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Simonetti S, Lanciotti S, Carlomagno D, De Cristofaro F, Galardo G, Cirillo B, Fiore F, Bonito G, Severi C, Ricci P. Acute diverticulitis: beyond the diagnosis: predictive role of CT in assessing risk of recurrence and clinical implications in non-operative management of acute diverticulitis. LA RADIOLOGIA MEDICA 2024; 129:1118-1129. [PMID: 39039300 PMCID: PMC11322399 DOI: 10.1007/s11547-024-01841-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/25/2024] [Indexed: 07/24/2024]
Abstract
PURPOSE The aim of the study is to identify CT findings that are predictive of recurrence of acute uncomplicated colonic diverticulitis, to better risk-stratify these patients for whom guidelines recommend a conservative outpatient treatment and to determine the appropriate management with an improvement of health costs. MATERIALS AND METHODS Over the past year, 33 patients enrolled in an outpatient integrated care pathway (PDTA) for uncomplicated acute diverticulitis with 1-year follow-up period, without recurrence, and 33 patients referred to Emergency Department for a recurrent acute diverticulitis were included. Images of admission CT were reviewed by two radiologists and the imaging features were analyzed and compared with Chi-square and Student t tests. Univariate and multivariate Cox regression models were employed to identify parameters that significantly predicted recurrence in 1-year follow-up period and establish cutoff and recurrence-free rates. The maximally selected rank statistics (MSRS) were used to identify the optimal wall thickening cutoff for the prediction of recurrence. RESULTS Patients with recurrence showed a greater mean parietal thickness compared to the group without recurrence (16 mm vs. 11.5 mm; HR 1.25, p < 0.001) and more evidence of grade 4 of peridiverticular inflammation (40% vs. 12%, p = 0.009, HR 3.44). 12-month recurrence-free rates progressively decrease with increasing thickness and inflammation. In multivariate analysis, only parietal thickness maintained its predictive power with an optimal cutpoint > 15 mm that causes a sixfold increased risk of recurrence (HR 6.22; 95% CI, 3.05-12.67; p < 0.001). Beyond thickness and peridiverticular inflammation, predictive value of early recurrence within 90 days from the 1st episode resulted also an Hinchey Ib on admission CT. CONCLUSIONS The maximum wall thickening and the grade of peridiverticular inflammation can be considered as predictive factors of recurrence and may be helpful in selecting patients for a tailored treatment to prevent the risk of recurrence.
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Affiliation(s)
- Stefania Simonetti
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Silvia Lanciotti
- Emergency Radiology Unit, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
| | - Dominga Carlomagno
- Translation and Precision Medicine Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Flaminia De Cristofaro
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Gioacchino Galardo
- Emergency Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Bruno Cirillo
- Emergency Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Fabio Fiore
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giacomo Bonito
- Emergency Radiology Unit, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
| | - Carola Severi
- Translation and Precision Medicine Department, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paolo Ricci
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
- Emergency Radiology Unit, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy.
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Weinstein S, Kim DH, Fowler KJ, Birkholz JH, Cash BD, Cilenti E, Dane B, Horvat N, Kambadakone AR, Korngold EK, Liu PS, Lo BM, McCrary M, Mellnick V, Pietryga JA, Santillan CS, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Left Lower Quadrant Pain: 2023 Update. J Am Coll Radiol 2023; 20:S471-S480. [PMID: 38040465 DOI: 10.1016/j.jacr.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The differential diagnosis for left lower quadrant pain is wide and conditions range from the benign and self-limited to life-threatening surgical emergencies. Along with patient history, physical examination, and laboratory tests, imaging is often critical to limit the differential diagnosis and identify life-threatening abnormalities. This document will discuss the guidelines for the appropriate use of imaging in the initial workup for patients who present with left lower quadrant pain, patients with suspected diverticulitis, and patients with suspected complications from diverticulitis. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California
| | - James H Birkholz
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Elizabeth Cilenti
- MedStar Georgetown University Hospital, Washington, District of Columbia, Primary care physician
| | - Bari Dane
- NYU Grossman School of Medicine, New York, New York
| | - Natally Horvat
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Bruce M Lo
- Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians
| | - Marion McCrary
- Duke Signature Care, Durham, North Carolina; American College of Physicians
| | - Vincent Mellnick
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri; Committee on Emergency Radiology-GSER
| | - Jason A Pietryga
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Katherine Zukotynski
- McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Fowler H, Gachabayov M, Vimalachandran D, Clifford R, Orangio GR, Bergamaschi R. Failure of nonoperative management in patients with acute diverticulitis complicated by abscess: a systematic review. Int J Colorectal Dis 2021; 36:1367-1383. [PMID: 33677750 DOI: 10.1007/s00384-021-03899-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to assess failure rates following nonoperative management of acute diverticulitis complicated by abscess and trends thereof. METHOD Pubmed, MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science were systematically searched. Nonoperative management was defined as a combination of nil per os, IV fluids, IV antibiotics, CT scan-guided percutaneous drainage, and total parenteral nutrition. The primary endpoint was failure of nonoperative management defined as persistent or worsening abscess and/or sepsis, development of new complications, such as peritonitis, ileus, or colocutaneous fistula, and urgent surgery within 30-90 days of index admission. Data were stratified by three arbitrary time intervals: 1986-2000, 2000-2010, and after 2010. The primary outcome was calculated for those groups and compared. RESULTS Thirty-eight of forty-four eligible studies published between 1986 and 2019 were included in the quantitative synthesis of data (n = 2598). The pooled rate of failed nonoperative management was 16.4% (12.6%, 20.2%) at 90 days. In studies published in 2000-2010 (n = 405), the pooled failure rate was 18.6% (10.5%, 26.7%). After 2000 (n = 2140), the pooled failure rate was 15.3% (10.7%, 20%). The difference was not statistically significant (p = 0.725). After controlling for heterogeneity in the definition of failure of nonoperative management, subgroup analysis yielded the pooled rate of failure of 21.8% (16.1%, 27.4%). CONCLUSION This meta-analysis found that failure rates following nonoperative management of acute diverticulitis complicated by abscess did not significantly decrease over the past three decades. The general quality of published data and the level and certainty of evidence produced were low.
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Affiliation(s)
| | - Mahir Gachabayov
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Suite D-361, Taylor Pavilion, 100 Woods Rd, Valhalla, NY, 10595, USA
| | | | | | - Guy R Orangio
- Section of Colon and Rectal Surgery, Department of Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Roberto Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Suite D-361, Taylor Pavilion, 100 Woods Rd, Valhalla, NY, 10595, USA.
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Hanna MH, Kaiser AM. Update on the management of sigmoid diverticulitis. World J Gastroenterol 2021; 27:760-781. [PMID: 33727769 PMCID: PMC7941864 DOI: 10.3748/wjg.v27.i9.760] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/11/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.
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Affiliation(s)
- Mark H Hanna
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010-3000, United States
| | - Andreas M Kaiser
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010-3000, United States
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CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study. Abdom Radiol (NY) 2021; 46:491-497. [PMID: 32748249 PMCID: PMC7897191 DOI: 10.1007/s00261-020-02690-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/16/2020] [Accepted: 07/25/2020] [Indexed: 11/21/2022]
Abstract
Purpose To perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD). Methods Fifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0–3 point scale for each variable. Results Of 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors. Conclusion DDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.
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A systematic review and meta-analysis of disease severity and risk of recurrence in young versus elderly patients with left-sided acute diverticulitis. Eur J Gastroenterol Hepatol 2020; 32:547-554. [PMID: 31972659 DOI: 10.1097/meg.0000000000001671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Young patients are thought to have a more severe disease course and a higher rate of recurrent diverticulitis. However, these understandings are mainly based on studies with important limitations. This review aimed to clarify the true natural history of acute diverticulitis in young patients compared to elderly patients. PubMed and MEDLINE were searched for studies reporting outcomes on disease severity or recurrences in young and elderly patients with a computed tomography-proven diagnosis of acute diverticulitis. Twenty-seven studies were included. The proportion of complicated diverticulitis at presentation (21 studies) was not different for young patients (age cut-off 40-50 years) compared to elderly patients [risk ratio (RR) 1.19; 95% confidence interval 0.94-1.50]. The need for emergency surgery (11 studies) or percutaneous abscess drainage (two studies) yielded comparable results for both groups with a RR of 0.93 (95% confidence interval 0.70-1.24) and 1.65 (95% confidence interval 0.60-4.57), respectively. Crude data on recurrent diverticulitis rates (12 studies) demonstrated a significantly higher RR of 1.47 (95% confidence interval 1.20-1.80) for young patients. Notably, no association between age and recurrent diverticulitis was found in the studies that used survival analyses, taking length of follow-up per age group into account. In conclusion, young patients do not have a more severe course of acute diverticulitis. Published data on the risk of recurrent diverticulitis in young patients are conflicting, but those with the most robust design do not demonstrate an increased risk. Therefore, young patients should not be treated more aggressively nor have a lower threshold for elective surgery just because of their age.
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Walter SS, Maurer M, Storz C, Weiss J, Archid R, Bamberg F, Kim JH, Nikolaou K, Othman AE. Effects of Radiation Dose Reduction on Diagnostic Accuracy of Abdominal CT in Young Adults with Suspected Acute Diverticulitis: A Retrospective Intraindividual Analysis. Acad Radiol 2019; 26:782-790. [PMID: 30268717 DOI: 10.1016/j.acra.2018.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022]
Abstract
RATIONALE AND OBJECTIVES To assess the effects of radiation dose reduction on image quality and diagnostic accuracy of abdominal computed tomography (CT) in young adults with suspected acute diverticulitis. MATERIALS AND METHODS Fifty-four patients ≤40 years who received contrast-enhanced abdominal CT for suspected acute diverticulitis were included. Low-dose CT (LDCT) datasets (25%, 50%, and 75% of the original dose) were generated using sinogram synthesis and quantum noise modeling. A five-point scale was used to assess images qualitatively (overall image quality, noise, artefacts, and sharpness) and for diagnostic confidence (5 being the best possible outcome). Furthermore, the diagnostic accuracy was determined for the presence of acute diverticulitis. RESULTS Among 54 patients (mean age: 35.2 ± 5.3 years, 77.8% male), the prevalence of acute diverticulitis was high (57.4%). Subjective image quality was highest for original datasets and lowest for LDCT datasets with 25% of the original dose (median [interquartile range]: 5 [5] vs. 3 [2-3], p < 0.001). Diagnostic confidence was high for all datasets down to 50% of the original dose, while 25% LDCT datasets were associated with a significantly decreased diagnostic confidence (p < 0.001). Diagnostic accuracy was high for all LDCT and original datasets (sensitivity: 100%, negative predictive value [NPV]: 100% for 75% and 100% dose levels; sensitivity: 96.8%, NPV: 95.8% for 50% dose level; sensitivity: 93.6%, NPV: 91.7% for 25% dose level, respectively). Inter-rater agreement regarding the detection of diverticulitis was almost perfect at doses ≥50% (kappa: >0.81), while lower for datasets of 25% of the original radiation dose agreement (kappa: 0.67-0.78). CONCLUSION Radiation dose reduction down to 50% of the original radiation exposure permits high image quality, diagnostic confidence, and accuracy for the assessment of acute diverticulitis in abdominal CT in young adults without the use of iterative reconstruction algorithms.
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Al Harakeh H, Paily AJ, Doughan S, Shaikh I. Recurrent Acute Diverticulitis: When to Operate? Inflamm Intest Dis 2018; 3:91-99. [PMID: 30733953 DOI: 10.1159/000494973] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/29/2018] [Indexed: 12/11/2022] Open
Abstract
Objective Recurrent acute diverticulitis carries a major burden to any form of health care. Patients present repeatedly to medical centers with a multitude of symptoms and may require different modalities of treatment with significant morbidities and impact on quality of life. Methods We therefore wanted to identify factors that would imply the need and time of surgery versus conservative management. The literature was thoroughly searched for major studies tackling this topic. Furthermore, studies reporting on decision making based on quality of life were included. Risks of developing recurrent diverticulitis and the potential need of surgery were identified. Relevant surgical details that would decrease recurrence were also denoted. Results Surgery has been the mainstay of treatment for quite some time. However, the paradigms of treatment have changed over the last few years, especially when long-term population studies confirmed that not all patients require surgical treatment with its associated risk of morbidity. Conclusion Treatment now has to be patient-tailored with special attention to the subgroup of high-risk patients. These patients must be adequately selected, identifying the impact of the disease on the quality of life and weighing in the risks of the surgical intervention.
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Affiliation(s)
| | - Abhilash J Paily
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Samer Doughan
- American University of Beirut - Medical Center, Beirut, Lebanon
| | - Irshad Shaikh
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
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Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters. Abdom Radiol (NY) 2018; 43:2060-2065. [PMID: 29204676 DOI: 10.1007/s00261-017-1422-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis. MATERIALS AND METHODS Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n = 127) male and 56.9% female (n = 168), with mean age 51.9 years (range 18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parameters obtained from medical record review, and modified Hinchey classification with management outcomes. RESULTS CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P = 0.0001), colonic fistula (13.2% vs. 0.4%, P = 0.0002), extraluminal air (26.4% vs. 9.3%, P = 0.0052), bowel obstruction (5.2% vs. 0.0%, P = 0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P = 0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2 mmHg vs. 128.2 mmHg, P = 0.0220). CONCLUSION Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.
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Acute Jejunoileal Diverticulitis: Multicenter Descriptive Study of 33 Patients. AJR Am J Roentgenol 2018; 210:1245-1251. [DOI: 10.2214/ajr.17.18777] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Shin S, Kim D, Kang UR, Yang CS. Impact of CT imaging on predicting the surgical management of acute diverticulitis. Ann Surg Treat Res 2018; 94:322-329. [PMID: 29854710 PMCID: PMC5976573 DOI: 10.4174/astr.2018.94.6.322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/15/2018] [Accepted: 02/06/2018] [Indexed: 01/26/2023] Open
Abstract
Purpose The incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment. Methods Three hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index. Results After propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively). Conclusion This study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.
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Affiliation(s)
- Seonhui Shin
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Daedong Kim
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ung Rae Kang
- Department of Radiology, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Chun-Seok Yang
- Department of Surgery, Daegu Catholic University Medical Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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CT Predictors of Unfavorable Clinical Outcomes of Acute Right Colonic Diverticulitis. AJR Am J Roentgenol 2017; 209:1263-1271. [DOI: 10.2214/ajr.17.17869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Colas PA, Duchalais E, Duplay Q, Serra-Maudet V, Kanane S, Ridereau-Zins C, Lermite E, Aubé C, Hamy A, Venara A. Failure of Conservative Treatment of Acute Diverticulitis with Extradigestive Air. World J Surg 2017; 41:1890-1895. [DOI: 10.1007/s00268-017-3931-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC, Rosenberg J. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg 2016; 35:201-208. [PMID: 27741423 DOI: 10.1016/j.ijsu.2016.10.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 09/30/2016] [Accepted: 10/08/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to systematically review the literature and present the evidence on outcomes after treatment for acute diverticulitis with abscess formation. Secondly, the paper aimed to compare different treatment options. METHODS PubMed, EMBASE and the Cochrane Library were searched. Two authors screened the records independently, initially on title and abstract and subsequently on full-text basis. Articles describing patients treated acutely for Hinchey Ib and II were included. Results were presented by treatment, classified as non-operative (percutaneous abscess drainage (PAD), antibiotics, or unspecified non-operative strategy), PAD, antibiotics, or acute surgery. The outcomes of interest were treatment failure, short-term mortality, and recurrence. RESULTS Of 1723 articles, 42 studies were included, describing 8766 patients with Hinchey Ib-II diverticulitis. Observational studies were the only available evidence. Treatment generally failed for 20% of patients, regardless of non-operative treatment choice. Abscesses with diameters less than 3 cm were sufficiently treated with antibiotics alone, possibly as outpatient treatment. Of patients treated non-operatively, 25% experienced a recurrent episode during long-term follow-up. When comparing PAD to antibiotic treatment, it appeared that PAD lead to recurrence less often (15.9% vs. 22.2%). Patients undergoing acute surgery had increased risk of death (12.1% vs. 1.1%) compared to patients treated non-operatively. Of patients undergoing PAD, 2.5% experienced procedure-related complications and 15.5% needed adjustment or replacement of the drain. CONCLUSIONS Observational studies with unmatched patients were the best available evidence which limited comparability and resulted in risk of selection bias and confounding by indication. Diverticular abscesses with diameters less than 3 cm might be sufficiently treated with antibiotics, while the best treatment for larger abscesses remains uncertain. Acute surgery should be reserved for critically ill patients failing non-operative treatment. Further research is needed to determine the best treatment for different sizes and types of diverticular abscesses, preferably randomized controlled trials.
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Affiliation(s)
- Rasmus Gregersen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Laura Quitzau Mortensen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Jakob Burcharth
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark
| | | | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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When Should We Operate for Recurrent Diverticulitis? J Clin Gastroenterol 2016; 50 Suppl 1:S80-2. [PMID: 27622374 DOI: 10.1097/mcg.0000000000000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Recent guidelines on elective surgery for recurrent diverticulitis have removed generalized recommendations for elective preventive surgery and advice individualized decision per patient. We discuss the clinical evidence and potential use of risk factors to help with decision-making for patient selection for elective surgery in the presence of a history of diverticulitis.
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Ambrosetti P. Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography. Clin Exp Gastroenterol 2016; 9:249-57. [PMID: 27574459 PMCID: PMC4993273 DOI: 10.2147/ceg.s110428] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.
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Affiliation(s)
- Patrick Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Geneva, Switzerland
- Correspondence: Patrick Ambrosetti, Department of Surgery, Clinique Générale Beaulieu, Ch Beau-Soleil, 1205 Geneva, Switzerland, Tel +41 22 830 0520, Fax +41 22 830 2343, Email
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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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Laqmani A, Veldhoen S, Dulz S, Derlin T, Behzadi C, Schmidt-Holtz J, Wassenberg F, Sehner S, Nagel HD, Adam G, Regier M. Reduced-dose abdominopelvic CT using hybrid iterative reconstruction in suspected left-sided colonic diverticulitis. Eur Radiol 2015; 26:216-24. [PMID: 26070499 DOI: 10.1007/s00330-015-3810-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 04/13/2015] [Accepted: 04/20/2015] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To assess the effect of hybrid iterative reconstruction (HIR) and filtered back projection (FBP) on abdominopelvic CT with reduced-dose (RD-APCT) in the evaluation of acute left-sided colonic diverticulitis (ALCD). METHODS Twenty-five consecutive patients with suspected ALCD who underwent RD-APCT (mean CTDIvol 11.2 ± 4.2 mGy) were enrolled in this study. Raw data were reconstructed using FBP and two increasing HIR levels, L4 & L6. Two radiologists assessed image quality, image noise and reviewer confidence in interpreting findings of ALCD, including wall thickening, pericolic fat inflammation, pericolic abscess, and contained or free extraluminal air. Objective image noise (OIN) was measured. RESULTS OIN was reduced up to 54 % with HIR compared to FBP. Subjective image quality of HIR images was superior to FBP; subjective image noise was reduced. The detection rate of extraluminal air was higher with HIR L6. Reviewer confidence in interpreting CT findings of ALCD significantly improved with application of HIR. CONCLUSIONS RD-APCT with HIR offers superior image quality and lower image noise compared to FBP, allowing a high level of reviewer confidence in interpreting CT findings in ALCD. HIR facilitates detection of ALCD findings that may be missed with the FBP algorithm. KEY POINTS HIR significantly reduces objective image noise in comparison to conventional FBP. HIR offers superior subjective image quality in comparison to conventional FBP. HIR allows reduced-dose abdominopelvic CT with acceptable image quality. Reviewer confidence in interpreting CT findings in ALCD significantly improves with HIR.
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Affiliation(s)
- Azien Laqmani
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Simon Veldhoen
- Department of Diagnostic and Interventional Radiology, University Medical Center Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Simon Dulz
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Thorsten Derlin
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Cyrus Behzadi
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jakob Schmidt-Holtz
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Felicia Wassenberg
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Dieter Nagel
- Scientific and Application-oriented Studies and Consulting in Radiology (SASCRAD), Fritz-Reuter-Weg 5f, 21244, Buchholz, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marc Regier
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Mora Lopez L, Serra Pla S, Serra-Aracil X, Ballesteros E, Navarro S. Application of a modified Neff classification to patients with uncomplicated diverticulitis. Colorectal Dis 2013; 15:1442-7. [PMID: 24192258 DOI: 10.1111/codi.12449] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/07/2013] [Indexed: 02/06/2023]
Abstract
AIM Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management. METHOD All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients. Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded. RESULTS Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25-90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixty-four (94%) successfully completed the outpatient treatment protocol; four patients were readmitted. CONCLUSION Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme.
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Affiliation(s)
- L Mora Lopez
- Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), Sabadell, Spain
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Katz LH, Guy DD, Lahat A, Gafter-Gvili A, Bar-Meir S. Diverticulitis in the young is not more aggressive than in the elderly, but it tends to recur more often: systematic review and meta-analysis. J Gastroenterol Hepatol 2013; 28:1274-81. [PMID: 23701446 DOI: 10.1111/jgh.12274] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM For years, the natural course of diverticulitis in the young has been debatable in terms of its severity and recurrence rate, and no consensus has been reached regarding its treatment and timing of surgery. Thus, the study aims to evaluate by meta-analysis the natural course of acute diverticulitis in the young. METHODS Data were obtained from electronic databases and manual search of studies comparing the course of diverticulitis in young versus elderly patients. The age cut-off was selected to be 40-50 years, and only studies using computed tomography as the sole modality for diagnosis were included. Primary outcomes were surgery during hospitalization and disease recurrence. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. RESULTS One thousand eighty publications were found, 12 of which were included. The total number of patients was 4982. Most young patients were males (RR 1.70, 95% CI 1.31-2.21), without tendency toward a more complicated disease at admission (RR 0.95, 95% CI 0.46-1.97). While there was no significant difference in the rate of surgery during hospitalization (RR 0.69, 95% CI 0.46-1.06), young patients underwent more elective surgeries (RR 2.39, 95% CI 1.82-3.15). No mortality was recorded among young patients. The disease recurrence rate was significantly higher than that of elderly patients (RR 1.70, 95% CI 1.31-2.21); however, no study specified the mean follow-up period for each group. CONCLUSIONS The course of diverticulitis in the young is not more severe than that in elderly patients; however, the disease tends to recur more often. Therefore, while choosing a therapeutic regimen, factors other than age should also be considered.
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Affiliation(s)
- Lior H Katz
- Department of Gastroenterology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel.
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Abbas MA, Cannom RR, Chiu VY, Burchette RJ, Radner GW, Haigh PI, Etzioni DA. Triage of patients with acute diverticulitis: are some inpatients candidates for outpatient treatment? Colorectal Dis 2013; 15:451-7. [PMID: 23061533 DOI: 10.1111/codi.12057] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 08/22/2012] [Indexed: 02/08/2023]
Abstract
AIM Current recommendations regarding the triage of patients with acute diverticulitis for inpatient or outpatient treatment are vague. We hypothesized that a significant number of patients treated as an inpatient could be managed as an outpatient. METHOD A retrospective cohort study was carried out of 639 patients admitted for a first episode of diverticulitis. The diagnosis of acute diverticulitis was confirmed by computed tomography (CT). The endpoints included length of stay, need for surgery, percutaneous drainage and mortality. Patients were considered to have had a minimal hospitalization, defined as survival to discharge without needing a procedure, hospitalization of ≤ 3 days and no readmission for diverticulitis within 30 days after discharge. RESULTS Of 639 patients, 368 (57.6%) had a minimal hospitalization. Female gender and CT scan findings of free air/fluid were negatively associated with the likelihood of minimal hospitalization. The presence of an abscess < 3 cm and stranding on CT did not predict the need for a higher level of care. Despite the statistical significance of several patient-level predictors, the model did not identify patients likely to need only minimal hospitalization. CONCLUSION Most patients admitted with acute diverticulitis are discharged after minimal hospitalization. Free air/liquid in a patient admitted for acute diverticulitis indicates a more severe clinical course.
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Affiliation(s)
- M A Abbas
- Department of Surgery, Kaiser Permanente, Los Angeles, CA, USA
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Ambrosetti P, Gervaz P, Fossung-Wiblishauser A. Sigmoid diverticulitis in 2011: many questions; few answers. Colorectal Dis 2012; 14:e439-46. [PMID: 22404743 DOI: 10.1111/j.1463-1318.2012.03026.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM Patients were studied after a first episode of acute left-colonic diverticulitis for the initial and later evolution of the disease with the aim of defining evidence-based indications for elective surgery. METHOD Relevant data from prospective studies were retrieved from a MEDLINE search of English language articles. RESULTS Young male patients (≤ 50 years of age) had a higher risk of CT-graded severe diverticulitis. After medical treatment of the first episode, the incidence of complications was highest for young patients with CT-graded severe diverticulitis and lowest for older patients with CT-graded moderate diverticulitis. Recurrence in the form of diffuse peritonitis was rare. CT grading of initial diverticulitis seemed to be a predictor of recurrence, whereas the role of age was less clear. A family history of diverticulitis might be predictive of recurrence. CONCLUSION CT grading of acute diverticulitis helps to predict poor outcome after medical treatment of a first episode. Elective surgical resection should be proposed to patients with residual symptoms who do not respond to conservative treatment. Additional research is needed to clarify the role of a genetic predisposition in the development of diverticulitis in young adults.
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Affiliation(s)
- P Ambrosetti
- Clinique Générale Beaulieu, Geneva, Switzerland.
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Abstract
AIM To determine the immediate and later role(s) of initial CT in patients presenting with their first episode of acute left-colonic diverticulitis. METHODS Prospective inclusion of 542 patients hospitalized in the University Hospital of Geneva between 1986 and 1997. 465 (86%) patients had a CT. CT grading of diverticulitis was divided between moderate diverticulitis (no sign of colonic perforation) and severe diverticulitis (signs of colonic perforation). RESULTS During the index hospitalization, surgical treatment of the first episode of acute diverticulitis was needed in 26% of patients with CT-severe diverticulitis compared to 4% for patients with CT-moderate diverticulitis. At 5 years of follow-up after medical treatment of the first episode, incidence of remote complications was the highest (49%) for patients with CT-severe diverticulitis and the lowest (22%) for patients with CT-moderate diverticulitis. Finally, we found that the location of the diseased segment, which is important to guide the type of resection in case of elective surgery, varies in 35% of patients who had 2 episodes of acute diverticulitis. CONCLUSION CT is the indispensable tool both to confirm the suspected diagnosis of acute diverticulitis and to appreciate the risk of surgical treatment during the initial acute episode. Moreover, CT grading of diverticulitis is a statistically significant prognostic parameter of the chance of secondary complicated outcome after a first acute diverticulitis episode successfully treated medically. Finally, CT gives the exact location of diverticulitis. In case of elective surgery this colonic segment should be removed.
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Abstract
The main organs in the left iliac fossa are the descending colon, sigmoid colon and, in women, internal reproductive organs. An infection of the left iliac fossa must lead the clinician firstly to suspect diverticulitis of the sigmoid colon in older patients and salpingitis in women of childbearing age. Other less common aetiologies are possible (inflammatory or infectious colitis, epiploic appendagitis, abscess of the psoas, pyelonephritis, renal abscess, etc.). Sonography as a first-line investigation may lead to diagnosis (especially in gynaecological disease), but a CT scan with intravenous injection of an iodine-containing contrast medium will allow for a full assessment of disease spread, and complications of sigmoid colitis or its differential diagnoses (abscess, fistula, perforation) to be investigated. It can also be used to guide percutaneous drainage or fine-needle aspiration for microbiology investigations.
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Danse E, Dragean A. Affections du côlon en situation d’urgence et en réanimation chez le patient adulte : qu’attendre du radiologue ? MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0340-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, Marcello PW, Schoetz DJ. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011; 54:283-8. [PMID: 21304297 DOI: 10.1007/dcr.0b013e3182028576] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively. METHODS We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008. Patients were identified with International Classification of Diseases, 9th Revision/Current Procedural Terminology codes. Patients were excluded if they had subsequent colectomy based on the first attack (n = 81), or if the attack they had between 2002 and 2008 was not their first attack (n = 201). We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists. These radiologists reviewed the available published literature for CT imaging characteristics thought to predict diverticulitis severity. CT variables (n = 20) were determined by prospective reevaluation of scans by blinded study radiologists. Clinical variables (n = 43) were coded based on a retrospective chart review. Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates. Multivariate analysis was performed using Cox proportional hazards modeling. Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm. RESULTS The study population included 672 patients; mean age, 61 ± 15 years; mean follow-up, 42.8 ± 24 months. The index presentation of diverticulitis was most commonly located in the sigmoid colon (72%), followed by descending colon (33%), right colon (5%), and transverse colon (3%). Overall recurrence at 5 years was 36% by (95% CI 31.4%-40.6%) Kaplan-Meier estimate. Complicated recurrence (fistula, abscess, free perforation) occurred in 3.9% (95% CI 2.2%-5.6%) of patients at 5 years by Kaplan-Meier estimate. Family history of diverticulitis (HR 2.2, 95% CI 1.4-3.2), length of involved colon >5 cm (HR 1.7, 95% CI 1.3-2.3), and retroperitoneal abscess (HR 4.5, 95% CI 1.1-18.4) were associated with diverticulitis recurrence. Right colon disease (HR 0.27, 95% CI 0.09-0.86) was associated with freedom from recurrence. CONCLUSION Although diverticulitis recurrence is common following an initial attack that has been managed medically, complicated recurrence is uncommon. Patients who present with a family history of diverticulitis, long segment of involved colon, and/or retroperitoneal abscess are at higher risk for recurrent disease. Patients who present with right-sided diverticulitis are at low risk for recurrent disease. These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy.
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Affiliation(s)
- Jason F Hall
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA, USA.
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Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010; 47:680-735. [PMID: 20684920 DOI: 10.1067/j.cpsurg.2010.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jason Hall
- Department of Colon and Rectal Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Hall JF, Roberts PL, Ricciardi R, Marcello PW, Scheirey C, Wald C, Scholz FJ, Schoetz D. Colonic diverticulitis: does age predict severity of disease on CT imaging? Dis Colon Rectum 2010; 53:121-5. [PMID: 20087085 DOI: 10.1007/dcr.0b013e3181c18d64] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of our study was to determine whether young patients with diverticulitis were more likely to present with abdominal CT evidence of severe disease. METHODS We analyzed the abdominal CT scans of 932 patients who presented to our institution with CT scan findings consistent with diverticulitis from January 2002 through June 2007. Radiologists retrospectively reviewed all abdominal scans for the presence of imaging findings consistent with diverticulitis (bowel wall thickness, extraluminal air, free perforation, abscess, or fistula). The cohort was divided into 2 groups; patients <or=50 years of age and patients >51 years of age. RESULTS Two hundred forty-three patients were <or=50 years and 689 patients were >51 years. Young patients were more likely to be male (63% vs 42%, P < .0001). Young patients had a higher proportion of scans with extraluminal air than older patients (19.7% vs 12.6%, P < .008). Young patients were more likely to present with severe disease found by CT than older patients (19.3% vs 11.5%). When we adjusted for gender, young males had a higher proportion of scans with extraluminal air than older males (22.4% vs 13.1%, P = .014). Young males were also more likely to present with severe disease (22% vs 12%). CONCLUSION Young patients were more likely to have extraluminal air and severe disease found by CT. Young male patients presented more commonly with evidence of severe disease. They did not differ from older patients in rates of free perforation, abscess, or fistula formation.
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Affiliation(s)
- Jason F Hall
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA
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Quelle est la valeur diagnostique des différents examens dans la diverticulite simple et compliquée ? Quelle doit être la stratégie diagnostique ? ACTA ACUST UNITED AC 2007; 31:15-9. [DOI: 10.1016/s0399-8320(07)91947-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Romano S, Lombardo P, Cinque T, Tortora G, Romano L. Acute colonic disease: How to image in emergency. Eur J Radiol 2007; 61:424-32. [PMID: 17174054 DOI: 10.1016/j.ejrad.2006.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Accepted: 11/13/2006] [Indexed: 11/24/2022]
Abstract
The diseases affecting the large intestine represent a diagnostic problem in adult patients with acute abdomen, especially when clinical symptoms are not specific. The role of the diagnostic imaging is to help clinicians and surgeons in differential diagnosis for an efficient early and prompt therapy to perform. This review article summarizes the imaging spectrum of findings of colonic acute disease, from mechanical obstruction to inflammatory diseases and perforation, offering keys to problem solving in doubtful cases as well as discussing regarding the more indicated imaging method to use in emergency, particularly MDCT.
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Affiliation(s)
- Stefania Romano
- Department of Diagnostic Imaging, A. Cardarelli Hospital, Viale Cardarelli 9, 80131 Naples, Italy.
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Hjern F, Josephson T, Altman D, Holmström B, Mellgren A, Pollack J, Johansson C. Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory? Scand J Gastroenterol 2007; 42:41-7. [PMID: 17190761 DOI: 10.1080/00365520600780650] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD. MATERIAL AND METHODS A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months. RESULTS Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61-1.74). CONCLUSIONS Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.
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Affiliation(s)
- Fredrik Hjern
- Division of Surgery, Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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Kaewlai R, Nazinitsky KJ. Acute colonic diverticulitis in a community-based hospital: CT evaluation in 138 patients. Emerg Radiol 2006; 13:171-9. [PMID: 17136376 DOI: 10.1007/s10140-006-0552-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Accepted: 10/19/2006] [Indexed: 12/11/2022]
Abstract
The purpose of this research is to retrospectively analyze computed tomography (CT) findings of patients with acute colonic diverticulitis presented to a community-based hospital. During a 1-year period from May 2004 to April 2005, CT scans of 138 patients [mean age 62.3 years (SD 14.9), range 30-100 years] with clinical diagnosis of diverticulitis were analyzed. Of the 138 patients, 136 CT scans were performed with oral and intravenous contrast administration except in two patients who received only oral contrast. Twenty-eight patients (28/138, 20.3%) had diverticulosis, 77 (77/138, 55.8%) had uncomplicated diverticulitis, and 33 (33/138, 23.9%) had complications. Left-sided diverticulitis predominated (137/138, 99.3%). Colonic diverticula were identified in almost every patient (136/138, 98.6%); the majority had moderate colonic wall thickening (82/110, 74.5%) and moderate pericolonic inflammation (65/110, 59.1%). Isolated extraluminal air bubbles (19/33, 57.6%) were the most commonly seen complication, followed by abscess (15/33, 45.5%). Bowel obstruction (2/33, 6.1%) and pylephlebitis (1/33, 3.0%) were less commonly seen but were observed as significant abnormalities. Complicated diverticulitis was less prevalent in this community hospital setting, in contrast with referral medical centers. Common CT findings of diverticulitis included presence of diverticula, moderate wall thickening, and pericolonic inflammation. Isolated air bubbles were the most commonly seen complication followed by abscess.
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Affiliation(s)
- Rathachai Kaewlai
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Tack D, Bohy P, Perlot I, De Maertelaer V, Alkeilani O, Sourtzis S, Gevenois PA. Suspected acute colon diverticulitis: imaging with low-dose unenhanced multi-detector row CT. Radiology 2005; 237:189-96. [PMID: 16126929 DOI: 10.1148/radiol.2371041432] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively compare the sensitivity and specificity of unenhanced low-dose multi-detector row computed tomography (CT) with those of contrast material-enhanced standard-dose multi-detector row CT in patients suspected of having acute diverticulitis. MATERIALS AND METHODS Institutional review board approval and informed consent were obtained. One hundred ten consecutive patients (40 men, 70 women; age range, 30-82 years; mean, 57 years) suspected of having acute diverticulitis underwent unenhanced multi-detector row CT with 4 x 2.5-mm collimation, 120 kVp, and 30 effective mAs, as well as contrast-enhanced standard-dose multi-detector row CT with the same parameters but with 120 mAs. All scans were independently read by four readers. Intra- and interobserver agreements were calculated with the kappa statistic. Contrast-enhanced standard-dose scans read by three other experts and considered together with results from colonoscopy, surgery, and pathologic evaluation were used as reference. Differences in sensitivity and specificity between readers, radiation doses, and reading sessions were investigated. Pearson exact test and logistic regression models were used. RESULTS Colon diverticulitis was present in 39 patients (34%) and was graded as mild in 22 patients (56%) and severe in 17 (44%). Agreement within and between readers was good to excellent. No significant difference was observed in sensitivity (P ranging from .081 to >.99) or in specificity (P ranging from .326 to >.99) for any sign or overall diagnosis between radiation doses by all readers, except wall thickening, which for one reader had a higher specificity at low dose than at standard dose (P = .025). No significant difference in misclassification was detected between doses, regardless of the reader (P ranging from .481 to >.99). At both doses, the most predictive sign for acute diverticulitis was retroperitoneal fat stranding (P < .001). CONCLUSION Low-dose unenhanced multi-detector row CT has a diagnostic performance similar to that of contrast-enhanced standard-dose multi-detector row CT in patients suspected of having acute diverticulitis.
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Affiliation(s)
- Denis Tack
- Department of Radiology, CHU de Charleroi, Charleroi, Belgium.
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Ajaj W, Ruehm SG, Lauenstein T, Goehde S, Kuehle C, Herborn CU, Langhorst J, Zoepf T, Gerken G, Goyen M. Dark-lumen magnetic resonance colonography in patients with suspected sigmoid diverticulitis: a feasibility study. Eur Radiol 2005; 15:2316-22. [PMID: 16132933 DOI: 10.1007/s00330-005-2862-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Revised: 06/17/2005] [Accepted: 07/04/2005] [Indexed: 01/29/2023]
Abstract
To assess dark-lumen magnetic resonance colonography (MRC) for the evaluation of patients with suspected sigmoid diverticulitis. Forty patients with suspected sigmoid diverticulitis underwent MRC within 72 h prior to conventional colonoscopy (CC). A three-dimensional T1-weighted volumetric interpolated breath-hold examination sequence was acquired after an aqueous enema and intravenous administration of gadolinium-based contrast agents. All MRC data were evaluated by two radiologists. Based on wall thickness and focal uptake of contrast material and pericolic reaction including mesenteric infiltration on T1-weighted sequence the sigmoid colon was assessed for the presence of diverticulitis. MRC classified 17 of the 40 patients as normal with regard to sigmoid diverticulitis. However, CC confirmed the presence of light inflammatory signs in four patients which were missed in MRC. MRC correctly identified wall thickness and contrast uptake of the sigmoid colon in the other 23 patients. In three of these patients false-positive findings were observed, and MRC classified the inflammation of the sigmoid colon as diverticulitis whereas CC and histopathology confirmed invasive carcinoma. MRC detected additionally relevant pathologies of the entire colon and could be performed in cases where CC was incomplete. MRC may be considered a promising alternative to CC for the detection of sigmoid diverticulitis.
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Affiliation(s)
- Waleed Ajaj
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital, Hufelandstrasse 55, 45122, Essen, Germany.
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