Current Management of Diverticulitis

Diverticulosis and diverticulitis remain common diagnoses in western countries, and the incidence continues to rise. Diverticulitis accounts for roughly one-third of admissions to acute care hospitals annually, with even more patients being treated as outpatients due to improved understanding of risk stratification and the natural history of disease progression. Thus, having a thorough understanding of the etiology of the disease in conjunction with computed tomography findings and patient presentation can help dictate the appropriate treatment.

Development of a Polygenic Risk Score to Predict Diverticulitis

BACKGROUND

Despite its prevalence and associated morbidity, we remain limited in our ability to predict the course of a patient with diverticular disease. Although several clinical and genetic risk factors have been identified, we do not know how these factors relate to one another.

OBJECTIVE

Our aim was to determine whether a polygenic risk score could improve risk prediction for diverticulitis and recurrent diverticulitis compared with a model using only clinical factors.

DESIGN

This is an observational study.

SETTING

The study examines the predictive ability of a polygenic risk score for diverticulitis developed using prior genome-wide association studies and validated using the MyCode biobank.

PATIENTS

This study included patients of European ancestry in the Geisinger Health System who were enrolled in the MyCode Community Health biobanking program.

MAIN OUTCOME MEASURES

The ability of a polygenic risk score to predict diverticulosis, diverticulitis, and recurrent diverticulitis was the main outcome measure of this study.

RESULTS

A total of 60,861 patients were included, of whom 9912 (16.3%) had diverticulosis or diverticulitis (5015 with diverticulosis and 4897 with diverticulitis). When divided into deciles, our polygenic risk score stratified patients by risk of both diverticulosis and diverticulitis with a 2-fold difference in disease risk between the highest and lowest deciles for diverticulitis and a 4.8-fold difference for recurrent complicated diverticulitis. When compared with clinical factors alone, our polygenic risk score was able to improve risk prediction of recurrent diverticulitis.

LIMITATIONS

Our population is largely located in a single geographic region and were classified by disease status, using international classification of diseases codes.

CONCLUSIONS

This predictive model stratifies patients based on genetic risk for diverticular disease. The increased frequency of recurrent disease in our high-risk patients suggests that a polygenic risk score, in addition to other factors, may help guide the discussion regarding surgical intervention. See Video Abstract .

DESARROLLO DE UNA PUNTUACIN DE RIESGO POLIGNICO PARA PREDECIR LA DIVERTICULITIS

ANTECEDENTES:A pesar de su prevalencia y morbilidad asociada, nuestra capacidad para predecir el curso en un paciente con enfermedad diverticular sigue siendo limitada. Si bien se han identificado varios factores de riesgo clínicos y genéticos, no sabemos cómo se relacionan estos factores entre sí.OBJETIVO:Determinar si una puntuación de riesgo poligénico podría mejorar la predicción del riesgo de diverticulitis y diverticulitis recurrente en comparación con un modelo que utiliza solo factores clínicos.DISEÑO:Un estudio observacional que examina la capacidad predictiva de una puntuación de riesgo poligénico para la diverticulitis desarrollada usando estudios previos de asociación amplia del genoma y validada usando el biobanco MyCode.ÁMBITOS Y PACIENTES:Pacientes de ascendencia europea en el Sistema de Salud Geisinger que estaban inscritos en el programa de biobancos MyCode Community Health.PRINCIPALES MEDIDAS DE VALORACIÓN:La capacidad de una puntuación de riesgo poligénico para predecir diverticulosis, diverticulitis y diverticulitis recurrente.RESULTADOS:Se incluyeron un total de 60.861 pacientes, de los cuales 9.912 (16,3%) presentaban diverticulosis o diverticulitis (5.015 con diverticulosis y 4.897 con diverticulitis). Cuando se dividió en deciles, nuestra puntuación de riesgo poligénico estratificó a los pacientes según el riesgo de diverticulosis y diverticulitis con una diferencia de 2 veces en el riesgo de enfermedad entre los deciles más alto y más bajo para diverticulitis y una diferencia de 4,8 veces para diverticulitis complicada recurrente. En comparación con los factores clínicos solos, nuestra puntuación de riesgo poligénico pudo mejorar la predicción del riesgo de diverticulitis recurrente.LIMITACIONES:Nuestra población se encuentra en gran parte en una sola región geográfica y se clasificó por estado de enfermedad utilizando códigos de clasificación internacional de enfermedades.CONCLUSIONES:Este modelo predictivo estratifica a los pacientes en función del riesgo genético de enfermedad diverticular. La mayor frecuencia de enfermedad recurrente en nuestros pacientes de alto riesgo sugiere que un puntaje de riesgo poligénico, además de otros factores, puede ayudar a guiar la discusión sobre la intervención quirúrgica. (Traducción- Dr. Ingrid Melo ).

Meckel's diverticulum mimicking acute appendicitis in children: a retrospective cohort study

BACKGROUND

The aims of this study were to summarize the clinical presentation and histological results of 20 cases of complicated Meckel diverticulum (MD) who were presumed to have acute appendicitis before surgery, as well as to improve the diagnosis and treatment of complicated MD in children.

MATERIALS AND METHODS

We retrospectively reviewed the records of 20 complicated MD admitted to our institution who were preoperatively diagnosed with acute appendicitis from January 2012 to January 2019. Patients were divided into the perforated MD group and the Meckel's diverticulitis group. Patient demographics, clinical manifestations, laboratory data, auxiliary examinations, surgical methods, and the result of heterotopic tissue were recorded.

RESULTS

A total of 20 cases of complicated MD (perforated or diverticulitis) were identified. Children were aged from 3 to 13 years, with a mean age of 7.75 years (median 7.75; range, 1-13 years). Perforated Meckel's diverticulum occurred in 5 of 20 (25%) cases. For perforated MD versus diverticulitis, no significant differences were found between age, time to intervention, length of hospital stay, and distance from the ileo-cecal valve. Heterotopic tissue was confirmed on histopathology in 75% of all patients, including 10 cases of gastric mucosa, 3 cases of coexistent gastric mucosa and pancreatic tissue, and 2 cases of pancreatic tissue. All patients underwent diverticulectomy or partial ileal resection under laparoscopy or laparotomy; two cases combined with appendectomy owing to slight inflammation of the appendix.

CONCLUSIONS

The most common presentation of symptomatic MD is painless rectal bleeding; however, it can present symptoms of acute abdomen mimicking acute appendicitis. The key point of diverticulectomy is to remove the ectopic mucosa completely.

Primary Epiploic Appendagitis: A Mimicker of Abdominal Pain

Epiploic appendagitis is a rare cause of acute lower abdominal pain. Epiploic appendices are fat-filled serosal outpouchings of the cecum and sigmoid colon. Primary epiploic appendagitis (PEA) is characterized by epiploic inflammation caused by torsion of the appendage leading to ischemia or thrombosis of the appendage draining vein. Secondary epiploic appendagitis occurs in association with other inflammatory conditions of the abdomen or pelvis, most commonly diverticulitis. PEA is an important clinical mimicker of more severe causes of acute abdominal pain, such as diverticulitis, appendicitis, or gynaecological causes. The ease of access to computed tomography (CT), the diagnostic test of choice, has resulted in increased recognition of PEA. The classic CT findings of PEA are an ovoid mass measuring between 1.5 and 3.5 cm surrounded by a hyperattenuating/hyperdense ring with a centrally located hyperdense area. It is important to diagnose PEA as it is self-limiting and the correct diagnosis can prevent unnecessary hospital admission, antibiotic use, or even surgical intervention. We present a case of a 65-year-old male with a history of diverticulitis, presenting with left lower quadrant abdominal pain who was diagnosed with PEA based on CT and successfully managed with conservative treatment.

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.

Acute Abdominal Pain in Adults: Evaluation and Diagnosis

Acute abdominal pain, defined as nontraumatic abdominal pain lasting fewer than seven days, is a common presenting concern with a broad differential diagnosis. The most common causes are gastroenteritis and nonspecific abdominal pain, followed by cholelithiasis, urolithiasis, diverticulitis, and appendicitis. Extra-abdominal causes such as respiratory infections and abdominal wall pain should be considered. Pain location, history, and examination findings help guide the workup after ensuring hemodynamic stability. Recommended tests may include a complete blood count, C-reactive protein, hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing. Several diagnoses, such as cholecystitis, appendicitis, and mesenteric ischemia, cannot be confirmed clinically and typically require imaging. Conditions such as urolithiasis and diverticulitis may be diagnosed clinically in certain cases. Imaging studies are chosen based on the location of pain and index of suspicion for specific etiologies. Computed tomography with intravenous contrast media is often chosen for generalized abdominal pain, left upper quadrant pain, and lower abdominal pain. Ultrasonography is the study of choice for right upper quadrant pain. Point-of-care ultrasonography can aid in the prompt diagnosis of several etiologies of acute abdominal pain, including cholelithiasis, urolithiasis, and appendicitis. In patients who have female reproductive organs, diagnoses such as ectopic pregnancy, pelvic inflammatory disease, and adnexal torsion should be considered. If ultrasonography results are inconclusive in pregnant patients, magnetic resonance imaging is preferred over computed tomography when available.

Case report Ileal diverticulitis with covered perforation complicated by pulmonary embolism - case report

Diverticulitis of the ileum is an inflammatory complication of diverticulosis. It is an uncommon cause of acute abdomen that can have a very serious course, leading, for example, to intestinal perforation or bleeding. Imaging findings are very often negative and the true cause of the condition is only revealed peroperatively. In this case report, we present a case of perforated ileal diverticulitis in a patient with bilateral pulmonary embolism. This was the main reason for conservative management in the first period of time. After resolution of the pulmonary embolism, resection of the affected bowel segment was performed at the time of the next attack.

Acute purulent diverticulitis in the cecum: case report

A 40-year-old female with a 24-hour course of abdominal pain suggestive of acute appendicitis. An emergency laparotomy was performed, finding plastron in the cecum and ascending colon, color changes, with purulent liquid and 5 cm in diameter, fixed to Toldt's. It was decided to perform a right hemicolectomy with an ileotransverse end-to-side anastomosis with adequate postsurgical evolution. The histopathological report showed acute purulent diverticulitis of the cecum, which is very low incidence in the Mexican population, that's why this case report is carried out.

[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.

Acute Diverticulitis in Young Patients: A Review of the Changing Epidemiology and Etiology

Acute diverticulitis is one of the leading gastrointestinal causes for hospitalization. The incidence of acute diverticulitis has been increasing in recent years, especially in patients under 50 years old. Historically, acute diverticulitis in younger patients was felt to represent a separate entity, being more virulent and associated with a higher rate of recurrence. Accordingly, young patients were often managed differently to older counterparts. Our understanding of the natural history of this condition has evolved, and current clinical practice guidelines suggest age should not alter management. The purpose of this review is to evaluate the changing epidemiology of acute diverticulitis, consider potential explanations for the observed increased incidence in younger patients, as well as review the natural history of acute diverticulitis in the younger population.

[A woman with right-sided abdominal pain]

A 59-year-old woman presented with right-sided abdominal pain. Ultrasound was suggestive of acute appendicitis. Laparoscopy showed inflammation of a solitary caecal diverticulum, a rare congenital malformation. Uncomplicated caecal diverticulitis can mimic appendicitis clinically and sonographically, but does not require surgical intervention. An additional CT-scan can clarify the diagnosis.

Jejunal diverticulitis as a rare cause of abdominal pain: a case report

Jejunal diverticulitis is an uncommon and underdiagnosed condition. Due to the rarity of This disease, diagnosis is often difficult and delayed. Medical treatment is usually sufficient for jejunal diverticulitis without peritonitis. Surgery is required in case of generalized peritonitis or voluminous abscess complicating diverticulitis. We report the case of a 76-year-old woman who suffered from recent abdominal pain. Diagnosis of uncomplicated jejunal diverticulitis was based on computed tomography (CT) scan. The evolution was favorable after antibiotic treatment. Jejunal diverticulitis have to be evoked among the differential diagnosis of patients with abdominal pain especially in the elderly and it is important for clinicians and radiologists to have awareness about this disease.

The effects of diabetes mellitus on clinical outcomes of hospitalized patients with acute diverticulitis

OBJECTIVES

Acute diverticulitis is a common gastrointestinal illness due to diverticular inflammation and focal necrosis. Diabetes mellitus has been reported to influence the outcomes of patients with diverticular disease. Our study aimed to examine the inpatient outcomes and complications of patients with acute diverticulitis and coexisting diabetes mellitus.

METHODS

The Nationwide Inpatient Sample was used to identify adult patients in 2014 admitted for acute diverticulitis. Primary outcomes were mortality, length of stay (LOS), and total hospitalization charges. Secondary outcomes were complications of acute diverticulitis and interventions.

RESULTS

In total, 44 330 of patients with acute diverticulitis and diabetes mellitus were included in the analysis. Acute diverticulitis patients with diabetes mellitus had a higher rate of diverticular bleeding (P < 0.0001), but lower rates of abscess (P < 0.0001), obstruction (P < 0.0001) and colectomy (P < 0.0001) when compared to acute diverticulitis patients without diabetes mellitus. Complicated diabetes mellitus was associated with a longer LOS (P = 0.00003) and greater total hospitalization charges (P = 0.0021) compared to uncomplicated diabetes mellitus when coexisting with acute diverticulitis.

CONCLUSIONS

Acute diverticulitis with diabetes mellitus is associated with a higher rate of diverticular bleeding, lower rates of abscess, obstruction, and colectomy compared to acute diverticulitis without diabetes mellitus. When coexisting with acute diverticulitis, complicated diabetes mellitus is not associated with higher rates of mortality or diverticulitis-related complications compared to uncomplicated diabetes mellitus.

Caecal diverticulitis can be misdiagnosed as acute appendicitis: a systematic review of the literature

AIM

Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management.

METHODS

This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD.

RESULTS

Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi-colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%).

CONCLUSION

CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.

Primary epiploic appendagitis as an unusual cause of acute abdominal pain in a middle-aged male: A case report

RATIONALE

Primary epiploic appendagitis (PEA) is a rare cause of acute abdomen caused by spontaneous torsion or venous thrombosis of epiploic appendices, it commonly manifests with acute lower quadrant pain, thus may mimic acute diverticulitis, appendicitis, or mesenteric infarction.

PATIENT CONCERNS

In this case report, we report a 44 years old man who presented with persistent sharp pain in the left lower quadrant abdomen, Laboratory tests were mostly normal, contrast enhanced computed tomography (CECT) revealed a slightly high density shadow with fat foci in the middle was presented around the local descending colon, accompanied by the adjacent peritoneal thickening.

DIAGNOSES

He was diagnosed with PEA as confirmed by an abdominal contrast enhanced computed tomography (CECT) scan.

INTERVENTIONS

He was followed up in the clinic without any dietary restrictions, antibiotic or analgesic drugs use.

OUTCOMES

The abdominal pain gradually subsided a week later, and there were no recurrence of the symptoms during follow-up.

LESSONS

In our case, the diagnosis of PEA using CECT allows the patient to avoid surgery and other invasive treatment.

Specific Factors Predict the Risk for Urgent and Emergent Colectomy in Patients Undergoing Surgery for Diverticulitis

The aim of this study was to identify preoperative characteristics that may determine the need for emergency surgery for diverticulitis and assess postoperative outcomes for these patients when compared with elective surgery. All patients included in the ACS-NSQIP-targeted colectomy database from 2012 to 2013 who underwent colectomy with an underlying diagnosis of diverticulitis were included. Preoperative characteristics and 30-day postoperative outcomes were evaluated for patients who underwent elective versus emergent/urgent surgery using univariable and multivariable analyses. Of 8708 patients with diverticular disease, 28.1 per cent underwent emergent/urgent colectomy. Patients who underwent emergent/urgent colectomy had greater preoperative steroid use, diabetes mellitus, disseminated cancer, chronic renal failure, hypertension, chronic heart failure, chronic liver disease, COPD, and dependent functional health status (P < 0001). There were more patients with age >65 years (P < 0001), smoking history (P < 0.05), and BMI < 18.5 kg/m² (P < 0001) in the emergent/urgent colectomy group. After performing multivariable analysis, preoperative steroid use, weight loss >10 per cent, BMI < 18 kg/m², smoking, age > 65, and comorbid conditions were associated with a higher rate of emergent/urgent surgery. Mortality (5.2% vs 0.2%) and infectious and noninfectious complications were higher after nonelective colectomy. Emergent/urgent colectomy was also associated with longer hospital stay and reoperation. Emergency and urgent colectomy for diverticulitis is associated with significantly worse outcomes than after elective surgery, and patients with comorbid conditions who develop attacks of diverticulitis may in fact be the population that might best benefit from a lower threshold for an elective colectomy.

Jejuno-ileal diverticulosis : a review of literature

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. The majority of cases are discovered incidentally during radiological investigations. Based on a case of a 77 year old woman with jejunal diverticulitis, the current literature about small bowel diverticulosis is reviewed. A jejunoileal diverticulum is usually uncomplicated and can be treated conservatively. Serious complications that require surgery can occur. Abdominal CT is the preferred diagnostic tool.

Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature

Jejunal diverticulitis is a rare entity with a higher prevalence among patients between 60 and 70 years. Jejunal diverticula are most often considered an incidental finding, but, they can have complications such as diverticulitis, perforation, abscess, generalized peritonitis, fistula, obstruction and bleeding.Setting the diagnosis still remains challenging. Physicians should be aware of their existence and the clinical suspicion should be raised, especially in the setting of acute abdominal pain where jejunal diverticulitis should be included in the differential diagnosis. A small amount of free air adjacent to the small bowel can be confusing and easily misdiagnosed as small bowel perforation, but, it can actually be found as a result of the inflammation itself without macroperforation or complications.This fact can change the therapeutic strategy to less aggressive, conservative treatments. We present a case of a patient coming to the emergency department with acute abdominal pain, signs of peritonitis, a small amount of extraluminal air, and jejunal diverticulitis without perforation was diagnosed on laparotomy, and a review of the current literature.

Diverticular disease: diagnosis and treatment

Diverticular disease is one of the most common gastroenterological diseases. Its morphological basis are diverticula, whose prevalence in adults nears 50 %, with 25% clinical symptomatology and 5% occurrence of complications. It is a disease of older age, however its incidence is also rising in younger individuals, where it takes a more severe course. Its incidence is ascribed to a diet with a relatively low fibre content, however studies do not yield such clear results. Further risk factors include smoking, use of opiates and corticoids, obesity, alcoholism and smoking, hypertension, polycystosis, immunosuppression and use of non-steroid antiflogistics. Patients with diverticular disease also present with abnormal intestinal motility, intestinal dysbiosis and other physiological and morphological abnormalities. The most types of diverticulosis occur in the sigmoid colon, though especially in Asia the colon ascendens is more frequently affected. There are several classification schemes among which an individual assessment of complications is gaining in importance. The diagnosis includes clinical data, routine laboratory tests for inflammation, calprotectin in stool, coloscopy, ultrasound, CT and magnetic resonance. The basis for the treatment of symptomatic uncomplicated diverticular disease consists of drugs bringing symptomatic relief, fibre, probiotics, mesalazine and non-absorbable antibiotics, nonetheless the results of a number of studies are not fully convincing. The recommended treatment should be initiated with dietary fibre and probiotics, in the case of lasting problems add a non-absorbable antibiotic rifaximine with cyclic administration. Mild diverticulitis should essentially be treated by means of hydration and adjustments in the dietary regimen, antibiotics are not necessary when its course is uncomplicated and improvement is achieved, however the decision is individual and risk factors such as immunosuppression, diabetes, old age, pregnancy etc. Antibiotics are reserved for the treatment of severe or repeated diverticulitis, sepsis and complications. As prevention of further attacks, again probiotics, mesalazine and cyclically non-absorbable antibiotics are used, e,g. for a period of 10 days at monthly intervals. The proportion of surgeries is decreasing also where acute conditions are concerned and the efficiency of conservative treatment of diverticulitis is on the increase. Abscess should primarily be treated via non-surgical drainage. Even perforation and peritonitis can be treated via laparoscopic drainage without subsequent surgery being necessary, of course considering an overall condition an individual decision needs to be made. Generalized and fecal peritonitis are treated by open surgery. Earlier, elective resection was recommended after 2 attacks of diverticulitis, currently an individual approach is emphasized with respect to age, comorbidities and a character of the complaint and it is only indicated exceptionally. The proportion of laparoscopic resections is growing. The results are basically identical for Hartmann's procedure as well as primary resection. Key words: calprotecin - diverticular disease - dietary fibre - diverticulosis - mesalazine - non-absorbable antibiotics - probiotics.

Mesalazine for People with Diverticular Disease: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms.

AIM

We systematically reviewed current evidence on benefits and harms of mesalazine versus all other treatments in people with diverticular disease.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov for studies published to July 2018. We estimated risk ratios (RR) for dichotomous outcomes (disease remission/recurrence, acute diverticulitis in symptomatic uncomplicated diverticular disease, need for surgery/hospitalization, all-cause/disease-related mortality, adverse events), mean differences (MD) or standardized MD (SMD) for continuous outcomes (quality of life, symptoms score, time to recurrence/remission), and their 95% confidence intervals (CI) using random-effects models. We quantified heterogeneity by Chi² and I² tests. We performed subgroup analyses by disease subtype, comparator, follow-up duration, mesalazine dose, and mode of administration.

RESULTS

We identified 13 randomized trials (n=3028 participants). There was a higher likelihood of disease remission with mesalazine than controls in acute uncomplicated diverticulitis (1 trial, 81 participants, RR=2.67, 95%CI=1.05-6.79), but not in symptomatic uncomplicated diverticular disease (1 trial, 123 participants, RR=1.04, 95%CI=0.81-1.34). There was a lower likelihood of disease recurrence with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 216 participants, RR=0.52, 95%CI=0.28-0.97), but not in acute uncomplicated diverticulitis (7 trials, 2196 participants, RR=0.90, 95%CI=0.61-1.33). There was no difference in the likelihood of developing acute diverticulitis in symptomatic uncomplicated diverticular disease between the two groups (3 trials, 484 participants, RR=0.26, 95%CI=0.06-1.20). There was a higher global symptoms score reduction with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 326 participants, SMD=-1.01, 95%CI=-1.51,-0.52) and acute uncomplicated diverticulitis (2 trials, 153 participants, SMD=-0.56, 95%CI=-0.88,-0.24).

CONCLUSIONS

Mesalazine may reduce recurrences in symptomatic uncomplicated diverticular disease. There is uncertainty on the effect of mesalazine in achieving diverticular disease remission. Mesalazine may not prevent acute diverticulitis in symptomatic uncomplicated diverticular disease.

Emergency Department Burden of Diverticulitis in the USA, 2006-2013

GOALS

The aim of this study was to analyze recent trends in emergency department (ED) visits for diverticulitis between 2006 and 2013.

BACKGROUND

Acute diverticulitis is a serious medical condition that frequently leads to ED visits, hospitalizations, and surgeries resulting in a significant health care burden.

METHODS

Data were obtained from the National Emergency Department Sample (NEDS) records in which diverticulitis (ICD-9-CM codes 562.11 and 562.13) was the primary diagnosis in the ED between 2006 and 2013. The NEDS collects data from more than 25 million visits in over 950 hospital emergency departments and is weighted to provide national estimates. Our findings reflected patient and hospital characteristics such as demographics, geographical region, and total charges for ED and inpatient stays.

RESULTS

Between 2006 and 2013, the rate of diverticulitis-related ED visits increased by 26.8% from 89.8 to 113.9 visits per 100,000 population. The aggregate national cost of diverticulitis-related ED visits increased by 105%, from approximately $822 million in 2006 to over $1.6 billion in 2013. Cost data were adjusted for inflation and reported in 2015 dollars. The percentage of individuals admitted to the same hospital from the ED decreased from 58.0 to 47.1% from 2006 to 2013, respectively, while the rate of bowel surgeries per 100,000 ED visits for diverticulitis decreased by 33.7% from 2006 to 2013.

CONCLUSIONS

The number of ED visits due to diverticulitis and associated costs continued to rise between 2006 and 2013, while the rate of bowel surgeries and inpatient admissions through the ED for diverticulitis decreased.

[Complicated jejunoileal diverticular disease: a 12 cases' serie and literature review]

OBJECTIVE

To perform a retrospective analysis of a series of complicated JID (jejunoileal diverticulitis) cases surgically treated in our service during the period from 2002 to 2015.

MATERIALS AND METHODS

We treated 12 cases of jejunoileal complicated diverticulosis. 7 women and 5 men. The mean age was 76 years. The clinical presentation in all cases was acute abdominal pain, one with gastrointestinal bleeding. All cases had leukocytosis, neutrophilia and increased acute phase reactants. All patients underwent emergency abdominal CT.

RESULTS

In 11 cases, there was consistency between imaging studies and surgical findings. Diverticula were located: jejunum (9) and ileum (3). Urgent exploratory laparotomy was always done and findings were: diverticular perforation with peritonitis (7 cases), diverticular perforation with abscess (4 cases) and in one case an ischemic area with diverticular perforation after embolization. Intestinal resection and anastomosis was performed in all cases. There were no patients, in which the diagnosis of diverticulosis jejunoileal was previously known. Complications were: Clavien I (2), Clavien IIIa (1), Clavien IVb (1), Clavien V (1).

CONCLUSIONS

Jejunoileal diverticulitis is a rare entity, usually the first sign of onset of diverticular disease not previously known. Abdominal CT is of great diagnostic value. Resection of the affected segment is the treatment of choice.

Meckel's diverticulum perforated by a fishbone. An unusual presentation

Finding a Meckel's diverticulum during a laparotomy is rare, operating on a patient for a complication of diverticulum is rare, but if this complication is the result of a perforation of the diverticulum by a foreign body, then we are in the presence of a medical curiosity.

OBJECTIVE

To present the following case because despite being known, the etiological agent that caused the perforation is very unusual.

METHOD

male 53 years old with a history of emergency surgically underwent surgery for acute appendicitis 10 years where he underwent an appendectomy and a non-complicated Meckel's diverticulum was identified. For the record, the clinical picture and complementary examinations Meckel diverticulitis was diagnosed and we decided to intervene with surgically emergency. During surgery a Meckel's diverticulum perforated by a fishbone was identified. Segmental bowel resection and an ileo-ileoanastomosis performed manually.

CONCLUSIONS

Meckel's diverticulum perforated by fishbone is extremely rare. Its diagnosis is challenging because of their variable clinical presentation.

Appendicular Diverticulosis with Appendicitis

Appendicular diverticulosis is one of the very rare diseases which is also difficult to diagnose, especially clinically, due to its silent course and non-specific symptoms. It comes under the notation usually due to its complications like diverticulitis or perforation, but sometimes it also presents with acute appendicitis. This report describes a 44-year male patient who presented with the complain of right iliac fossa pain and was clinically diagnosed as acute appendicitis; but intraoperatively, it was found that the appendix also had diverticulosis along with appendicitis.

Recent Advances in Diverticular Disease

Diverticular disease is common and accounts for substantial health care utilization in the USA. Recent publications in the areas of diverticulosis and diverticular disease have highlighted several notable advances that are now changing practice. Despite colonic diverticula being common, only 1-4 % of individuals with colonic diverticula will develop diverticulitis. After a first occurrence of acute diverticulitis, the risk of recurrence is 20 % at 5 years. Complications most commonly occur with the first occurrence of acute diverticulitis and not with recurrent episodes. After an episode of diverticulitis, many patients continue to experience chronic gastrointestinal symptoms. Prophylactic surgery is an option to reduce the risk of recurrence and its negative impact on quality of life. Importantly, the rationale for surgery is no longer to prevent complications because this risk is low. The review concludes with practical recommendations for patients with diverticulosis and diverticular disease.

Rare cases imitating acute appendicitis: Three case reports and a review of literature

Acute appendicitis with its characteristic clinical course is one of the most common diagnoses that require urgent surgery. The following three case reports present patients with symptoms typical of acute appendicitis which was, however, not confirmed intraoperatively. Preoperative CT or MRI were not requested because symptoms clearly indicated acute appendicitis. The first case describes a male patient with right-sided diverticulitis, the second case report involves a pregnant woman in 33rd week of gestation with right adnexal torsion due to a dermoid cyst, and in the last report, a case of spontaneous perforation of appendiceal mucinous neoplasm is presented.Key words: right-sided diverticulitis - dermoid cyst - adnexal torsion - mucinous neoplasm - pseudomyxoma peritonei - appendicitis.

Anaphylaxis to Polyethylene Glycol (Colyte®) in a Patient with Diverticulitis

Polyethylene glycols (PEGs) are believed to be chemically inert agents, but larger PEG polymers could have immunogenicity. A 39-year-old man was referred to emergency room for loss of consciousness and dyspnea after taking of PEG-3350 (Colyte®). In laboratory findings, the initial serum tryptase level was increased to 91.9 mg/L (normal range: 0.00-11.40 mg/L) without any other laboratory abnormalities. The intradermal test with 10 mg/mL Colyte® showed a 5 × 5 mm wheal, but basophil activation and histamine releasability tests were negative. PEG-3350 is widely used as an osmotic laxative due to its lack of absorption from the gastrointestinal tract. However, the loss of mucosal integrity at gastrointestinal membrane such as diverticulitis may be a predisposing factor for anaphylaxis to Colyte®. We report a case of anaphylaxis induced by the ingestion of PEG-3350 in a patient with diverticulitis which might be a risk factor of anaphylaxis.

Short-term mortality, readmission, and recurrence in treatment of acute diverticulitis with abscess formation: a nationwide register-based cohort study

PURPOSE

The aim of the study was to investigate short-term mortality, readmission, and recurrence in a national cohort of patients with Hinchey Ib-II diverticulitis.

METHODS

The retrospective cohort-investigation was conducted using a database consisting of the entire Danish population (n = 6,641,672) in year 2000-2012, formed by linking the Danish Registers. Patients admitted with acute Hinchey Ib-II diverticulitis were identified from ICD-10 discharge codes and stratified according to treatment into an operative, drainage, and antibiotics group. The primary outcome was 30-day mortality from admission, secondary outcomes were mortality, readmission, and recurrence within 30 days post-discharge. The study was reported using RECORD guidelines.

RESULTS

A total of 3148 eligible patients were identified. The cohort had a mean age of 65.1 year, 25.6 % had previously been admitted with diverticulitis, and 48.1 % had registered comorbidities. Within 30 days from admission, 8.7 % of the patients died. Of patients discharged, 2.5 % died, 23.8 % was readmitted, and 5.9 % was readmitted due to diverticulitis within 30 days from discharge. In multivariate analyses, increasing age was associated with mortality at odds-ratio (95 % CI) 1.10 (1.09-1.12). Previous complicated and uncomplicated diverticulitis reduced mortality with odds-ratio 0.50 (0.33-0.76) and 0.73 (0.58-0.92), while uncomplicated diverticulitis also increased risk of recurrence with odds-ratio 1.51 (1.24-1.84). Glucocorticoid usage was associated with mortality with odds-ratio 1.49 (1.23-1.81) and readmission with odds-ratio 2.91 (1.24-6.80).

CONCLUSION

Acute diverticulitis with abscess formation is a severe and life-threatening condition. Direct comparisons of treatment groups were not possible due to possible confounding by indication.

Current management of acute diverticulitis: a survey of Australasian surgeons

AIMS

To evaluate the current practice and degree of consensus amongst Australasian surgeons regarding non-surgical management of acute diverticulitis (AD) and to determine whether newer approaches to management are being translated into practice.

METHODS

An online survey was distributed to all Australasian colorectal surgeons and all general surgeons in the Auckland region. Responses were collected over two months and analysed to identify points of consensus and areas of significant difference in opinion between these groups.

RESULTS

Responses were received from a total of 99 of 200 (49.5%) colorectal surgeons, and 19 of 36 (52.7%) general surgeons. The Hinchey Classification was the most commonly used measure of disease severity, used by 67 (95.7%) colorectal surgeons and 12 (92.3%) general surgeons. There was lack of consensus around important aspects of AD management, including antibiotic therapy, and use and modality of follow-up imaging. Selective antibiotic therapy and use of anti-inflammatory medication as adjuncts to treatment were practised by a minority of those surveyed.

CONCLUSIONS

Newer approaches to management were being utilised by some respondents. The lack of consensus regarding management of AD may be a consequence of a paucity of high-level evidence to support specific management approaches, particularly in patients with uncomplicated AD.

Probiotics in the Treatment of Diverticular Disease. A Systematic Review

BACKGROUND AND AIMS

Diverticular disease is a common gastrointestinal condition. Low-grade inflammation and altered intestinal microbiota have been identified as factors contributing to abdominal symptoms. Probiotics may lead to symptoms improvement by modifying the gut microbiota and are promising treatments for diverticular disease. The aim of this study was to systematically review the efficacy of probiotics in diverticular disease in terms of remission of abdominal symptoms and prevention of acute diverticulitis.

METHODS

According to PRISMA, we identified studies on diverticular disease patients treated with probiotics (Pubmed, Embase, Cochrane). The quality of these studies was evaluated by the Jadad scale. Main outcomes measures were remission of abdominal symptoms and prevention of acute diverticulitis.

RESULTS

11 studies (2 double-blind randomized placebo-controlled, 5 open randomized, 4 non-randomized open studies) were eligible. Overall, diverticular disease patients were 764 (55.1% females, age 58-75 years). Three studies included patients with symptomatic uncomplicated diverticular disease, 4 studies with symptomatic uncomplicated diverticular disease in remission, 4 studies with complicated or acute diverticulitis. Mainly (72.7%) single probiotic strains had been used, most frequently Lactobacilli. Follow-up ranged from 1 to 24 months. Interventions were variable: in 8 studies the probiotic was administered together with antibiotic or anti-inflammatory agents and compared with the efficacy of the drug alone; in 3 studies the probiotic was compared with a high-fibre diet or used together with phytoextracts. As an outcome measure, 4 studies evaluated the occurrence rate of acute diverticulitis, 6 studies the reduction of abdominal symptoms, and 6 studies the recurrence of abdominal symptoms. Meta-analysis on the efficacy of probiotics in diverticular disease could not be performed due to the poor quality of retrieved studies.

CONCLUSION

This systematic review showed that high-quality data on the efficacy of probiotics in diverticular disease are scant: the available data do not permit conclusions. Further investigation is required to understand how probiotics can be employed in this condition.

Highlighted Steps of the Management Algorithm in Acute Lower Gastrointestinal Bleeding - Case Reports and Literature Review

Acute lower gastrointestinal bleeding is a major problem worldwide, being a rare and life threatening condition, with a mortality rate situated between 2 and 4%. Acute lower gastrointestinal bleeding is solvent for 1 - 2% of the entire hospital emergencies, 15% presenting as massive bleeding and up to 5% requiring surgery. Lower gastrointestinal bleeding can be classified depending on their location in the small or large intestine. The small bowel is the rarest site of lower gastrointestinal bleeding, at the same time being the commonest cause of obscure bleeding. 5% of total lower GI bleeding appears in the small bowel. When endoscopic therapy associated with medical treatment are insufficient, endovascular intervention can be lifesaving. Unfortunately in some rare cases of acute lower gastrointestinal bleeding with hemo-dynamic instability and the angiography performed being unable to locate the source of bleeding, the last therapeutic resource remains surgery. In the following we exemplify two cases of acute lower gastrointestinal bleeding which were resolved in different ways, followed by a thorough description of the different types of available treatment and finally, in the conclusions, we systematize the most important stages of the management algorithm in acute lower gastrointestinal bleeding.

[Current treatment for diverticulitis: state of affairs in 2016]

- Uncomplicated diverticulitis does not routinely require antibiotic treatment and can even be managed in the outpatient setting.- As yet no medical therapies have proven themselves useful in the prevention of recurrence.- Complicated diverticulitis with an abscess smaller than 4 cm is treated with antibiotics, larger abscesses are treated by percutaneous drainage, and only if treatment fails surgery is required.- Laparoscopic lavage is no better than partial resection in purulent peritonitis.- Perforated diverticulitis with faecal peritonitis is treated by a Hartmann's procedure; in selected cases resection and primary anastomosis may be considered.- The decision whether a resection should be laparoscopic or open is based on the surgeon's experience.- The choice for elective resection for recurrent diverticulitis is still made on a patient-by-patient basis.- Only high-risk patients should have a follow-up colonoscopy to exclude malignancy. The remaining patients are referred back to the Dutch national colorectal cancer screening programme.

Perforated appendiceal diverticulitis associated with appendiceal neurofibroma in neurofibromatosis type 1

An appendiceal neurofibroma (ANF) is a rare neoplasm associated with neurofibromatosis type 1(NF-1), an inheritable neurocutaneous disorder that involves multiple systems including the intraabdominal organs. Appendiceal diverticulitis occasionally ruptures in the absence of intense abdominal pain, which can lead to serious consequences. Recent reports highlight the association between appendiceal diverticulum and appendiceal neoplasms; however, there is still little information on the association between appendiceal diverticulitis and ANF in NF-1. A 51-year-old Japanese male with NF-1 was referred to the division of surgery for mild right lower quadrant pain. It was suspected he had perforated acute appendicitis with periappendiceal abscess based on clinical manifestations and findings of computed tomography. An emergency appendectomy was conducted. The pathological examination revealed diffusely proliferated tumor cells of a neurofibroma, coexistent with multiple appendiceal diverticulums, leading to the diagnosis of perforated appendiceal diverticulitis associated with ANF. Although he developed a remnant abscess, he recovered with the conservative treatments of antibiotics and drainage. This case suggests that appendiceal diverticulitis might be a complication of appendiceal involvement of NF-1, and that it occasionally ruptures in the absence of intense abdominal pain. Clinicians should recognize that NF-1 can cause various abdominal manifestations.

Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis

AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.

METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay.

RESULTS: Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03).

CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.

[Diagnostic imaging and acute abdominal pain]

Acute abdominal pain is a common clinical condition. Clinical signs and symptoms can be difficult to interpret, and diagnostic imaging may help to identify intra-abdominal disease. Conventional X-ray, ultrasound (US) and computed tomography (CT) of the abdomen vary in usability between common surgical causes of acute abdominal pain. Overall, conventional X-ray cannot confidently diagnose or rule out disease. US and CT are equally trustworthy for most diseases. US with subsequent CT may enhance diagnostic precision. Magnetic resonance seems promising for future use in acute abdominal imaging.