anemia, abnormal liver biopsy, pancreatitis, anorectal diseases, diarrhea, fecal incontinence, and foreign body ingestion.

Hospital Admission, Medical, and Surgical Procedures for Acute Diverticulitis Are More Appropriate when Using a Diagnostic and Therapeutic Assistance Pathway: An Experience from a Referral Center

INTRODUCTION

Our aim was to assess the impact of the Diagnostic and Therapeutic Assistance Pathway (PDTA) developed for acute diverticulitis (AD) on the management of patients with AD and referring to the emergency room (ER) in a referral center.

METHODS

This retrospective study includes all patients diagnosed with AD and referring to the ER between January 1, 2021, and December 31, 2022 (after approval of PDTA), compared to the same period of 2015-2019. Length of stay in ER, medical and surgical management, and length in hospital stay (in days) were also measured according to the type of disease (uncomplicated vs. complicated).

RESULTS

ER admission due to AD during the period 2015-2019 was 240 ± 13 cases per year, while it was 290 cases in 2022 (p = 0.05). After adopting the PDTA, the rate of length of stay in ER >24 h for AD was significantly reduced (p = 0.01); the median rate of hospital admission for AD was significantly reduced (p < 0.05); the rate of medical treatment of uncomplicated disease was increased (p = 0.01), while the rate of surgical management was decreased (p = 0.05); the rate of medical treatment of complicated disease was increased (p = 0.01), while the rate of surgical management was decreased (p = 0.001); the hospital stay was significantly reduced in both uncomplicated (p = 0.05) and complicated (p = 0.05) AD.

CONCLUSIONS

The development and the routine use of a PDTA dedicated to AD have significantly improved the management of these patients, reducing the ER stay, the surgical procedures, and the overall hospital stay.

The Prevalence and Characteristics of Symptomatic Uncomplicated Diverticular Disease Among Asian Patients With Unexplained Abdominal Symptoms

Background/Aims

The precise incidence of symptomatic uncomplicated diverticular disease (SUDD) and its effects on the quality of life (QOL) remain unclear, particularly in Asian patients with right-sided SUDD. We assess the prevalence of SUDD and its impact on QOL in a real-world population.

Methods

Five institutional cohorts of patients who received outpatient treatment for unexplained abdominal symptoms from January 15, 2020 to March 31, 2022, were included. All patients underwent colonoscopy. SUDD was defined as the presence of recurrent abdominal symptoms, particularly pain in the lower right or left quadrant lasting > 24 hours in patients with diverticulosis at the site of pain. The 36-item short-form health survey was used to assess QOL.

Results

Diverticula were identified in 108 of 361 patients. Among these 108 patients, 31% had SUDD, which was right-sided in 39% of cases. Of the 50 patients with right-sided diverticula, 36% had SUDD, as did 15 of 35 patients with left-sided diverticula (43%). Among the 33 patients with SUDD, diverticula were right-sided, left-sided, and bilateral in 39%, 45%, and 15% of patients, respectively. Diarrhea was more frequent in the SUDD group than in the non-SUDD group. Patients with SUDD had significantly lower physical, mental, and role/social component scores than those without SUDD.

Conclusions

It is important to recognize that patients with SUDD account for as high as 31% of outpatients with unexplained abdominal symptoms; these patients have diarrhea and a low QOL. The presence of right-sided SUDD was characteristic of Asian patients.

Trends in the Management of Non-emergent Surgery for Diverticular Disease and the Impact of Practice Parameters

BACKGROUND

Due to the rise in diverticular disease, the ASCRS developed practice parameters to ensure high-quality patient care. Our study aims to evaluate the impact of the 2014 practice parameters on the treatment of non-emergent left-sided diverticular disease.

METHODS

This is a retrospective cohort study using the ACS-National Surgical Quality Improvement Project (ACS-NSQIP). Elective sigmoid resections performed by year were evaluated and compared before and after practice parameters were published.

RESULTS

Overall, 46,950 patients met inclusion criteria. There was a significant decrease in the number of non-emergent operations when evaluating before and after guideline implementation (P < .001). There was a significant decrease in the number of patients younger than 50 years of age operated electively for diverticular disease (25.8% vs. 23.9%, P = .005). Adoption of minimally invasive surgery continued to increase significantly throughout the study period.

CONCLUSIONS

Publication of the 2014 ASCRS practice parameters is associated with a change in management of diverticular disease in the non-emergent setting.

Ultrasonographic and Functional Features of Symptomatic Uncomplicated Diverticular Disease

INTRODUCTION

To evaluate the ability of intestinal ultrasound (IUS) in discriminating symptomatic uncomplicated diverticular disease (SUDD) among patients with abdominal symptoms including irritable bowel syndrome (IBS).

METHODS

This observational, prospective study included consecutive patients classified into the following categories: (i) SUDD; (ii) IBS; (iii) unclassifiable abdominal symptoms; and (iv) controls, including asymptomatic healthy subjects and diverticulosis. The IUS evaluation of the sigmoid: assessed the presence of diverticula, thickness of the muscularis propria, and IUS-evoked pain, namely the intensity of pain evoked by compression with the ultrasound probe on sigmoid colon compared with an area of the left lower abdominal quadrant without underlying sigmoid colon.

RESULTS

We enrolled 40 patients with SUDD, 20 patients with IBS, 28 patients with unclassifiable abdominal symptoms, 10 healthy controls, and 20 patients with diverticulosis. Patients with SUDD displayed significantly ( P < 0.001) greater muscle thickness (2.25 ± 0.73 mm) compared with patients with IBS (1.66 ± 0.32 mm), patients with unclassifiable abdominal pain, and healthy subjects, but comparable with that of patients with diverticulosis (2.35 ± 0.71 mm). Patients with SUDD showed a greater (not significant) differential pain score than other patients. There was a significant correlation between the thickness of the muscularis propria and the differential pain score only for patients with SUDD ( r = 0.460; P : 0.01). Sigmoid diverticula were detected by colonoscopy in 40 patients (42.4%) and by IUS with a sensitivity of 96.0% and a specificity of 98.5%.

DISCUSSION

IUS could represent a useful diagnostic tool for SUDD, potentially useful in characterizing the disease and appropriately address the therapeutic approach.

Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

When to Perform a Colonoscopy in Diverticular Disease and Why: A Personalized Approach

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize "when" to safely perform a colonoscopy in the different DD settings and "why".

Normal Gastrointestinal Mucosa at Biopsy and Overall Mortality: Nationwide Population-Based Cohort Study

Background

Normal gastrointestinal (GI) mucosa on endoscopy has been linked to a lower risk of colorectal cancer (CRC) but its association to overall death is unknown.

Methods

We identified 466,987 individuals with a first GI biopsy 1965–2016 with normal mucosa (60.6% upper GI and 39.4% lower GI) through all Swedish pathology departments (n = 28). They were individually matched to 2,321,217 reference individuals without a GI biopsy and also compared to 505,076 full siblings. Flexible parametric models were applied to estimate hazard ratio (HRs) and 95% confidence interval (95% CI) for death.

Results

During a median follow-up of ~11 years, 85,859 (18.39%) of individuals with normal mucosa and 377,653 (16.27%) of reference individuals died. This corresponded to incidence rates of 147.56/10,000 vs 127.90/10,000 person-years respectively (rate difference: 19.66/10,000 person-years), with the multivariable-adjusted HR of 1.21 (95% CI: 1.20–1.22). Excess mortality was seen for both upper and lower biopsy with normal mucosa. Particularly higher HRs for death were seen in males, individuals biopsied when aged <40 years, those without a prior record of GI disease, and those with high education. Mortality risk was most increased in the first five years after biopsy (HR = 1.34; 95% CI: 1.32–1.36) but decreased thereafter. Having a GI biopsy with normal mucosa was associated with excess mortality from cardiovascular (CVD)disease (HR = 1.02; 95% CI: 1.01–1.03), cancer (HR = 1.58; 95% CI: 1.56–1.61), GI disease (HR = 1.65; 95% CI: 1.58–1.71), and other causes (HR = 1.10; 95% CI: 1.08–1.11). Sibling comparisons yielded similar results.

Conclusion

Compared with individuals without a GI biopsy, those with a normal GI biopsy due to clinical symptoms had a higher mortality particularly in the first five years after biopsy, and especially from GI disease and cancer.

Prognostic performance of the 'DICA' endoscopic classification and the 'CODA' score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study

OBJECTIVE

To investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA).

DESIGN

A multicentre, prospective, international cohort study.

SETTING

43 gastroenterology and endoscopy centres located in Europe and South America.

PARTICIPANTS

2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications.

INTERVENTIONS

A 3-year follow-up was performed.

MAIN OUTCOME MEASURES

To predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score).

RESULTS

The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).

CONCLUSIONS

DICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score.

TRIAL REGISTRATION NUMBER

NCT02758860.

Performance of a multi-compounds nutraceutical formulation in patients with symptomatic uncomplicated diverticular disease

BACKGROUND

Symptomatic uncomplicated diverticular disease (SUDD) is a recognized clinical condition characterized by abdominal pain and changes in bowel habits, attributed to diverticula but without macroscopic signs of diverticulitis. There is no consensus about the management of these patients. Enteroflegin®, an association of natural active ingredients, could be effective in the treatment of those patients.

METHODS

We conducted a retrospective observational study to evaluate the performances of Enteroflegin® in patients with SUDD. Patients were treated with Enteroflegin® 2 cp/day for 10 days per month for 6 months. Primary endpoint was the clinical remission rate, defined as the absence of any symptoms; secondary endpoints were the impact of the treatment on reduction of symptoms, on fecal calprotectin (FC) expression, and the prevention of acute diverticulitis.

RESULTS

Three hundred and fifty patients were retrospectively enrolled (183 males, median age 64 yrs, IQR 54-70). Enteroflegin® was effective in inducing remission in 9.34% and 17.64% of patients at 3 and 6 months respectively (p<0.001). Reduction of symptoms occurred in 92.3% and in 85.3% of patients at 3 and 6 months respectively (p<0.001), and symptoms' recurrence or worsening was recorded in only 1.71% of patients during the follow-up. FC expression dropped from 181,3 μg/g at baseline to 100,2 μg/g (p<0.001) and to 67,9 μg/g (p<0.001) at 3 and 6 months of follow-up respectively. No adverse event was recorded during the follow-up. Finally, acute diverticulitis occurred in just 2% of patients during the follow-up.

CONCLUSIONS

Enteroflegin® seems to be an effective nutraceutical compound in obtaining remission and symptom relief in SUDD patients. Further randomized, placebo-controlled clinical trials are needed to confirm these preliminary data.

Colonic Diverticulosis and Non-Alcoholic Fatty Liver Disease: Is There a Connection?

Background and Objectives: The development and severity of colonic diverticulosis and non-alcoholic fatty liver disease (NAFLD) has been associated with several components of metabolic syndrome (MetS). Therefore, this study aimed to evaluate a possible connection between NAFLD, colonic diverticulosis, and MetS. Materials and Methods: This retrospective study included patients diagnosed with diverticulosis between January 2017 and December 2019. Data regarding the patient demographics, Diverticular Inflammation and Complication Assessment (DICA) score and category, disease localization, hepatic steatosis, blood pressure, comprehensive metabolic panel, need for colonic surgery, and co-morbidities were collected from medical records. Results: A total of 407 patients with a median age of 68 years (range, 34-89 years) were included (male: 53.81%). The majority was diagnosed with left-sided diverticulosis (n = 367, 90.17%) and an uncomplicated disease course (DICA category 1, n = 347, 85.3%). Concomitant hepatic steatosis was detected in 47.42% (n = 193) of patients. The systolic blood pressure, triglycerides, total cholesterol, C-reactive protein (CRP), and fasting glucose were higher in the NAFLD group (p < 0.001, p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively). A higher prevalence of hypertension (HTA), type 2 diabetes mellitus (T2DM), and hypothyroidism was noted in the same group of patients (p < 0.001, p < 0.001, and p = 0.008, respectively). High-density lipoprotein cholesterol was lower in patients with more severe forms of diverticulosis (DICA category 2 and 3), while CRP levels were significantly higher (p = 0.006 and p = 0.015, respectively). HTA and NAFLD were more common in patients with more severe forms of colonic diverticulosis (p = 0.016 and p = 0.025, respectively). Using a multivariate logistic regression, the DICA score, CRP, total cholesterol, HTA, and hypothyroidism were identified as discriminating factors for the presence of hepatic steatosis. Conclusion: Components of metabolic dysregulation were prominent in patients diagnosed with colonic diverticulosis and concomitant hepatic steatosis. HTA, T2DM, and hypothyroidism were more frequently observed in this group. Hepatic steatosis was more commonly detected in more severe forms of colonic diverticulosis.

Conservative Management of Complicated Colonic Diverticulitis in Early and Late Elderly

Background and Objectives: The management of complicated diverticulitis in the elderly can be a challenge and initial non-operative treatment remains controversial. In this study, we investigate the effectiveness of conservative treatment in elderly people after the first episode of complicated diverticulitis. Materials and Methods: This retrospective single-centre study describes 71 cases of elderly patients with complicated acute colonic diverticulitis treated with conservative management at Parma University Hospital from 1 January 2012 to 31 December 2019. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Patients was divided into two groups: early (65-74 yo) and late elderly (>75 yo). Results: We enrolled 71 elderly patients conservatively treated for complicated acute colonic diverticulitis, 25 males and 46 females. The mean age was 74.78 ± 6.8 years (range 65-92). Localized abdominal pain and fever were the most common symptoms reported in 34 cases (47.88%). Average white cells count was 10.04 ± 5.05 × 109/L in the early elderly group and 11.24 ± 7.89 in the late elderly group. CRP was elevated in 29 (78.3%) cases in early elderly and in 23 late elderly patients (67.6%). A CT scan of the abdomen was performed in every case (100%). Almost all patients were treated with bowel rest and antibiotics (95.7%). Average length of stay was 7.74 ± 7.1 days (range 1-48). Thirty-day hospital readmission and mortality were not reported. Average follow-up was 52.32 ± 31.8 months. During follow-up, home therapy was prescribed in 48 cases (67.6%). New episodes of acute diverticulitis were reported in 20 patients (28.1%), elevated WBC and chronic NSAID therapy were related to a higher risk of recurrence in early elderly patients (p < 0.05). Stage IIb-III with elevated WBC during first episode, had a higher recurrence rate compared to the other CT-stage (p = 0.006). Conclusions: The management of ACD in the elderly can be a challenge. Conservative treatment is safe and effective in older patients, avoiding unnecessary surgery that can lead to unexpected complications due to co-morbidities.

The prevalence of symptomatic uncomplicated diverticular disease could be lower than expected: a single-center colonoscopy-based cohort study

AIM

The real prevalence of symptomatic uncomplicated diverticular disease (SUDD) is still unknown. The aim of this study was to assess the prevalence of SUDD, post-diverticulitis SUDD (PD-SUDD) and irritable bowel syndrome (IBS)-like symptoms in a real-life population.

METHODS

A cohort of patients, submitted to colonoscopy from 1st January 2012 to 30th April 2018 was revised.

RESULTS

A cohort of 5451 patients with diverticulosis was identified during the study period. Abdominal pain was recorded in 1141 patients (20.93%), diarrhea in 288 (5.28%) and constipation in 536 (9.83%) patients. SUDD was recorded in 371 patients (6.81% of the patients having diverticulosis and 32.51% of the patients experiencing abdominal pain), PD-SUDD was recorded in 103 patients (1.89% of the patients having diverticulosis and 9.03% of the patients experiencing abdominal pain) and IBS-like was recorded in 348 patients (6.38% of the patients having diverticulosis and 30.5% of the patients experiencing abdominal pain). Three hundred and nineteen patients were not part of any of the previous categories (5.85% of the patients having diverticulosis and 27.96% of the patients experiencing abdominal pain). SUDD and PD-SUDD were more frequent in older ages (>60 years), while IBS-like symptoms were more frequent in younger. Nonspecific abdominal pain was equally distributed in through the ages.

CONCLUSION

The prevalence of SUDD seems to be lower than expected, and most of patients with diverticulosis and abdominal symptoms may suffer from IBS-like or other causes.

The Management of Acute Colonic Diverticulitis in the COVID-19 Era: A Scoping Review

Background and Objective: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of pathologies. Concerning surgery, there was an evident reduction in all elective and emergency activities, particularly for benign pathologies such as acute diverticulitis, for which we have identified a reduction in emergency room presentation with mild forms and an increase with more severe forms. The aim of our review was to discover new data on emergency presentation for patients with acute diverticulitis during the Covid-19 pandemic and their current management, and to define a better methodology for surgical decision-making. Method: We conducted a scoping review on 25 trials, analyzing five points: reduced hospital access for patients with diverticulitis, the preferred treatment for non-complicated diverticulitis, the role of CT scanning in primary evaluation and percutaneous drainage as a treatment, and changes in surgical decision-making and preferred treatment strategies for complicated diverticulitis. Results: We found a decrease in emergency access for patients with diverticular disease, with an increased incidence of complicated diverticulitis. The preferred treatment was conservative for non-complicated forms and in patients with COVID-related pneumonia, percutaneous drainage for abscess, or with surgery delayed or reserved for diffuse peritonitis or sepsis. Conclusion: During the COVID-19 pandemic we observed an increased number of complicated forms of diverticulitis, while the total number decreased, possibly due to delay in hospital or ambulatory presentation because of the fear of contracting COVID-19. We observed a greater tendency to treat these more severe forms by conservative means or drainage. When surgery was necessary, there was a preference for an open approach or a delayed operation.

[Diverticular disease: stage-related diagnostic imaging]

BACKGROUND

Diverticular disease frequently leads to emergency admissions. Clinical parameters are not sufficiently accurate to determine the extent of acute colonic diverticulitis, thus a quick, reproducible and valid diagnostic imaging procedure is required.

OBJECTIVE

In the following, the imaging methods commonly used for the diagnostic work-up and staging of diverticulitis are presented and classified in the context of the data situation and clinical reality.

RESULTS

Multidetector computed tomography (MDCT) is the current diagnostic gold standard for the imaging evaluation of diverticulitis and the basis for guideline-conform treatment decisions according to the classification of diverticular disease (CDD).

DISCUSSION

The role of magnetic resonance imaging (MRI) in the evaluation of diverticulitis will have to be investigated but a more profound integration of this method can already be predicted. Point-of-care ultrasound for initial diagnosis and follow-up assessment will become more important, analogous to FAST in trauma patients.

Development and Validation of Predictive Assessment of Complicated Diverticulitis Score

The prevalence of acute diverticulitis (AD) has progressively increased in recent decades, with correspondingly greater morbidity and mortality. The aim of the study is to develop a predictive score to identify patients with the highest risk of complicated AD. The clinical records of 1089 patients referred to the emergency department (ED) over a five-year period were reviewed. In multivariate analysis, male sex (p < 0.001), constipation (p = 0.002), hemoglobin < 11.9 g/dL (p < 0.001), C reactive protein > 80 mg/L (p < 0.001), severe obesity (p = 0.049), and no proton pump inhibitor treatment (p = 0.003) were independently associated with complicated AD. The predictive assessment of complicated (PACO)-diverticulitis (D) score, including these six variables, was applied to the retrospective cohort and then validated prospectively in a cohort including 282 patients. It categorized patients into three risk classes for complicated AD. The PACO-D score showed fair discrimination for complicated AD with an area under the receiver operating characteristic curve of 0.674 and 0.648, in the retrospective and prospective cohorts, respectively. The PACO-D score could be a practical clinical tool to identify patients at highest risk for complicated AD referred to the ED so that appropriate diagnostic and therapeutic resources could be appropriately allocated. Further external validation is needed to confirm these results.

The natural history of symptomatic uncomplicated diverticular disease: a long-term follow-up study

Background

Symptomatic uncomplicated diverticular disease (SUDD) affects about 20% of patients who have diverticulosis. However, the natural history of SUDD is not yet completely understood. Our aim was to assess the outcomes of a cohort of SUDD patients during a long-term follow up.

Methods

One hundred eighty-five patients suffering from SUDD were identified from a large electronic database. Symptoms assessed were abdominal pain, bloating, bowel movement/day, each of which was scored using a visual analogic scale (VAS); the symptom score was calculated by considering the value of the worst symptom present during assessment. Another VAS was used to assess patients' quality of life (QoL). Patients were treated at the physician's discretion (with rifaximin, mesalazine, probiotics, spasmolytics) only when symptoms occurred during the follow up. Follow-up visit was performed every year or whenever patients consider it necessary.

Results

During the follow up (156 months, interquartile range 9-171), 47 patients were lost to follow up. Among these, 9 died from causes not related to SUDD. Acute diverticulitis occurred in 14 patients (7.6% of the overall population): 6 patients (3.2% of the overall population) underwent surgery, and 2 patients (1.1% of the overall population) died because of peritonitis. Both the symptom score and the QoL score were substantially unmodified during the study period.

Conclusions

SUDD is an important disease able to affect patients significantly in the long term. Acute diverticulitis may sometimes occur in these patients, often leading to surgery with possible severe complications.

Development and validation of a diverticular clinical score for symptomatic uncomplicated diverticular disease after acute diverticulitis in a prospective patient cohort

BACKGROUND

Following an attack of acute diverticulitis (AD), many patients continue to suffer from a complex of symptoms, titled 'symptomatic uncomplicated diverticular disease (SUDD)'. To date, there is no validated clinical score for standardized assessment of patients with SUDD, thereby hampering the interpretation of observational studies and the conductance of clinical trials.We aimed to develop a validated SUDD clinical score.

METHODS

Data from previous prospective study of patients after AD was used to devise the score's first version. Validation was first performed using a focus group of patients after AD SUDD who underwent a structured cognitive personal interview. Thereafter, the diverticular clinical score (DICS) was applied for a second validation cohort. DICS scores of validation cohort were compared with physicians' global assessment for disease severity and inflammatory markers.

RESULTS

In DICS second validation using 48 patients prospectively recruited after AD SUDD, a correlation matrix demonstrated strong correlation between total questionnaire's score and the presence of elevated inflammatory markers (ρ = 0.84). Mean score in patients with elevated inflammatory markers compared with those without inflammation was 17.8 versus 6.2, respectively, p < 0.001. Cronbach's α for measuring internal consistency was 0.91. DICS discriminated accurately between patients with/without active disease, as gauged by the physicians global assessment (area under the curve receiver operating characteristic = 0.989).

CONCLUSIONS

Patients suffering from post-AD SUDD exhibit a wide range of symptoms. The newly developed DICS accurately and reproducibly quantitates SUDD-related symptom severity. The DICS may prove useful for monitoring SUDD in clinical practice and in research settings, as well as facilitating patient stratification and therapeutic decisions.