No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis
... Konsumsi probiotik menunjukkan efek yang positif dalam mengurangi gejala abdominal (Lahner et al., 2016). Meskipun begitu, kurangnya data mengenai peran probiotik dalam mencegah munculnya komplikasi dan kekambuhan, serta berdasarkan rekomendasi American Gastroenterological Association (AGA), konsumsi probiotik setelah terjadinya divertikulitis akut tanpa komplikasi tidak dianjurkan (Rezapour et al., 2018;Stollman et al., 2015). Aktivitas fisik intens seperti lari juga ditemukan mengurangi risiko divertikulitis dan pendarahan divertikula. ...
... Pemberian antibiotik disarankan pada pengobatan divertikulitis dengan komplikasi dan divertikulitis tanpa komplikasi dengan perkembangan penyakit yang cepat serta tingkat kekambuhan yang tinggi (Isacson et al., 2014;Rezapour et al., 2018). AGA menyarankan penggunaan antibiotik secara selektif pada pasien dengan divertikulitis akut (Stollman et al., 2015). Penggunaan mesalamine menunjukkan perbaikan gejala umum pada pasien yang baru sekali mengalami divertikulitis akut, tetapi tidak mengurangi tingkat kekambuhan (Raskin et al., 2014). ...
... Penggunaan mesalamine menunjukkan perbaikan gejala umum pada pasien yang baru sekali mengalami divertikulitis akut, tetapi tidak mengurangi tingkat kekambuhan (Raskin et al., 2014). AGA juga tidak menyarankan penggunaan mesalamine untuk mencegah kekambuhan divertikulitis (Stollman et al., 2015). Selain itu, terdapat antibiotik spektrum luas rifaximin yang digunakan untuk pengobatan penyakit divertikular bergejala tanpa komplikasi (symptomatic uncomplicated diverticular disease/SUDD). ...
Diverticulitis is a symptomatic diverticular disease characterized by inflammation of the diverticulum. Until now, the pathophysiology of diverticulitis is not known with certainty. Interactions between factors such as genetic factors, colonic structure and motility, colonic microbiota, age, and diet are thought to play a role in the occurrence of the disease. Diverticulitis should be considered as a differential diagnosis of acute abdominal pain specifically in the lower left part of the abdomen. Diagnostic criteria in cases of diverticulitis are the presence of inflamed diverticula, intestinal wall thickening exceeding 3 or 5 mm, and increased contrast absorbing medium on CT Scan and MRI examinations. Any perforation, obstruction, fistulization, and abscess detected on any imaging examination can be a sign of complicating diverticulitis. The prognosis in patients with diverticulitis depends on age, the presence of comorbidities, and the severity of the disease. Keywords: Diverticulitis; Diverticular Disease; Acute Lower Left Abdominal Pain; Diverticulum
... 3 A number of published guidelines or consensus statements on the diagnosis and treatment of DD are available from Europe 2,4-8 and the USA. 9,10 There are no specific guidelines from Asia, although discussion of DD in Asia is included in guidance from the World Gastroenterology Organisation (WGO). 11 Most guidelines focus principally on acute diverticulitis (treatment and primary and secondary prevention), and specific discussion on diverticulosis and SUDD is often lacking. ...
... 2,7,8 SUDD is not discussed in the current USA guidelines because the currently available evidence was considered limited. 10 ...
... The most recent guidelines from the USA suggest that a fibre-rich diet or fibre supplementation may be beneficial in patients with a history of acute diverticulitis. 10 The evidence base for the role of fibre supplements is relatively limited and is principally from older studies, many of which have substantial methodological limitations, which leads to difficulty in drawing firm conclusions. 36 This was reflected in recent Italian guidelines, which concluded that fibre supplementation alone provides controversial results in terms of symptom relief for SUDD. 2 While it has been proposed that certain foodstuffs (e.g., seeds, nuts, and popcorn) can predispose to DD, data from a large prospective cohort study show no increased risk of diverticulosis or DD; indeed, subjects with the greatest consumption of nuts or popcorn had significantly lower risk than those with lowest consumption. ...
The epidemiology of diverticular disease (DD) is changing, with an increasing prevalence in younger patients from Europe and the USA, and changing disease patterns also seen in Asian populations. This epidemiological shift has substantial implications for disease management policy and healthcare costs. Most (75–80%) patients with diverticulosis never develop symptoms. Around 5% develop acute diverticulitis or other complications, while 10–15% develop symptomatic uncomplicated DD (SUDD) with symptoms resembling irritable bowel syndrome (IBS). However, most available guidelines highlight the importance of diverticulitis, with less emphasis on and often limited discussion about SUDD and its management. Recent data suggest an important relationship between gut microbiota and DD, including SUDD. In healthy individuals, the gut microbiota exists in harmony (eubiosis); in individuals with disease, quantitative and qualitative changes in microbial diversity (dysbiosis) may adversely influence colonic metabolism and homeostasis. Addressing this imbalance and restoring a healthier microbiota via eubiotic or probiotic therapy may be of value. In SUDD, clinical benefit has been seen with the use of rifaximin, which acts by multiple mechanisms: direct antibiotic activity, a modulatory eubiotic effect with an increase in muco-protective Lactobacillus and Bifidobacterium organisms, and anti-inflammatory effects, among others. Clinical studies have demonstrated symptom improvement and reduction in complications in patients with SUDD, with a favourable safety and tolerability profile and no evidence of microbial resistance. Evidence for other agents in DD is less robust. Mesalamine is not effective at preventing recurrence of acute diverticulitis, although it may provide some symptom improvement. At present, there is insufficient evidence to recommend the use of probiotics in SUDD symptom management.
... This strategy, besides being focused on the patient's quality of life, regards patients' preferences, coexisting medical conditions, and surgical risk rather than fear of future life-threatening complications [7,27]. Moreover, elective surgery can improve quality of life [28,29], the results are imperfect, with an overall morbidity of 7.6% to 19.6%, namely leak and stoma risk, with persistent symptoms in 25% of the patients, even in the laparoscopic era [8,[30][31][32]. It would be interesting to have predictive factors for symptom persistence. ...
... Considering actual data, the goals of elective surgery for AD are the improvement of QoL in symptomatic patients with ongoing chronic inflammation or recurrent boats and the management of complications such as abscess, fistula, or stenosis [9,18,26]. This decision should be individualized, keeping in mind that although surgery can improve a patient's QoL and treat complications, the results are imperfect, with an overall morbidity of 7.6% to 19.6%, namely with leak and stoma, with persisting symptoms in at least 25% of the patients [8,[30][31][32]. In addition, while a significant reduction in the need for emergency surgery is no longer expected, it also does not eliminate the risk of relapse [14,33]. ...
Although the incidence of acute diverticulitis (AD) has risen over the past few decades, particularly in younger patients, the rate of emergency surgery has been dropping due to a major paradigm shift toward more conservative management approaches. The long-term management strategy after successful nonoperative treatment of AD remains unclear, and indications for elective resection are a matter of ongoing debate. Most modern professional guidelines advise considering elective surgery in an individualized approach, particularly after recovery of acute complicated diverticulitis (ACD) with abscess and in patients with recurrence, persisting symptoms, and complications such as abscess, fistula, and stenosis, focusing on the patient’s quality of life, where recurrence, severity, and symptoms are major determinants. However, guidelines are still not clearly standardized for appropriate decision-making, with patients being managed very differently from institution to institution, and surgeon to surgeon, mainly due to a lack of risk stratification for recurrence and severity that have been the scope of numerous studies but still need to be clarified. In this chapter, we explore the current surgical indications for AD, considering this disease’s ongoing prognostic factors, for proper decision-making.
... Se encontró un estudio realizado en la ciudad de Bogotá hace más de 30 años, que mostró una mayor prevalencia de la diverticulitis en hombres (59 %), mayor presentación a partir de los 50 años, necesidad de tratamiento quirúrgico en el 11 % de los casos y una mortalidad global del 4 % 11 . Los datos actuales disponibles en nuestro medio son extrapolados de las experiencias documentadas por profesionales de otros lugares del mundo [12][13][14] , por ello, se decidió realizar una caracterización de los pacientes locales tomando los ingresos a un centro de referencia en un período de 5 años, con el objetivo de identificar las particularidades del comportamiento de esta enfermedad en un hospital local, los tratamientos y sus desenlaces. ...
... Para el manejo de la diverticulitis, clásicamente se ha definido que los pacientes con estadios 0 y Ia tienen enfermedad no complicada y se benefician de manejo conservador, consistente en analgésicos y antibióticos en casos seleccionados 12,13 . Incluso pueden ser tratados como pacientes ambulatorios si no tiene comorbilidades significativas y se puede asegurar un autocuidado con un tratamiento adecuado. ...
Introducción. Los datos epidemiológicos de la diverticulitis en Colombia son limitados. El objetivo de este artículo fue caracterizar una población que ingresó con diverticulitis aguda al Hospital Universitario San Vicente Fundación, un centro de referencia de la ciudad de Medellín, Colombia, para analizar la presentación y comportamiento de la enfermedad en la población local, con estadísticas propias y desenlaces de la enfermedad en los últimos años. Métodos. Estudio observacional retrospectivo, descriptivo, entre enero de 2015 y diciembre de 2019. Se hizo un estudio exploratorio uni-, bi- y multivariado de factores de riesgo para fallo en el tratamiento y la mortalidad. Resultados. Se incluyeron 103 pacientes. Se presentó principalmente en mujeres y la edad promedio fue de 65 años. La diverticulitis Hinchey Ia fue la más frecuente (41,7 %) y el manejo médico fue exitoso en todos los casos, mientras que en las tipo III y IV, todos se manejaron de forma quirúrgica, con tasas de éxito entre el 50 y el 64 %. La presencia de signos de irritación peritoneal al examen físico, el recuento de leucocitos y la PCR, el ingreso a la Unidad de Cuidados Intensivos y la mortalidad aumentaron de forma directamente proporcional con el estadio de Hinchey. Conclusiones. Existe una relación directamente proporcional entre la clasificación de Hinchey y los signos de respuesta inflamatoria clínicos y paraclínicos, la necesidad de manejo quirúrgico, la estancia en la Unidad de Cuidados Intensivos y la mortalidad.
... Nevertheless, studies have reached mixed conclusions regarding the true risk of advanced neoplasia in patients with diverticulitis [10][11][12][13][14][15][16]. For this reason, multiple medical societies have published recommendations regarding performance of a routine colonoscopy to exclude CRC 4-6 weeks after an episode of acute diverticulosis, especially after complicated diverticulitis and after the first episode of uncomplicated disease [8,[17][18][19]. ...
... These findings are emphasized in light of the older age of the control population, which is one of the significant risk factors for advanced lesions [28]. All our CRC patients had complicated diverticulitis and [9,13], knowing that, despite increased accuracy of CT, acute diverticulitis and CRC can sometimes simulate eachother [7,8], and with the resultant universal recommendation for performing a colonoscopy after recovery from the acute episode [8,[17][18][19]. ...
Background:
Guidelines recommend a colonoscopy after an episode of complicated diverticulitis and after a first episode of uncomplicated diverticulitis. The influence of a previous colonoscopy on post-diverticulitis colonoscopic findings was not studied. We examined the incidence of adenoma detection rates (ADR), advanced adenoma (AA) and colorectal cancer (CRC) in patients with diverticulitis with and without previous colonoscopies.
Methods:
This was a retrospective case-control study of subjects with acute diverticulitis. Subsequent and previous colonoscopies were abstracted for ADR, AA and CRC diagnoses. Neoplasia incidence was compared between patients with and without previous colonoscopies and also with that of a screening population.
Results:
Compared to a healthy control group (N=975), diverticulitis patients without prior co-lonoscopies (N=325) had a significantly higher ADR (26.8% vs. 20.5%, P = 0.019, respectively) and invasive CRC rate (0.9% vs. 0, P= 0.016, respectively). Risk factors for advanced neoplasia included age ≥ 70 years and complicated diverticulitis. Among subjects with diverticulitis and previous colonoscopies (N=124), only one patient developed AA and there were no cancer cases.
Conclusions:
A previous normal colonoscopy within 5 years before diverticulitis, probably overshadows other risk factors for findings of advanced neoplasia and should be considered in the decision to repeat a colonoscopy.
... Although now widely contested (see Table 3) [32], a high-fiber diet has long been thought to play a major role in prevention of diverticular disease [33,34]. This observation was first made by Burkitt and Painter in 1971, who hypothesized that a high-fiber diet would facilitate a shorter transit time through the colon [33,34]. ...
... Similarly, the American Society of Colon and Rectal Surgeons (ASCRS) gave a 1A recommendation to treat select patients with Hinchey Class I and Ia complicated diverticulitis without antibiotics, however they noted that patients treated without antibiotics were more likely to have elective surgery during follow-up [19]. The American Gastroenterological Association's (AGA) 2015 guideline provided a conditional recommendation for selective rather than routine use of antibiotics in uncomplicated diverticulitis in the absence of severe disease, immunocompromised status, pregnancy, or significant comorbidity [2,32]. ...
Diverticular disease is highly prevalent in the Western world, placing an increased burden on healthcare systems. This review clarifies the consensus in the literature on the disease’s classification, etiology, and management. Diverticular disease, caused by sac-like protrusions of colonic mucosa through the muscular colonic wall, has a varied disease course. Multiple theories contribute to our understanding of the etiology of the disease, with pathogenesis affected by age, diet, environmental conditions, lifestyle, the microbiome, genetics, and motility. The subtypes of diverticular disease in this review include symptomatic uncomplicated diverticular disease, segmental colitis associated with diverticulosis, and uncomplicated and complicated diverticulitis. We discuss emerging treatments and outline management options, such as supportive care, conservative management with or without antibiotics, and surgical intervention.
... Published guidelines also suggest the selective rather than routine approach to the use of anti-bacterial therapy. These include the American Gastroenterological Association Institute [47] and the World Society of Emergency Surgery [1]. The latter recommends NABX use in systemically well, immune-competent patients. ...
Background
To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis.
Methods
A systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters.
Results
The literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61).
Conclusion
Observation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis.
... There are currently fewer case reports presented that display a patient with uncomplicated ileal diverticulitis and the difference in the management of these patients as compared to more severe cases. In patients with uncomplicated acute small intestine diverticulitis, a restricted liquid diet and selective antibiotics are recommended similarly to colonic diverticulitis in patients at risk for poorer outcomes and those with systemic disturbances or medical comorbidities [4,11]. Yet, due to the varying severity of patient presentations, therapeutic management of patients with ileal diverticulitis is often individualized and can be complicated. ...
Ileal diverticulitis is a rare cause of abdominal pain. Even though small intestine diverticulosis is relatively rare, resulting pathologies including diverticulitis are still clinically relevant in both an inpatient and outpatient setting often presenting with varying levels of severity. Most reported cases of ileal diverticulitis are complicated and managed surgically. In contrast to these more complicated presentations, this report illustrates an uncomplicated case of ileal diverticulitis presenting with right lower quadrant abdominal pain and leukocytosis treated successfully conservatively with medical management. Although rare, uncomplicated ileal diverticulitis is clinically pertinent and should be included in the differential diagnosis of abdominal pain as this disease presentation can cause symptoms that are commonly associated with more prevalent pathologies such as acute appendicitis. Thus, these presentations are often mistaken for other more common and/or emergent pathologies depending on the region of the symptomatic small bowel diverticulitis. In this case report, the patient’s presentation initially mimicked mild atypical appendicitis and was thus managed with this diagnosis in mind without the need for more extensive treatment including surgery.
There are currently fewer case reports available that display a patient with uncomplicated ileal diverticulitis and the difference in the presentation and management of these patients compared to more severe cases. Physicians should have a heightened awareness of this disease process to avoid delayed management or prevent/postpone complications. This lack of current awareness in part may be due to the less volatile presentation associated with uncomplicated ileal diverticulitis and thus delayed patient presentation, as was seen with this case. However, it is important to note that as with any patient’s care, proper treatment must be individualized, especially given the variable nature of patient presentations with ileal diverticulitis. All in all, one hope is that improving clinician awareness of uncomplicated cases of ileal diverticulitis such as this patient presentation will result in improved outcomes for a multitude of future patients.
... The approach to conservative treatment for AD is evolving from the recommendation of not administering antibiotic therapy in lower grade patients 21,22 . There is also a consideration for an outpatient approach in lowrisk cases 23 . ...
Left-sided acute diverticulitis in WSES Stage 0-IIb preferentially undergoes conservative management. However, there is limited understanding of the risk factors for failure of this approach. The aim of this study was to investigate the factors associated with the decision to perform conservative treatment as well as the predictors of its failure. We included patients with a diagnosis of WSES diverticulitis CT-driven classification Stage 0-IIb treated in the Emergency Surgery Unit of the Agostino Gemelli University Hospital Foundation between 2014 and 2020. The endpoints were the comparison between the characteristics and clinical outcomes of acute diverticulitis patients undergoing conservative versus operative treatment. We also identified predictors of conservative treatment failure. A set of multivariable backward logistic analyses were conducted for this purpose. The study included 187 patients. The choice for operative versus conservative treatment was associated with clinical presentation, older age, higher WSES grade, and previous conservative treatment. There were 21% who failed conservative treatment. Of those, major morbidity and mortality rates were 17.9% and 7.1%, respectively. A previously failed conservative treatment as well as a greater WSES grade and a lower hemoglobin value were significantly associated with failure of conservative treatment. WSES classification and hemoglobin value at admission were the best predictors of failure of conservative treatment. Patients failing conservative treatment had non-negligible morbidity and mortality. These results promote the consideration of a combined approach including baseline patients’ characteristics, radiologic features, and laboratory biomarkers to predict conservative treatment failure and therefore optimize treatment of acute diverticulitis.
... Additionally, an increased risk of CRC has been demonstrated during short-term follow-up after diverticulitis treatment [2]. Therefore, colonoscopy is recommended at 6-8 weeks after diverticulitis treatment [3,4]. ...
Colorectal cancer (CRC) can occasionally coexist with diverticulitis, thereby complicating diagnosis and treatment. In cases of refractory diverticulitis, it is important to consider the possibility of malignancy and determine appropriate treatment strategies. An 85-year-old male presented with lower left abdominal pain; he was admitted for further examination and the treatment of suspected sigmoid diverticulitis. On examination, a firm mass was palpated in the lower left quadrant. Imaging revealed sigmoid diverticulitis, partial abscess formation, and the involvement of the small bowel and abdominal wall. Although malignancy was suspected, a definitive diagnosis was not made. Because of the refractory nature of the disease, early surgical intervention, sigmoid colectomy, partial small bowel resection, abdominal wall resection, and lymph node dissection, was performed in accordance with the malignancy protocol. Pathologic diagnosis revealed adenocarcinoma within the diverticulitis with negative resection margins, indicating curative surgery. The low preoperative diagnostic rate of CRC associated with diverticulitis highlights the need for vigilance. Refractory diverticulitis may indicate the presence of concealed malignancy requiring surgical intervention. In the management of refractory diverticulitis, it is important to consider the potential coexistence of cancer. Even if extensive investigations are performed and a definitive diagnosis remains elusive, surgery must be considered.
... On the other hand, there are medications to avoid. The American Gastroenterology Association guidelines recommend avoiding nonaspirin NSAIDs (but not avoiding therapeutic aspirin) in patients after acute diverticulitis; however, it is a very low quality of evidence, given that it is derived from observational data [12]. ...
Colonic diverticulosis is the presence of outpouchings of the intestinal walls in the colon. It remains without symptoms in most individuals, but about 25% of individuals will develop symptoms of diverticulosis at some point in time, and this is termed as colonic diverticular disease. The severity of this illness is variable and ranges from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as inflammation of these outpouchings or occasional bleeding. The diagnosis of diverticular disease depends mainly on radiological studies, such as computed tomography (CT) abdomen pelvis and magnetic resonance imaging (MRI) scan. The management is a multilevel approach that focuses on lifestyle modifications and pharmacotherapies to provide symptomatic relief and reduce progression risks into complicated diseases. Rarely, endoscopic interventions may be needed in some complicated cases.
... Multiple studies over the last two decades have investigated the yield of colonic evaluation after AD, resulting in heterogeneous conclusions (5,10,15). Multiple international guidelines recommend routine interval Colonoscopy after an episode of AD to exclude malignancy (16)(17)(18). Yet other international guidelines have challenged this recommendation and published conflicting advice (19), and others, such as the NICE guidelines, have conveniently ignored the issue although have approved the Royal College of Surgeons' position of routine colonoscopy for all (20,21). ...
... Studies suggest that up to 10-25% of patients with diverticulosis may develop diverticulitis [2][3][4], with a significant proportion (between 10% and 30%) presenting with symptoms such as sepsis, bowel obstruction, or perforation, fistula formation, and bleeding [5][6][7][8]. Although the proportion of deaths attributed to diverticular disease has shown a decline over the past 12 years as well as the past two decades, rates of hospital admissions and surgical interventions have witnessed a notable increase of 15% [9]. ...
Background: The normal pattern of acute colonic diverticulitis is still unknown, and prophylactic surgery after conservative treatment of diverticulitis is a topic of growing debate. The aim of this study was to investigate the patterns and frequency of recurrences and the likelihood of complications in conservatively treated uncomplicated and complicated diverticulitis in our epidemiological setting. Methods: This retrospective study was conducted to investigate 98 inpatients admitted to Benghazi Medical Center with acute colonic diverticulitis, between February 2021 and August 2022. Acute diverticulitis discharge summaries were reviewed to identify eligible patients, and their medical records were meticulously reviewed retrospectively to confirm that their clinical presentation was consistent with colonic diverticulitis. Results: A retrospective study of 98 patients with acute colonic diverticulitis found that uncomplicated diverticulitis was associated with younger age, better 2-year survival rates, and more conservative management. Recurrence rates were almost similar between uncomplicated and complicated diverticulitis (23% vs. 25%) and typically occurred within 12 months of the initial attack. Surgical intervention was necessary for patients with perforations, while conservative management was used for other cases. Complications included abscesses in 44% of cases and perforations in 38% of cases. Conclusion: This study found that acute diverticulitis has a low recurrence rate and a limited propensity for progression into complications. It is recommended that elective surgery is used as a preventive measure against recurrences and associated complications. These findings have implications for clinical practice.
... This recommendation is shared by the ACP, the American Gastroenterological Association, and the ASCRS in patients with suspected diverticulitis when there is diagnostic uncertainty. 1,3,4 The differential diagnosis for lower abdominal pain is wide, particularly in females. CT is highly sensitive and specifi c for diverticulitis and can simultaneously rule out other underlying causes of abdominal pain. ...
... Distinguishing between these diseases and a normal appendix is also sometimes difficult for a physician (e.g., an internal medicine specialist or a surgeon). Although clinical presentations of the two diseases are similar, the treatments differ between surgical and medical treatments [4,[6][7][8], with acute appendicitis requiring surgery and acute diverticulitis requiring medical treatment in uncomplicated cases [9,10]. Thus, correct classification of each condition in patients with acute abdominal pain is crucial for rapid and accurate decision-making regarding appropriate treatment [8]. ...
This study aimed to develop a convolutional neural network (CNN) using the EfficientNet algorithm for the automated classification of acute appendicitis, acute diverticulitis, and normal appendix and to evaluate its diagnostic performance. We retrospectively enrolled 715 patients who underwent contrast-enhanced abdominopelvic computed tomography (CT). Of these, 246 patients had acute appendicitis, 254 had acute diverticulitis, and 215 had normal appendix. Training, validation, and test data were obtained from 4,078 CT images (1,959 acute appendicitis, 823 acute diverticulitis, and 1,296 normal appendix cases) using both single and serial (RGB [red, green, blue]) image methods. We augmented the training dataset to avoid training disturbances caused by unbalanced CT datasets. For classification of the normal appendix, the RGB serial image method showed a slightly higher sensitivity (89.66 vs. 87.89%; p = 0.244), accuracy (93.62% vs. 92.35%), and specificity (95.47% vs. 94.43%) than did the single image method. For the classification of acute diverticulitis, the RGB serial image method also yielded a slightly higher sensitivity (83.35 vs. 80.44%; p = 0.019), accuracy (93.48% vs. 92.15%), and specificity (96.04% vs. 95.12%) than the single image method. Moreover, the mean areas under the receiver operating characteristic curve (AUCs) were significantly higher for acute appendicitis (0.951 vs. 0.937; p < 0.0001), acute diverticulitis (0.972 vs. 0.963; p = 0.0025), and normal appendix (0.979 vs. 0.972; p = 0.0101) with the RGB serial image method than those obtained by the single method for each condition. Thus, acute appendicitis, acute diverticulitis, and normal appendix could be accurately distinguished on CT images by our model, particularly when using the RGB serial image method.
... Outpatient treatment is required for patients who have simple non-septic diverticulitis, are immunocompetent, and can tolerate oral intake. However, approximately 15% of diverticulitis cases have been reported to be complicated forms and were manifested with abscess, stricture, obstruction, fistulae to adjacent organs, or perforation [8][9][10]. As a consequence of bacterial translocation, fecal contamination, or phlegmon development, complicated diverticulitis may present with severe abdominal pain, bloating, dehydration, and signs of sepsis [11]. ...
Background:
Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis.
Methods:
This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher's exact test. The Mann-Whitney U test was used for continuous variables. Multivariable regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases.
Results:
Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that the left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784-0.956); CRP, 0.800 (95% CI, 0.707-0.892); NLR, 0.724 (95% CI, 0.616-0.832); PLR, 0.662 (95% CI, 0.525-0.798); and WBC, 0.679 (95% CI, 0.563-0.795). When the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively.
Conclusions:
A large MDW was a significant and independent predictor of complicated diverticulitis. The optimal cutoff value for MDW is 20.38 as it exhibits maximum sensitivity and specificity for distinguishing between simple and complicated diverticulitis The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.
... However, the open-label design of these studies, as well as the small number of patients and heterogeneity of the therapeutic regimens used, limit the ability to draw conclusions about the effectiveness of rifaximin for the secondary prevention of acute diverticulitis. American guidelines do not consider sufficient evidence to recommend the use of Rifaximin in secondary prevention [123]. The same conclusion was seen in more recent Italian guidelines [106]. ...
There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.
... Colonic diverticulitis is usually diagnosed in the ED through computed tomography (CT), which can also distinguish simple (uncomplicated) from complicated diverticulitis. Approximately 15% of diverticulitis cases have been reported to be complicated with abscess, stricture, obstruction, or perforation [4,5]. The current therapeutic options for diverticulitis vary with disease severity, which can be determined on the basis of clinical, radiological, and laboratory ndings. ...
Background
Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis.
Methods
This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher’s exact test. The Mann–Whitney U test was used for continuous variables. Multivariate regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases.
Results
Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that the left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784–0.956); CRP, 0.800 (95% CI, 0.707–0.892); NLR, 0.724 (95% CI, 0.616–0.832); PLR, 0.662 (95% CI, 0.525–0.798); and WBC, 0.679 (95% CI, 0.563–0.795). The MDW had the largest AUC for diagnosing complicated diverticulitis; when the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively.
Conclusions
Patients with complicated diverticulitis were significantly older and predominantly had left-sided colonic diverticulitis. A large MDW was a significant and independent predictor of complicated diverticulitis. The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.
... La DCD es más común que la DCI en las poblaciones asiáticas, a diferencia de las occidentales. (9,10) En la DCD, los pacientes tienden a ser más jóvenes y la inflamación tiende a ser menos extensa (principalmente limitada a un solo divertículo). (3,9,11) Si bien la DCI debe diferenciarse clínicamente del cáncer de colon; la DCD es el diagnóstico alternativo más frecuente en pacientes con sospecha clínica de apendicitis aguda, (12) por lo que puede diagnosticarse erróneamente. ...
La enfermedad diverticular del colon es frecuente en personas de la tercera edad, sobre todo en mayores de 70 años, con una incidencia mayor al 63%. Se diagnostica frecuentemente en pacientes que acuden a la emergencia con síntomas abdominales agudos. La presentación clínica de la diverticulitis aguda varía desde dolor abdominal leve hasta peritonitis con sepsis. La diverticulitis del colon derecho (DCD), es una entidad infrecuente en los países occidentales y frecuente en países asiáticos, constituyendo entre 1% y 3.6% de todas las enfermedades diverticulares colónicas; presenta etiopatogenia y síntomas complejos aún no comprendidos completamente. Se distingue clínicamente de la diverticulitis del colon izquierdo (DCI) y suele acompañarse de dolor en el cuadrante inferior derecho o en la fosa ilíaca con vómitos, náuseas, fiebre y anorexia; lo que constituye una presentación similar a la apendicitis aguda, por lo que es común un diagnóstico clínico erróneo. El diagnóstico clínico de la DCD puede ser un desafío y las imágenes se han convertido en una herramienta esencial para ayudar en el diagnóstico, evaluar la gravedad de la enfermedad y contribuir en la planificación del tratamiento. El diagnóstico presuntivo a menudo se puede realizar basándose únicamente en las características clínicas; sin embargo, las imágenes son necesarias en presentaciones desde las más leves a las más graves con la finalidad de descartar complicaciones como abscesos y perforaciones. Es por ello que la tomografía espiral multicorte (TEM) se constituye en el procedimiento de imagen de elección para el diagnóstico de diverticulitis.
... Americana de Gastroenterólogos que recomienda que los antibióticos no sean empleados de forma rutinaria en esta complicación, apoyada por varios estudios. (29,30,31,32) Un estudio alemán aleatorizado compara el tratamiento antibiótico frente a observación del paciente demostró que en estadio de Hinchey 1a confirmado por TAC esta última conducta no prolonga la recuperación en estos pacientes y puede ser considerada adecuada. (28) (33) publicó un metaanálisis de la evidencia existente hasta ese entonces sobre la eficacia del tratamiento sin antibióticos de la DA y su tasa de complicaciones y recurrencias frente al tratamiento médico habitual. ...
Introducción:
La diverticulitis aguda es la complicación más frecuente de la enfermedad diverticular del colon y causa de ingresos hospitalarios. Su tratamiento ha sido evaluado en los últimos años y muestra una tendencia a limitar el tratamiento quirúrgico y potenciar el de tipo conservador.
Objetivo:
Realizar una revisión sobre la aplicabilidad, la seguridad y la eficacia del tratamiento ambulatorio de la diverticulitis aguda no complicada en pacientes seleccionados.
Métodos:
Se realizó una revisión bibliográfica en fuentes de información disponibles en las bases de datos SciELO, Medline (Pubmed), así como Google académico, donde se escogieron un total de 36 referencias.
Desarrollo:
Históricamente los pacientes diagnosticados de diverticulitis aguda han sido internados en centros hospitalarios para estudio y tratamiento dietético, antibiótico y analgésico. En los últimos años ha crecido la tendencia en el mundo a tratar estos pacientes de forma ambulatoria una vez comprobado que no se encuentra complicada, lo que ha demostrado con nivel de evidencia, que estos logran presentar una evolución favorable sin necesidad de ingreso, con menos gastos para el sistema de salud.
Conclusiones:
El tratamiento ambulatorio de la diverticulitis aguda no complicada no solo es eficaz y seguro, sino también aplicable en la mayoría de los pacientes, siempre que toleren la ingesta oral y dispongan de un entorno familiar adecuado.
... Las indicaciones de tratamiento médico, resección quirúrgica y posterior colonoscopía han variado. La Sociedad Americana de Gastroenterología en su guía del año 2015 recomienda la indicación selectiva del uso de antibióticos, colonoscopia y resección quirúrgica (Stollman et al., 2015). La Sociedad Americana de Cirujanos de Colon y Recto, en su guía publicada el año 2020 plantea recomendaciones más específicas en cuanto a la indicación de colonoscopía y resección quirúrgica (Hall et al., 2020). ...
La prevalencia de enfermedad diverticular en Chile se estima en 28% y cada vez es más frecuente su presentación como diverticulitis complicada. Durante los últimos años ha surgido evidencia que ha hecho replantear el manejo de la diverticulitis aguda. Históricamente los antibióticos han sido pilar fundamental del tratamiento de la diverticulitis aguda, sin embargo, evidencia reciente muestra que pacientes con un episodio de diverticulitis aguda no complicada pueden ser tratados sin ellos. Con respecto al manejo quirúrgico, la cirugía de emergencia está indicada en peritonitis difusa, absceso no puncionable asociado a sepsis y fracaso de tratamiento; tanto la cirugía de Hartmann como resección y anastomosis primaria son opciones válidas según el escenario. La cirugía electiva debe indicarse caso a caso y se debe optar por abordaje laparoscópico dentro de lo posible. Al enfrentarse a pacientes inmunosuprimidos se debe ser más agresivo en el manejo. La indicación de colonoscopía posterior a un episodio de diverticulitis aguda se reserva para pacientes en los que se haya presentado como un episodio de diverticulitis complicada, en aquellos que corresponda realizar tamizaje para cáncer colorrectal y en los que presenten síntomas o signos sugerentes de neoplasia colorrectal.
... Colonic diverticulitis is usually diagnosed in the ED through computed tomography (CT), which can also distinguish simple (uncomplicated) from complicated diverticulitis. Approximately 15% of diverticulitis cases have been reported to be complicated with abscess, stricture, obstruction, or perforation [4,5]. The current therapeutic options for diverticulitis vary with disease severity, which can be determined on the basis of clinical, radiological, and laboratory ndings. ...
Background
Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis.
Methods
This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher’s exact test. The Mann–Whitney U test was used for continuous variables. Multivariate regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases.
Results
Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784–0.956); CRP, 0.800 (95% CI, 0.707–0.892); NLR, 0.724 (95% CI, 0.616–0.832); PLR, 0.662 (95% CI, 0.525–0.798); and WBC, 0.679 (95% CI, 0.563–0.795). The MDW had the largest AUC for diagnosing complicated diverticulitis; when the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively.
Conclusions
Patients with complicated diverticulitis were significantly older and predominantly had left-sided colonic diverticulitis. A large MDW was a significant and independent predictor of complicated diverticulitis. The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.
... The American Gastroenterological Association recommends all patients with an episode of complicated diverticulitis (and those after a first episode of acute uncomplicated diverticulitis) to undergo colonoscopy 6-8 weeks after the resolution of symptoms. 11 This recommendation is also supported by guidelines from the American Society of Colon and Rectal Surgeons. 12 These guidelines exist primarily to exclude colorectal cancer. ...
Colorectal cancer may masquerade as acute diverticulitis. Our case is a 71-year-old man who presented to the emergency department with abdominal pain and was diagnosed with acute diverticulitis. He was ultimately found to have metastatic hepatocellular carcinoma to the colon without any evidence of diverticular disease on colonoscopy. Although the most common malignancy to masquerade as diverticulitis is colorectal cancer, metastatic deposits should also be considered, especially in patients with a history of extracolonic malignancy.
... [2] The majority of guidelines recommend routine colonoscopy after an episode of acute diverticulitis, due to the historical detection inaccuracy of an underlying colorectal cancer (CRC) by ultrasound and classical barium enema. [3][4][5] With the rise of CT-based diagnostics and its increased accuracy, there has been a paradigm shift in the last decade. ...
Purpose
Diverticular disease is common in the western world. Due to the risk of undetected underlying colorectal cancer, most guidelines recommend a follow-up colonoscopy after an episode of diverticulitis. With the increased accuracy of computer tomography scans, there is an increased challenge to these guidelines in cases of uncomplicated diverticulitis. The aim of this study was to investigate the compliance to the recommended follow-up colonoscopies and to report the incidence of detection of advanced neoplasms.
Methods
In this single-center retrospective cohort study, all patients > 18 years that were admitted to the Hospital Center Biel with an episode of acute uncomplicated diverticulitis between 01.01.2013 and 31.12.2017 were identified. The incidence of advanced neoplasia was calculated by analyzing the follow-up colonoscopies performed and reviewing the histological findings.
Results
257 Patients with uncomplicated diverticulitis were included in this study. The mean age of the patients was 63 (range 22–96) years, and 54.5% were female. In 197 (77%) patients we recommended a follow-up colonoscopy. However, only 144 (73%) of these patients underwent the procedure. In the histological analysis, 2 (1.2%) carcinomas, one high-grade adenoma (0.6%) and 20 low-grade adenomas (12%) were detected.
Conclusion
The compliance to the recommendation of follow-up colonoscopies after uncomplicated diverticulitis is poor and has to be improved. A follow-up colonoscopy has its justification because of relevant findings in almost 14% of patients, more so in patients above screening age with 20% pathological findings, including 2 (5%) carcinomas.
... Finally, Lau et al. [37] found that the ORs for colonic malignancy in patients with complicated diverticulitis were 6.7 (95% CI: 2.4-18.7) in patients with abscesses, 4 (95% CI: 1.1-14.9) in patients with local perforation, and 18 (95% CI: 5.1-63.7) in patients with concomitant fistula when compared with uncomplicated diverticulitis. Considering these epidemiological data, two recent meta-analyses assessed the role of routine colonoscopy following an episode of AD [38,39]: both found that colonoscopy had a strong indication following a bout of complicated diverticulitis or in patients in whom a high-quality examination of the colon has not been recently performed [40]. ...
Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize “when” to safely perform a colonoscopy in the different DD settings and “why”.
... Acute diverticulitis is a common surgical problem managed in inpatient and outpatient settings. Current guidelines suggest that patients with an index episode of acute diverticulitis, and no recent colonoscopy, should be followed up with a colonoscopy in 6-8 weeks to exclude colorectal cancer (CRC) [4][5][6]. ...
Background
To investigate the value of routine colonoscopy, post-computed tomography (CT) confirmed diverticulitis. The current practice is to scope patients 6–8 weeks post an episode of acute diverticulitis. We hypothesise that this practice has a relatively low value.
Methods
A retrospective cohort study was conducted on adult patients presenting acute diverticulitis n = 1680 (uncomplicated = 1005, complicated = 675) between January 2017 and July 2019 at three tertiary hospitals in Perth. The National Bowel Cancer Screening Program (NBCSP) positive cases were the reference group (n = 1800). Data were analysed using SPSS v.27.
Results
One thousand two hundred seventy-two patients had a subsequent colonoscopy during the follow-up period, of which 24% (n = 306) were uncomplicated diverticulitis, 34% (n = 432) complicated diverticulitis, and 42% (n = 534) as the reference cohort. Patient demographics were similar between centres and subgroups. Incidence of primary colorectal cancer (CRC) was n = 3 (1.0%), n = 9 (2.1%), and n = 10 (1.9%) for uncomplicated diverticulitis, complicated diverticulitis, and NBCSP, respectively (p = 0.50). Subgroup analysis by age revealed a statistically significant higher rate of negative colonoscopy in uncomplicated diverticulitis patients aged over 50.
Conclusion
Routine colonoscopy for patients with uncomplicated diverticulitis is not a cost-effective strategy for colorectal cancer screening patients over 50 years. These patients should participate in the NBCSP with biennial FOBT instead. We suggest continuing routine endoscopic evaluation for patients with uncomplicated diverticulitis under 50 years and all patients admitted with complicated diverticulitis.
Importance
Care of patients with diverticulitis is undergoing a paradigm shift. This narrative review summarizes the current evidence for left-sided uncomplicated and complicated diverticulitis. The latest pathophysiology, advances in diagnosis, and prevention strategies are also reviewed.
Observations
Treatment is moving to the outpatient setting, physicians are forgoing antibiotics for uncomplicated disease, and the decision for elective surgery for diverticulitis has become preference sensitive. Furthermore, the most current data guiding surgical management of diverticulitis include the adoption of new minimally invasive and robot-assisted techniques.
Conclusions and Relevance
This review provides an updated summary of the best practices in the management of diverticulitis to guide colorectal and general surgeons in their treatment of patients with this common disease.
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML were reviewed and categorized into three groups: Access, Watch and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance, and the implications for their appropriate use. The 2023 AWaRe classification provides empiric guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes.
This article describes the development of AWaRe focussing on the clinical evidence base that guided the selection of Access, Watch or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimising the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update of national prescribing guidelines and surveillance of antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries to expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
Background
Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients.
Methods
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs).
Results
5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: −.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002).
Conclusion
There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.
Acute diverticulitis represents a common colorectal emergency seen in the Western world. Over time, management of this condition has evolved. This review aims to highlight recent evidence and update current recommendations. Notable evidence has emerged in certain aspects of diverticulitis. This includes disease pathogenesis, as emerging data suggest a potentially greater role for the microbiome and genetic predisposition than previously thought. Acute management has also seen major shifts, where traditional antibiotic treatment may no longer be necessary for acute uncomplicated diverticulitis. Following successful medical management of acute diverticulitis, indications for elective sigmoidectomy have decreased. The benefit of emergency surgery remains for peritonitis, sepsis, obstruction, and acute diverticulitis in certain immunocompromised patients. Routine colonoscopy, once recommended after all acute diverticulitis episodes, has been shown to be beneficial for cancer exclusion in a distinct patient population. Despite advances in research, certain entities remain poorly understood, such as smoldering diverticulitis and symptomatic uncomplicated diverticular disease. As research in the field expands, paradigm shifts will shape our understanding of diverticulitis, influencing how clinicians approach management and educate patients.
Introducción. Para el diagnóstico de la diverticulitis aguda no complicada (DANC) es necesario una prueba de imagen. Tradicionalmente la tomografía axial computarizada (TAC) ha sido la prueba gold standard, pero cada vez hay más evidencia de que la ecografía abdominal (ECO) podría ser también tan eficaz como la TAC. Material y métodos. Se realizó un estudio observacional de cohortes retrospectivo en un hospital terciario que incluyó a todos los pacientes con diagnóstico de DANC confirmada por imagen (ya sea TAC o ECO) desde el servicio de Urgencias durante un periodo de 2 años. Los pacientes fueron designados como DANC en base a una clasificación de Hinchey modificada por nuestro centro, considerando enfermedad complicada la evidencia de absceso pericólico o intraabdominal, neumoperitoneo o peritonitis difusa. Resultados. Un total de 104 pacientes con diagnóstico de DANC se incluyeron en el estudio. El manejo ambulatorio fue exitoso en el 94,2% de los pacientes (n=97), con sólo 6 reingresos (5,8%), sin diferencias entre el grupo de TC o de ECO (p=0,09). Hubo 6 reingresos, 5 habían sido diagnosticados por TAC, y 1 por ECO. No se encontraron diferencias estadísticamente significativas en la tasa de fracaso del tratamiento ambulatorio entre los grupos (p>0,05). Conclusión. La ecografía abdominal es una técnica segura y factible que podría utilizarse como técnica de imagen de primera línea para el diagnóstico de la DANC. Además, en los casos aptos para el manejo ambulatorio, presentó un éxito de tratamiento similar y sin más reingresos que los diagnosticados por TAC
b>
Introduction: The treatment of diverticulosis symptoms in patients with a history of diverticulitis is a challenge in everyday clinical practice.
Aim: Efficacy assessment of a cyclic, year-long treatment with rifaximin-α in patients with symptomatic uncomplicated diverticular disease (SUDD) and a history of past diverticulitis.
Material and methods: This study is a multicenter, retrospective, observational study involving 48 centers. The study group included patients who reported to the outpatient clinic within a month with SUDD symptoms, who had a history of diverticulitis, and who were given a cyclic rifaximin-α treatment of 2 x 400 mg/day for 7 days and then once a month for 12 months. Epidemiological and demographic data, the course of diverticulosis, the number of inflammation episodes and their diagnoses, complications, symptoms of SUDD, and its treatment were evaluated. The efficacy of rifaximin-α therapy was assessed on a 4-point scale (0 – no symptoms, 3 – severe symptoms) every 3 months, and analyzed: pain, tenderness, bloating, bowel movements, and recurrence of inflammation during the 12-month treatment.
Results: 178 patients (67% women, median age 65 years [34–92]) were included in the study. The average duration of diverticulosis was 6.4 years (3–20), and 59% of patients had more than one episode of diverticulitis during this period. In total, 87% of patients had symptoms of SUDD after or between episodes of diverticulitis. Abdominal pain was the most common symptom (92%). An inflammation episode was diagnosed using imaging in 50.5% of cases, and the rest – based on typical clinical symptoms. As many as 46.2% of patients required hospitalization, and complications were diagnosed in 44% of cases. One hundred and seventy (95%) patients completed the 12-month rifaximin-α therapy. Changes in the severity of pain, abdominal tenderness, diarrhea, constipation, and bloating were assessed every 3 months. After 12 months of treatment with rifaximin-α, there was a statistically significant reduction in the severity of symptoms overall (median from 1.5 [0–3 points] to 0.2; P<0.001) and each symptom evaluated individually. Regardless of the previous diagnostic method of diverticulitis (imaging or typical clinical presentation) or its complications (e.g. perforation, abscess), treatment with rifaximin-α was equally effective.
Conclusions: Cyclic therapy with rifaximin-α is effective in treating SUDD symptoms and in preventing the recurrence of symptoms, also in patients with a history of diverticulitis – regardless of how the diagnosis was made and disease complications. The extended treatment regimen leads to a gradual resolution of symptoms during 12 months of observation. Cyclic use of rifaximin-α is necessary to maintain symptom remission.</br
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.
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 feasibility of a trial and facilitate an informed approach to recruitment and consent.
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.
Background and objective:
Colorectal cancer (CRC) can mimic acute diverticulitis and can thus be misdiagnosed. Therefore, colonic evaluation is recommended after an episode of acute diverticulitis. The aim of this study was to analyze the risk of CRC after computed tomography (CT) verified uncomplicated and complicated acute diverticulitis in short-term and, particularly, long-term follow-up to ensure the feasibility of the primary CT imaging in separating patients with uncomplicated and complicated acute diverticulitis.
Methods:
A retrospective cohort study was conducted in patients with CT-verified acute diverticulitis in 2003-2012. Data on CT findings and colonic evaluations were analyzed. The patients were divided into those with uncomplicated and complicated acute diverticulitis. Patient charts were reviewed 9-18 years after the initial acute diverticulitis episode.
Results:
The study population consisted of 270 patients. According to CT scans, 170 (63%) patients had uncomplicated acute diverticulitis and 100 (37%) had complicated acute diverticulitis. Further colonic evaluation was made in 146 (54%) patients. In the whole study population, CRC was found in 7 (2.6%) patients, but CRC was associated with acute diverticulitis in only 4 (1.5%) patients. The short-term risk for CRC was 0.6% (1/170) in uncomplicated acute diverticulitis and 3.0% (3/100) in complicated acute diverticulitis. No additional CRC was found in patients with complicated acute diverticulitis during the long-term follow-up and three cases of CRC found after uncomplicated acute diverticulitis had no observable association with previous diverticulitis.
Conclusions:
In short-term follow-up, the risk of underlying CRC is very low in CT-verified uncomplicated acute diverticulitis but increased in complicated acute diverticulitis. Long-term follow-up revealed no additional CRCs associated with previous acute diverticulitis, indicating that the short-term results remain consistent also in the long run. These long-term results confirm that colonoscopy should be reserved for patients with complicated acute diverticulitis or with persisting or alarming symptoms.
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.
Background
Diverticulitis of the colon is widespread in the industrialized world so that there are many national and international guidelines on the treatment of the disease. In the past, inconsistent recommendations have repeatedly been reported in the respective guidelines. The aim of this study is an up to date systematic comparison of the current guidelines on the diagnostics and treatment of diverticulitis regarding their content.Methods
Since 2015 a total of 11 guidelines were identified via a systematic literature review, of which 10 could be included in the comparison. Overall, 37 central statements regarding 5 topics were collected and compared.ResultsThere was concordance concerning the treatment of uncomplicated diverticulitis, which does not necessarily need to include antibiotics (9/10) or does not principally need to be treated in hospital (7/7). The diagnostics should include computed tomography (CT, 8/8) and possibly colonoscopy at intervals (6/7). For perforated diverticulitis with peritonitis surgical treatment is recommended (7/7). Discordance is reported for the surgical strategy as only some guidelines recommend a primary anastomosis (4/7) and a minimally invasive approach (4/7). Further discordance can be seen in the indications for elective surgery.Conclusion
There are still inconsistent recommendations regarding central aspects in the treatment of diverticulitis. Discordance can especially be seen if new evidence disproves common practice or recommendations are based on low-quality evidence. Over time, however, high-quality evidence is also increasingly being implemented in the guidelines.
Background:
'Choosing Wisely' is an international campaign against inappropriateness in medical practices that aims to promote a rational and evidence-based use of resources. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) joined the Campaign in 2017 releasing five recommendations.
Aims:
To identify five new recommendations for a correct, evidence-based approach to the management of gastrointestinal diseases.
Methods:
All AIGO members were asked to identify practices or interventions that, even though diffuse in clinical practice, do not provide benefit for patients. The proposed items were then revised, divided by topic and ranked. After a systematic review of the literature for each item, five new recommendations were identified.
Results:
The five recommendations are: do not request surveillance investigations for patients with pancreatic cysts who are poor surgical candidates, irrespective of cysts nature and characteristics; do not request esophagogastroduodenoscopy in patients with recent onset of upper gastrointestinal symptoms younger than 50 years, without alarm features; do not request surveillance colonoscopy for asymptomatic colonic diverticular disease without changes in symptoms; do not perform food intolerance tests except for those scientifically validated; do not prescribe proton pump inhibitors to patients with liver cirrhosis, outside of established indications.
Conclusion:
The Choosing Wisely recommendations will reduce unnecessary testing and treatments, increasing patient safety and overall healthcare quality.
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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.
Background
Hospital admissions for diverticulitis, a complication of diverticular disease, are very much on the increase. Prevention of diverticulitis could cut costs and save lives.
Aims
To identify whether the risk of the first episode of diverticulitis (primary prevention) or recurrence of diverticulitis (secondary prevention) can be reduced in patients with diverticular disease using non-absorbable antibiotics (mainly rifaximin).
Methods
The studies were identified by searching PubMed and CENTRAL from 1990 to May 2022. The methodological quality of each study was also evaluated. The outcome of the meta-analysis was the occurrence of a first or subsequent episode of diverticulitis. In addition, a trial sequential analysis was performed to evaluate whether the results would be subject to type I or type II errors.
Results
Primary prevention: the risk difference was statistically significant in favor of rifaximin (-0,019, or -1.9%, CI -0,6 to -3,3%). There was no evidence of heterogeneity (I ² 0%). At one year, two years, and eight years of age, the NNT was 62, 52, and 42, respectively. The level of evidence had a moderate degree of certainty. Secondary prevention: the risk difference was statistically significant in favor of rifaximin (- 0,24, or -24%, CI -47 to -2%). There was evidence of heterogeneity ( I ² 92%); NNT resulted in 5. The grade level was low.
Conclusions
Rifaximin can lower the risk of a first episode of diverticulitis. However, the cost-benefit ratio currently appears too high. Rifaximin could also reduce the risk of a second episode, but the quality of the evidence is low.
Systematic review registration
https://www.crd.york.ac.uk/prospero/ , identifier CRD42022379258.
Diverticulitis is a common disease. Recent changes in understanding its natural history have substantially modified treatment paradigms.
To review the etiology and natural history of diverticulitis and recent changes in treatment guidelines.
We searched the MEDLINE and Cochrane databases for English-language articles pertaining to diagnosis and management of diverticulitis published between January 1, 2000, and March 31, 2013. Search terms applied to 4 thematic topics: pathophysiology, natural history, medical management, and indications for surgery. We excluded small case series and articles based on data accrued prior to 2000. We hand searched the bibliographies of included studies, yielding a total of 186 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines.
Eighty articles met criteria for analysis. The pathophysiology of diverticulitis is associated with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment. Several studies examined histologic commonalities with inflammatory bowel disease and irritable bowel syndrome but were focused on associative rather than causal pathways. The natural history of uncomplicated diverticulitis is often benign. For example, in a cohort study of 2366 of 3165 patients hospitalized for acute diverticulitis and followed up for 8.9 years, only 13.3% of patients had a recurrence and 3.9%, a second recurrence. In contrast to what was previously thought, the risk of septic peritonitis is reduced and not increased with each recurrence. Patient-reported outcomes studies show 20% to 35% of patients managed nonoperatively progress to chronic abdominal pain compared with 5% to 25% of patients treated operatively. Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought and that mesalamine might be useful. Surgical therapy for chronic disease is not always warranted.
Recent studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.
This article, by Dr John Inadomi and colleagues, is the first of a 2-part series (the second part to be published later this year) on the AGA's process for developing guidelines. The importance of guidelines has increased considerably over the last 25 years. In the first wave of managed care, we were practicing with few if any clinical guidelines. Now, as we move forward toward a value-based reimbursement system, the need for evidence-based practice is paramount. Dr Inadomi and the AGA Clinical Practice and Quality Management Committee have fine-tuned this process over the last 3 years and now describe their results. While many guidelines are labeled as "GRADE," some are simply opinion documents designed with GRADE wording. A fully implemented GRADE process involves rigorous analysis of published data, input from trained GRADE methodologists, and opportunities for both public and expert comment from all involved stakeholders. John I. Allen, MD, MBA, AGAF Special Section Editor
The American Journal of Gastroenterology is published by Nature Publishing Group (NPG) on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, the journal aims to be easily accessible, organizing its content by topic, both online and in print. www.amjgastro.com, *2007 Journal Citation Report (Thomson Reuters, 2008)