Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians

Development of an ultrasound-based clinical decision rule to rule-out diverticulitis

The concern for diverticulitis often leads to the use of computed tomography (CT) scans for diagnosis. We aim to develop an ultrasound-based clinical decision rule (CDR) to confidently rule-out the disease without requiring a CT scan. We analyzed data from a prospective study of adult emergency department (ED) patients with suspected diverticulitis who underwent both bedside ultrasound (US) and CT. Patient history, physical examination, laboratory findings, and US results were used to create a CDR via a recursive partitioning model designed to prioritize sensitivity, with a loss matrix heavily penalizing false negatives. We calculated the test characteristics for this CDR (TICS-Rule) and assessed the potential reduction in CT scans and ED length of stay. Data from 149 patients (84 female; mean age 58 ± 16) were used to develop the TICS-Rule. The final model integrates US diagnosis of simple and complicated diverticulitis, along with variables of heart rate, age, history of diverticulosis, vomiting, and leukocytosis. Negative US results and a heart rate below 100 effectively excluded diverticulitis. The sensitivity increased from 54.5% (32.2-75.6) in the US alone to 100% (84.6-100%) for complicated diverticulitis in the model. The TICS-Rule missed no cases of complicated diverticulitis but one case of simple diverticulitis. The median time from ED greeting to US interpretation was 103 min (IQR 62-169), compared to 285 min (IQR 229-372) for CT. The TICS-Rule uses a combination of negative US and heart rate less thanQ1 100 to exclude diverticulitis without the need for a CT scan. Integration of the TICS-Rule offers a promising enhancement to clinical decision-making while reducing both CT use and ED length of stay.

Current Trends in the Treatment of Acute Uncomplicated Diverticulitis

Introduction: Acute diverticulitis represents a significant disease burden in the United States and developed world. This article examines current trends in the treatment of acute diverticulitis and concentrates on the utility of antibiotics in acute uncomplicated cases managed in the outpatient setting. Methods: The literature was reviewed for randomized controlled trials (RCTs) to discern the best practice and recommendations for antibiotics for diverticulitis. The time period included relevant RCTs after 2000. Results: Four recent RCTs examine the use of antibiotics in acute uncomplicated diverticulitis. The AVOD study was an RCT that managed inpatients with either antibiotics or IV fluids alone and demonstrated non-inferiority of non-antibiotic management with respect to recovery, complication rates, or recurrence. The DIABLO trial randomized first episodes of acute uncomplicated diverticulitis admitted to the hospital with antibiotics or supportive care and found no difference in morbidity or mortality between the two groups and longer hospital stay for patients treated with antibiotics. The DINAMO study examined outpatients managed with antibiotics by mouth or without and found no difference in morbidity in 90 day follow-up. The STAND study was the only of these four to use a placebo and found no difference between hospital stay or other adverse events at 30 days. In response to this, the ASCRS, AAFP and other societies now recommend against the routine use of antibiotics in acute uncomplicated diverticulitis. Conclusions: Several quality studies found similar outcomes in cases of acute uncomplicated diverticulitis treated with or without antibiotics. Based on these findings, societal guidelines do not recommend routine antibiotics for acute diverticulitis.

A novel scoring system for predicting disease severity without CT imaging in acute diverticulitis

PURPOSE

Clinical scoring could help physicians identify patients with suspected acute diverticulitis who would benefit from further evaluation using computed tomography imaging. The aim of the study was to identify risk factors for complicated acute diverticulitis and create a risk score to predict disease severity in acute diverticulitis.

METHODS

Patients diagnosed with CT-verified acute diverticulitis between 2015 and 2017 were included. Data on patients' clinical and laboratory findings and medical histories were collected retrospectively. Risk factors for complicated acute diverticulitis were identified using univariate and multivariate analyses. Continuous laboratory values were categorised by cut-off points determined using receiver operating characteristic (ROC) analysis. The Acute Diverticulitis Severity Score was formulated using logistic regression analysis.

RESULTS

Of the total 513 patients included in the study, 449 (88%) had UAD, and 64 (12%) had CAD. Older age, significant comorbidities, C-reactive protein level, leucocyte count, vomiting, and body temperature were found to be independently associated with a higher risk for CAD. The novel Acute Diverticulitis Severity Score could reliably detect patients with CAD. The area under the ROC curve was 0.856 (p < 0.001) in discriminating disease severity. While higher scores indicate radiological studies, patients with low scores face an almost non-existent risk for complicated disease, making such studies possibly redundant.

CONCLUSIONS

The Acute Diverticulitis Severity Score accurately separated patients with uncomplicated disease from those at risk for complicated disease. This score can be applied in daily clinical practice to select patients requiring further investigation, consequently reducing healthcare costs and burdens.

Recent updates on classification and unsolved issues of diverticular disease: a narrative review

Recently, a paradigm shift has occurred in the classification of diverticular disease and the understanding of its pathogenesis. Diverticular disease is now defined as a variety of clinically significant conditions such as diverticulitis, diverticular bleeding, symptomatic uncomplicated diverticular disease, and segmental colitis associated with diverticulosis. Low-grade inflammation, visceral hypersensitivity, abnormal intestinal motility, and genetic factors have emerged as the key contributors to the pathogenesis of diverticular disease. Routine antibiotic use is no longer recommended for all cases of diverticulitis, and simple recurrence is not an indication for surgical treatment. Early colonoscopy with proper preparation is recommended for the treatment of diverticular bleeding, although recent studies have not shown significant efficacy in preventing recurrence. The roles of dietary fiber, nonabsorbable antibiotics, 5-aminosalicylates, and probiotics in the prevention of diverticular disease are controversial and require further investigation.

Patient Perspectives on Evolving Diverticulitis Treatment: An Assessment of Patient Willingness to Enroll in a Randomized Controlled Trial

Objective

The objective of the study was to assess patients' attitudes regarding participation in a randomized trial of antibiotics versus placebo for acute diverticulitis.

Background

Despite evidence that antibiotics may not be necessary to treat acute uncomplicated diverticulitis, they remain the mainstay of treatment in the United States. A randomized trial in the United States evaluating antibiotic effectiveness could accelerate the implementation of antibiotic-free treatment, but providers maintain concerns that patients may be unwilling to participate.

Methods

This mixed-methods study conducted semi-structured interviews of patients presenting to a quaternary care emergency department with acute diverticulitis and a web-based survey of a larger cohort. The interviews assessed patients' experiences with diverticulitis and perceptions of participation in a trial comparing antibiotics versus placebo. The survey quantified patients' willingness to participate in such a study and the relative importance of factors influencing the process.

Results

Thirteen patients completed an interview. Reasons to participate included a desire to help others or contribute to scientific knowledge. Doubts about the efficacy of observation as a treatment method were the main barrier to participation. In a survey of 218 subjects, 62% of respondents reported willingness to participate in a randomized clinical trial. "What my doctor thinks," followed by "What I have experienced in the past" were the most important decision-making factors.

Conclusion

Patients with acute uncomplicated diverticulitis maintain complex and varying perceptions of antibiotic use. Most surveyed patients would be willing to participate in a trial of antibiotics versus placebo. Our findings support the trial's feasibility and may facilitate an informed approach to recruitment and consent.

Acute diverticulitis management: evolving trends among Italian surgeons. A survey of the Italian Society of Colorectal Surgery (SICCR)

Acute diverticulitis (AD) is associated with relevant morbidity/mortality and is increasing worldwide, thus becoming a major issue for national health systems. AD may be challenging, as clinical relevance varies widely, ranging from asymptomatic picture to life-threatening conditions, with continuously evolving diagnostic tools, classifications, and management. A 33-item-questionnaire was administered to residents and surgeons to analyze the actual clinical practice and to verify the real spread of recent recommendations, also by stratifying surgeons by experience. CT-scan remains the mainstay of AD assessment, including cases presenting with recurrent mild episodes or women of child-bearing age. Outpatient management of mild AD is slowly gaining acceptance. A conservative management is preferred in non-severe cases with extradigestive air or small/non-radiologically drainable abscesses. In severe cases, a laparoscopic approach is preferred, with a non-negligible number of surgeons confident in performing emergency complex procedures. Surgeons are seemingly aware of several options during emergency surgery for AD, since the rate of Hartmann procedures does not exceed 50% in most environments and damage control surgery is spreading in life-threatening cases. Quality of life and history of complicated AD are the main indications for delayed colectomy, which is mostly performed avoiding the proximal vessel ligation, mobilizing the splenic flexure and performing a colorectal anastomosis. ICG is spreading to check anastomotic stumps' vascularization. Differences between the two experience groups were found about the type of investigation to exclude colon cancer (considering the experience only in terms of number of colectomies performed), the size of the peritoneal abscess to be drained, practice of damage control surgery and the attitude towards colovesical fistula.

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.

Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease

Colonic diverticulosis and diverticular disease are among the most common gastrointestinal disorders encountered in clinical practice. These Italian guidelines focus on the diagnosis and management of diverticulosis and diverticular disease in the adult population, providing practical and evidence-based recommendations for clinicians. Experts from five Italian scientific societies, constituting a multidisciplinary panel, conducted a comprehensive review of meta-analyses, systematic reviews, randomised controlled trials, and observational studies to formulate 14 PICO questions. The assessment of the quality of the evidence and the formulation of the recommendations were carried out using an adaptation of the GRADE methodology. The guidelines covered the following topics: i) Management of diverticulosis; ii) Symptomatic uncomplicated diverticular disease: diagnosis and treatment; iii) Acute diverticulitis: diagnosis and treatment; iv) Management of diverticular disease complications; v) Prevention of recurrent acute diverticulitis; vi) Interventional management of diverticular disease.

Contemporary management of diverticulitis

The treatment of diverticulitis is experiencing a shift in management due to a number of large scale clinical trials. For instance, clinicians are beginning to recognize that avoidance of antibiotics in uncomplicated diverticulitis is not associated with worse outcomes. Additionally, while the decision to proceed with elective surgical resection for recurrent uncomplicated disease is less conclusive and favors a patient-centric approach, complicated disease with a large abscess denotes more aggressive disease and would likely benefit from elective surgical resection. Lastly, in patient with acutely perforated diverticulitis who require urgent surgical intervention, laparoscopic lavage is generally not recommended due to high re-intervention rates and the preferred surgical procedure is primary anastomosis with or without diversion due to high morbidity and low rates of Hartmann reversal.

Acute Colonic Diverticulitis

Acute colonic diverticulitis is a gastrointestinal condition that is frequently encountered by primary care and emergency department practitioners, hospitalists, surgeons, and gastroenterologists. Clinical presentation ranges from mild abdominal pain to peritonitis with sepsis. It is often diagnosed on the basis of clinical features alone, but imaging is necessary in more severe presentations to rule out such complications as abscess and perforation. Treatment depends on the severity of the presentation, the presence of complications, and underlying comorbid conditions. Medical and surgical treatment algorithms are evolving. This article provides an evidence-based, clinically relevant overview of the epidemiology, diagnosis, and treatment of acute diverticulitis.

Inpatient treatment of acute diverticulitis between 2010 and 2021 - A German nationwide study about long-term trends and effects of the SARS-CoV-2 pandemic

AIM

The aims of this study were to analyse all hospitalizations for acute diverticulitis in Germany from 2010 to 2021 and to assess the effects of the first 2 years of the SARS-CoV-2 pandemic on hospitalizations for acute diverticulitis.

METHOD

Using data from the German Federal Statistical Office, we analysed fully anonymized healthcare data of hospitalizations and treatment regimens with acute diverticulitis as the main diagnosis between 2010 and 2021. Logistic regression analyses for in-hospital mortality were performed.

RESULTS

A total of 608,162 hospitalizations were included. While the number of hospitalizations constantly increased until 2019 (+52.4%), a relative decrease of 10.1% was observed between 2019 and 2020, followed by stable numbers of hospitalizations in 2021 (+1.1% compared with 2020). In-hospital mortality showed a relative decrease of 33.2% until 2019 and thereafter a relative increase of 26.9% in 2020 and of 7.5% in 2021. A 21.6% and a 19.3% drop in hospitalizations was observed during the first and second waves of the SARS-CoV-2 pandemic, mostly affecting hospitalizations for uncomplicated diverticulitis, with a corresponding 11.6% and 16.8% increase in admissions for complicated diverticulitis. Multivariable logistic regression analyses showed significantly higher in-hospital mortality for hospitalizations in which surgery (OR = 2.76) and CT (OR = 1.32) were given, as well as lower mortality for women (OR = 0.88), whereas percutaneous drainage was not associated with higher in-hospital mortality compared with conservative treatment (OR = 0.71).

CONCLUSION

This study points out the long-term trends in inpatient treatment for acute diverticulitis and the in-hospital mortality risk factors of patients hospitalized for acute diverticulitis in a large nationwide cohort, as well as changes in these trends and factors resulting from the SARS-CoV-2 pandemic. These changes might be attributable to delayed diagnosis and thus more severe stages of disease as a result of containment measures.

Emergency medicine updates: Acute diverticulitis

INTRODUCTION

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSIONS

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

Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey

OBJECTIVE

International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change.

METHODS

A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change.

RESULTS

The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%).

CONCLUSION

Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.

Understanding the Geographic Distribution of Diverticulitis Hospitalizations in Washington State

BACKGROUND

The incidence of diverticulitis in the United States is increasing, and hospitalization remains a surrogate for disease severity. State-level characterization of diverticulitis hospitalization is necessary to better understand the distribution of disease burden and target interventions.

METHODS

A retrospective cohort of diverticulitis hospitalizations from 2008 through 2019 was created using Washington State's Comprehensive Hospital Abstract Reporting System. Hospitalizations were stratified by acuity, presence of complicated diverticulitis, and surgical intervention using ICD diagnosis and procedure codes. Patterns of regionalization were characterized by hospital case burden and distance travelled by patients.

RESULTS

During the study period, 56,508 diverticulitis hospitalizations occurred across 100 hospitals. Most hospitalizations were emergent (77.2%). Of these, 17.5% were for complicated diverticulitis, and 6.6% required surgery. No single hospital received more than 5% (n = 235) of average annual hospitalizations. Surgeons operated in 26.5% of total hospitalizations (13.9% of emergent hospitalizations, and 69.2% of elective hospitalizations). Operations for complicated disease made up 40% of emergent surgery and 28.7% of elective surgery. Most patients traveled fewer than 20 miles for hospitalization, regardless of acuity (84% for emergent hospitalization and 77.5% for elective hospitalization).

DISCUSSION

Hospitalizations for diverticulitis are primarily emergent, nonoperative, and broadly distributed across Washington State. Hospitalization and surgery occur close to patients' homes, regardless of acuity. This decentralization needs to be considered if improvement initiatives and research in diverticulitis are to have meaningful, population-level impact.

Efficacy of antimicrobial therapy in patients with uncomplicated acute colonic diverticulitis: an updated systematic review and meta-analysis

The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of antimicrobial agents against this disease, including new randomized controlled trials (RCTs) reported in recent years, and evaluated their efficacy using a meta-analytic approach. RCTs were searched using PubMed, EMBASE, Google Scholar, Cochrane Library, Ichushi-Web, and eight registries. Keywords were 'colonic diverticulitis', 'diverticulitis', 'antimicrobial agents', ''antibiotics, 'complication', 'abscess', 'gastrointestinal perforation', 'gastrointestinal obstruction', 'diverticular hemorrhage', and 'fistula'. Studies with antimicrobial treatment in the intervention group and placebo or no treatment in the control group were selected by multiple reviewers using uniform inclusion criteria, and data were extracted. Prevention of any complication was assessed as the primary outcome, and efficacy was expressed as risk ratio (RR) and risk difference (RD). A meta-analysis was performed using 5 RCTs of the 21 studies that were eligible for scrutiny in the initial search and which qualified for final inclusion. Three of these studies were not included in the previous meta-analysis. Subjects included 1039 in the intervention group and 1040 in the control group. Pooled RR = 0.86 (95% confidence interval, 0.58-1.28) and pooled RD = -0.01 (-0.03 to 0.01) for the effect of antimicrobial agents in reducing any complications. Recurrences, readmissions, and surgical interventions did not significantly show the efficacies of using antimicrobial agents. A meta-analysis of recently reported RCTs did not provide evidence that antimicrobial therapy improves clinical outcomes in uncomplicated acute diverticulitis of the colon.

Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review

BACKGROUND

This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses.

MATERIAL AND METHODS

A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses.

CONCLUSIONS

Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Complex Patient Perspectives on Evolving Diverticulitis Treatment Patient Perspectives on Diverticulitis

Background

Despite evidence that antibiotics may not be necessary to treat acute uncomplicated diverticulitis, they remain the mainstay of treatment in the United States. A randomized controlled trial evaluating antibiotic effectiveness could accelerate implementation of an antibiotic-free treatment strategy, but patients may be unwilling to participate.

Objective

This study aims to assess patients' attitudes regarding participation in a randomized trial of antibiotics versus placebo for acute diverticulitis, including willingness to participate.

Design

This is a mixed-methods study with qualitative and descriptive methods.

Settings

Interviews were conducted in a quaternary care emergency department and surveys were administered virtually through a web-based portal.

Patients

Patients with either current or previous acute uncomplicated diverticulitis participated.

Interventions

Patients underwent semi-structured interviews or completed a web-based survey. Main Outcome measures: Rates of willingness to participate in a randomized controlled trial was measured. Salient factors related to healthcare decision-making were also identified and analyzed.

Results

Thirteen patients completed an interview. Reasons to participate included a desire to help others or contribute to scientific knowledge. Doubts about the efficacy of observation as a treatment method were the main barrier to participation. In a survey of 218 subjects, 62% of respondents reported willingness to participate in a randomized clinical trial. "What my doctor thinks," followed by "What I've experienced in the past" were the most important decision-making factors.

Limitations

There is possible selection bias inherent to using a study to evaluate willingness to participate in a study. Also, the population sampled was disproportionately White compared to the population affected by diverticulitis.

Conclusions

Patients with acute uncomplicated diverticulitis maintain complex and varying perceptions of the use of antibiotics. Most surveyed patients would be willing to participate in a trial of antibiotics versus placebo. Our findings support a trial's feasibility and facilitate an informed approach to recruitment and consent.

How Would You Manage This Patient With Recurrent Diverticulitis? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Acute diverticulitis, which refers to inflammation or infection, or both, of a colonic diverticulum, is a common medical condition that may occur repeatedly in some persons. It most often manifests with left-sided abdominal pain, which may be associated with low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction. The American College of Physicians recently published practice guidelines on the diagnosis and management of acute diverticulitis, the role of colonoscopy after resolution, and interventions to prevent recurrence of this condition. Among the recommendations were the use of abdominal computed tomography (CT) scanning in cases where there was diagnostic uncertainty, initial management of uncomplicated cases in the outpatient setting without antibiotics, referral for colonoscopy after an initial episode if not performed recently, and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. Here, 2 gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease.

Endoscopic ultrasound-guided transrectal drainage of a pelvic abscess after Hinchey II sigmoid colon diverticulitis: A case report

BACKGROUND

Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound (EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization.

CASE SUMMARY

A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography (CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey II diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient's general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection.

CONCLUSION

We report the first successful management of a pelvic abscess in patient with Hinchey II acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.

Development and Validation of a Deep Learning Algorithm to Differentiate Colon Carcinoma From Acute Diverticulitis in Computed Tomography Images

IMPORTANCE

Differentiating between malignant and benign etiology in large-bowel wall thickening on computed tomography (CT) images can be a challenging task. Artificial intelligence (AI) support systems can improve the diagnostic accuracy of radiologists, as shown for a variety of imaging tasks. Improvements in diagnostic performance, in particular the reduction of false-negative findings, may be useful in patient care.

OBJECTIVE

To develop and evaluate a deep learning algorithm able to differentiate colon carcinoma (CC) and acute diverticulitis (AD) on CT images and analyze the impact of the AI-support system in a reader study.

DESIGN, SETTING, AND PARTICIPANTS

In this diagnostic study, patients who underwent surgery between July 1, 2005, and October 1, 2020, for CC or AD were included. Three-dimensional (3-D) bounding boxes including the diseased bowel segment and surrounding mesentery were manually delineated and used to develop a 3-D convolutional neural network (CNN). A reader study with 10 observers of different experience levels was conducted. Readers were asked to classify the testing cohort under reading room conditions, first without and then with algorithmic support.

MAIN OUTCOMES AND MEASURES

To evaluate the diagnostic performance, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all readers and reader groups with and without AI support. Metrics were compared using the McNemar test and relative and absolute predictive value comparisons.

RESULTS

A total of 585 patients (AD: n = 267, CC: n = 318; mean [SD] age, 63.2 [13.4] years; 341 men [58.3%]) were included. The 3-D CNN reached a sensitivity of 83.3% (95% CI, 70.0%-96.6%) and specificity of 86.6% (95% CI, 74.5%-98.8%) for the test set, compared with the mean reader sensitivity of 77.6% (95% CI, 72.9%-82.3%) and specificity of 81.6% (95% CI, 77.2%-86.1%). The combined group of readers improved significantly with AI support from a sensitivity of 77.6% to 85.6% (95% CI, 81.3%-89.3%; P < .001) and a specificity of 81.6% to 91.3% (95% CI, 88.1%-94.5%; P < .001). Artificial intelligence support significantly reduced the number of false-negative and false-positive findings (NPV from 78.5% to 86.4% and PPV from 80.9% to 90.8%; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a deep learning model able to distinguish CC and AD in CT images as a support system may significantly improve the diagnostic performance of radiologists, which may improve patient care.

When a polyester mesh causes an enterocutaneous fistula, 30 years after its implantation

Digestive fistula on mesh is an exceptional and late complication of hernioplasty. The type of mesh and its position are often implicated in its occurrence. Clinical presentation is multiform. Morphological examinations are essential to confirm the diagnosis, and the curative treatment remains surgical.

[Diagnosis and Treatment of Colonic Diverticular Disease]

Colonic diverticulosis is one of the most common conditions of the digestive system and patients generally remain asymptomatic. However, about 20% of patients develop symptomatic diverticular disease such as acute diverticulitis or diverticular hemorrhage, and these have become a huge burden on healthcare systems worldwide. Recent understanding of the pathophysiology of diverticulosis and diverticular disease suggests the role of multiple factors including genetic and environment. Based on this understanding, a preventive strategy to reduce the risk factors of diverticulosis and diverticular disease is highly recommended. The diagnosis of the acute diverticulitis relies on imaging modalities such as an abdominal-pelvic CT scan together with symptoms and signs. Treatment of diverticular disease should be individualized and include modification of lifestyle, use of antibiotics, and surgery. Recent guidelines recommend pursuing less aggressive treatment for patients with acute diverticulitis. This review will provide an overview of both the existing and evolving understanding regarding colonic diverticulosis and diverticular disease and can help clinicians in the management of their patients with diverticular disease.