Acute Colonic Diverticulitis Research Articles

Left-Sided Appendicitis

2 38-year-old man presented with a 24-hour history of left arailiac pain. Physical examination revealed left parailiac enderness with localized rebound. His white cell blood ount was 14,200/cumm. The clinical diagnosis was acute eft colonic diverticulitis, but a CT scan showed a “mobile” ecum adjacent to the descending colon. An inflamed, tuular, nonopacified structure projected leftward from the ecum, suggesting acute appendicitis (A). The descending nd sigmoid colon appeared normal. Laparoscopy conirmed the diagnosis of acute left-sided appendicitis, and a aparoscopic appendectomy was performed. The postopertive course was uneventful. A left-sided appendix occurs with an estimated freuency of 0.2% in the adult population. This anatomic ondition results from the failure of the embryonic midgut o rotate around an axis formed by the superior mesenteric rtery. Consequently, the small intestine lies on the right side f the peritoneal cavity, while the colon (including right colon nd appendix) lies on the left side (B). The descending colon

Cetuximab (C-mab) and chemo-radiation (CT-RT) for loco-regional advanced squamous cell carcinoma of the head and neck (HNC): A phase II study

6043 Background: C-mab is a monoclonal antibody targeting EGFR. C-mab combined with radiotherapy (RT) improved loco- regional control and overall survival over RT alone in HNC pts (Bonner 2006). Prior data of C-mab and CT-RT (Pfister 2006) were encouraging but the trial was stopped due to an excess of severe toxicities, suggesting the need for a less toxic scheduling. For these reasons we evaluate the safety and activity of C-mab combined with alternating CT-RT in HNC pts. Methods: The primary end-point is C.R. rate. The optimal two stage design was used: the calculated sample size is 45 pts. Eligible pts have locally advanced, measurable, untreated, stage III/IV HNC (excluding nasopharynx). Chemotherapy (CT) consists of Cis-PT 20 mg/m2/day and bolus 5Fu 200 mg/m2/day from day 1 to 5, repeated on days 22 and 43. RT, 2 Gy/day, 5 days a week, is given in the pauses between the chemotherapy courses and after the last CT week, up to a total dose of 70 Gy. Results: From 10/2005 to 12/2006 24 pts were enrolled: median age 59 (49–75); median ECOG P.S. 0 (0–1); Stage IV 73%; N1–3 86%; EGFR >80% cells: 55%; EGFR 3+: 91%; most pts had hypopharynx cancer, only 1 had oral cavity tumor. Toxicity is evaluable on 20 pts (4 ongoing). Grade 3–4 toxicities included febrile neutropenia (20%), diarrhea (20%), hypomagnesaemia (10%), mucositis (60%). Unexpected skin toxicity, starting as desquamating moist dermatitis and confined at the irradiated field, occurred in 18/20 pts, usually during the second part of the treatment. Acute colon diverticulitis with perforation (1 pt), gastric perforation (1 pt), fatal myocardial infarction (1 pt) and arterial thrombosis (1 pt) also occurred. Responses, evaluated 3 months after the treatment, are available for the first 16 pts. Objective responses were observed in all them (11 CR + 5 PR). Two PRs were then rendered disease free with salvage surgery. At a maximum follow-up of 15 months, 16/20 pts are alive and 16/20 progression free. Conclusions: This trial showed a skin toxicity not previously reported in other experiences of C-mab combined with RT or CT-RT. Preliminary activity data seems to confirm the Pfister experience. No significant financial relationships to disclose.

Acute colonic diverticulitis: a systematic review of diagnostic accuracy

To appraise the literature on the diagnosis of acute colonic diverticulitis by ultrasound (US), computed tomography (CT), barium enema (BE) and magnetic resonance imaging (MRI). The databases of Pub Med, the Cochrane Library and EMBASE were searched for articles on the diagnosis of diverticulitis published up to November 2005. Studies where US, CT, BE, or MRI were compared with a reference standard on consecutive or randomly selected patients were included. Three examiners independently read the articles according to a prespecified protocol. In case of disagreement consensus was sought. The level of evidence of each article was classified according to the criteria of the Centre for Evidence-Based Medicine (CEBM), Oxford, UK. Forty-nine articles relevant to the subject were found and read in full. Twenty-nine of these were excluded. Among the remaining 20 articles, only one study, evaluating both US and CT reached level of evidence 1b according to the CEBM criteria. Two US studies and one MRI study reached level 2b. The remaining studies were level 4. The best evidence for diagnosis of diverticulitis in the literature is on US. Only one small study of good quality was found for CT and for MRI-colonoscopy.

El uso precoz de la tomografía computarizada en el manejo de la diverticulitis aguda

To assess the early use of CT for the diagnosis, staging, and management of acute diverticulitis. A prospective study of 102 patients with a clinical diagnosis of acute diverticulitis of the left colon. Acute diverticulitis was initially divided into 3 clinical stages. Patients were restaged according to CT findings into stages I, IIa, IIb, and III. Diagnosis was subsequently confirmed intraoperatively or by colonoscopy or barium studies. 102 patients (52 females and 50 males, mean age of 59.4 (SD + 14.96 years)) were included; 84 (82.35%) patients with a clinical diagnosis of acute diverticulitis were confirmed to suffer this disease for a diagnostic error of 17.65% (n=18). Acute diverticulitis was diagnosed by CT in 84.3% (n=86). CT had a sensitivity of 100% and a specificity of 88.9%. CT changed clinical stage for 38% of patients because of understaging in 13% and of overstaging in 25%. When stages II and III were analyzed separately, 60 and 50% were overstaged, respectively. The reclassification of patients according to CT results had a significant impact on treatment. Early clinical staging with CT avoids diagnostic clinical errors in 17.65% of patients. CT changes the initial clinical staging of acute episodes in 38% of cases, thus avoiding unnecessary delays in surgery for severe cases, and unnecessary surgeries for mild cases.

Comorbidity is a major determinant of severity in acute diverticulitis

Background Acute colonic diverticulitis may be simple or very complicated. Not much is understood about what factors determine severity. Answering this question may have therapeutic implications. Methods A retrospective review was performed consisting of teaching hospital admissions for simple or complicated acute diverticulitis. The intent was to identify characteristics of and differences between the 2 groups. The Charlson index was used to assess states of preexisting health (comorbidity). Results In multivariate analysis, the presence of a major degree of comorbidity (Charlson score 3 or greater) was strongly associated with complicated disease ( P = 0.02) as was the use of nonsteroidal anti-inflammatory drugs ( P = .01). Deaths were not seen below age 50, and high Charlson score also strongly predicted mortality ( P < .0001). Conclusions There are significant differences between patients presenting with simple and complicated diverticulitis, and the amount of associated comorbidity (as measured by Charlson score) appears to be a major one. Because of the high mortality seen in patients with Charlson scores 3 or greater and complicated diverticulitis, we believe that an early surgical approach should be considered for them, particularly if they are 50 or older.

Conservative treatment of acute colonic diverticulitis: Are antibiotics always mandatory?

Objective. Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD. Material and methods. A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months. Results. Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61–1.74). Conclusions. Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.

Acute colonic diverticulitis in a community-based hospital: CT evaluation in 138 patients

The purpose of this research is to retrospectively analyze computed tomography (CT) findings of patients with acute colonic diverticulitis presented to a community-based hospital. During a 1-year period from May 2004 to April 2005, CT scans of 138 patients [mean age 62.3 years (SD 14.9), range 30-100 years] with clinical diagnosis of diverticulitis were analyzed. Of the 138 patients, 136 CT scans were performed with oral and intravenous contrast administration except in two patients who received only oral contrast. Twenty-eight patients (28/138, 20.3%) had diverticulosis, 77 (77/138, 55.8%) had uncomplicated diverticulitis, and 33 (33/138, 23.9%) had complications. Left-sided diverticulitis predominated (137/138, 99.3%). Colonic diverticula were identified in almost every patient (136/138, 98.6%); the majority had moderate colonic wall thickening (82/110, 74.5%) and moderate pericolonic inflammation (65/110, 59.1%). Isolated extraluminal air bubbles (19/33, 57.6%) were the most commonly seen complication, followed by abscess (15/33, 45.5%). Bowel obstruction (2/33, 6.1%) and pylephlebitis (1/33, 3.0%) were less commonly seen but were observed as significant abnormalities. Complicated diverticulitis was less prevalent in this community hospital setting, in contrast with referral medical centers. Common CT findings of diverticulitis included presence of diverticula, moderate wall thickening, and pericolonic inflammation. Isolated air bubbles were the most commonly seen complication followed by abscess.

Acute diverticulitis after Duhamel–Martin procedure for total colonic Hirschsprung’s disease

A 28-year-old man with a history of total colonic Hirschsprung's disease treated with a Duhamel-Martin procedure in infancy, presented with signs and symptoms of acute colonic diverticulitis. Flexible sigmoidoscopy demonstrated a 20 cm jejunocolonic anastomosis, consistent with his previous operation in childhood, with a large diverticulum at the proximal end of the anastomosis containing fecal concretions. The patient returned one month later after a course of antibiotics for definitive resection of the diverticulum. Intra-operative colonoscopy localized three large diverticula and resection of the involved segment was performed. The case is presented as an adult complication of total colonic Hirschsprung's disease treated with childhood resection and reconstruction.

Primary Resection With Anastomosis vs . Hartmann's Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Ultrasound in the ED Diagnosis of Left Acute Colonic Diverticulitis

Ultrasound in the ED Diagnosis of Left Acute Colonic Diverticulitis

Prognostic factors from computed tomography in acute left colonic diverticulitis.

This prospective study examined factors which may predict a poor outcome (complications and recurrence) after a first attack of diverticulitis which has been successfully managed conservatively. Twenty-four of 107 patients who entered the study had a poor outcome: persistent diverticulitis (nine cases), recurrence (seven cases), colonic stenosis (six cases), residual parasigmoid abscess (one case) and colovesical fistula (one case). Eight of the 18 men aged 50 years or less had a poor outcome compared with 16 of the remaining 89 patients (P = 0.032). Twelve of 76 patients (16 per cent) with mild findings on computed tomography (CT) (localized thickening of colonic wall and inflammation of pericolic fat) had a poor outcome compared with 11 of 23 patients (48 per cent) whose CT was estimated as severe (abscess and/or extraluminal air and/or extraluminal Gastrografin) (P = 0.004). These results suggest that elective colectomy can be proposed after a first attack of acute left diverticulitis in men up to 50 years of age and/or in patients whose initial CT reveals findings of severe diverticulitis.

Suspected Acute Colon Diverticulitis: Imaging with Low-Dose Unenhanced Multi–Detector Row CT

To prospectively compare the sensitivity and specificity of unenhanced low-dose multi-detector row computed tomography (CT) with those of contrast material-enhanced standard-dose multi-detector row CT in patients suspected of having acute diverticulitis. Institutional review board approval and informed consent were obtained. One hundred ten consecutive patients (40 men, 70 women; age range, 30-82 years; mean, 57 years) suspected of having acute diverticulitis underwent unenhanced multi-detector row CT with 4 x 2.5-mm collimation, 120 kVp, and 30 effective mAs, as well as contrast-enhanced standard-dose multi-detector row CT with the same parameters but with 120 mAs. All scans were independently read by four readers. Intra- and interobserver agreements were calculated with the kappa statistic. Contrast-enhanced standard-dose scans read by three other experts and considered together with results from colonoscopy, surgery, and pathologic evaluation were used as reference. Differences in sensitivity and specificity between readers, radiation doses, and reading sessions were investigated. Pearson exact test and logistic regression models were used. Colon diverticulitis was present in 39 patients (34%) and was graded as mild in 22 patients (56%) and severe in 17 (44%). Agreement within and between readers was good to excellent. No significant difference was observed in sensitivity (P ranging from .081 to >.99) or in specificity (P ranging from .326 to >.99) for any sign or overall diagnosis between radiation doses by all readers, except wall thickening, which for one reader had a higher specificity at low dose than at standard dose (P = .025). No significant difference in misclassification was detected between doses, regardless of the reader (P ranging from .481 to >.99). At both doses, the most predictive sign for acute diverticulitis was retroperitoneal fat stranding (P < .001). Low-dose unenhanced multi-detector row CT has a diagnostic performance similar to that of contrast-enhanced standard-dose multi-detector row CT in patients suspected of having acute diverticulitis.

Computertomographische Diagnostik der akuten linksseitigen Kolondivertikulitis und ihre Differenzialdiagnostik

This review shows the diagnostic potential of computed tomography (CT) in the diagnosis and differential diagnosis of acute left-sided colonic diverticulitis. Using a single detector spiral CT, standard examination of the entire abdomen is performed after oral and rectal administration of diluted iodinated contrast medium with collimation of 8 mm, pitch of 1.5, and reconstruction increment of 8 mm before and after intravenous contrast injection. Intravenous administration of spasmolytic agents, various patient positions, and the thin-section technique with 3-5 mm slices are beneficial in difficult cases. The differential diagnosis of acute left-sided colonic diverticulitis includes tumorous, inflammatory, and ischemic diseases of the colon as well as infarctions of epiploic appendages and the omentum majus. The knowledge of the various CT criteria of acute colonic diverticulitis and their differential diagnoses helps to establish a correct diagnosis in a wide majority of cases. At present, CT is the diagnostic procedure of choice for assessing acute diverticulitis. Distinct knowledge of the CT features helps to differentiate the various entities accurately.

The out‐patient management of patients with acute mild‐to‐moderate colonic diverticulitis

There are no management criteria for optimum out-patient care in mild-to-moderate acute colonic diverticulitis. To enable such patients to be managed in an out-patient setting, by establishing criteria and treatment protocols. We conducted an open trial and follow-up study from 1997 to 2002. On the basis of ultrasonography, we defined and categorized mild-to-moderate acute colonic diverticulitis ranging from limited inflammation within diverticulum to an abscess < 2 cm in diameter. Subjects were treated as out-patients and followed a 10-day treatment protocol consisting of an oral antibiotic and a sports drink for the first 3 days. Physical examination and laboratory testing helped determine whether or not a patient could resume a liquid diet on day 4, and a regular diet on day 7. Of the 70 patients, 68 were successfully treated. Two patients required hospitalization. Of the 65 patients who were tracked over several months [median (intraquarter range) = 30.8 (11.9-44.2) months], 16 had one or more clinical recurrences. The medical cost per episode was 80% lower than in-patient treatment. Patients with mild-to-moderate acute colonic diverticulitis can be safely and successfully treated as out-patients using this protocol.

Long-Term Outcome of Mesocolic and Pelvic Diverticular Abscesses of the Left Colon: A Prospective Study of 73 Cases

The aim of of this study was to evaluate prospectively the long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon. Between October 1986 and October 1997, a total of 465 patients urgently admitted to our hospital with a suspected diagnosis of acute left-sided colonic diverticulitis had a CT scan. Of 76 patients (17 percent) who had an associated mesocolic or pelvic abscess, 3 were lost to follow-up. The remaining 73 patients (45 with a mesocolic abscess and 28 with a pelvic abscess) were followed for a median of 43 months. of the 45 patients with a mesocolic abscess, 7 (15 percent) required surgery during their first hospitalization versus 11 (39 percent) of the 28 patients with a pelvic abscess (P = 0.04). At the end of follow-up, 22 (58 percent) of the 38 patients with a mesocolic abscess who had successful conservative treatment during their first hospitalization did not need surgical treatment vs. 8 (47 percent) of the 17 who had a pelvic abscess. Altogether, 51 percent of the patients with a mesocolic abscess had surgical treatment versus 71 percent of those with a pelvic abscess (P = 0.09). Considering the poor outcome of pelvic abscess associated with acute left-sided colonic diverticulitis, percutaneous drainage followed by secondary colectomy seems justified. Mesocolic abscess by itself is not an absolute indication for colectomy.

Low-Dose CT Without Contrast for Evaluating Acute Diverticulitis

Physicians often order contrast-enhanced computed tomography (CT) to evaluate patients with suspected acute colonic diverticulitis, but studies suggest that intravenous contrast is unnecessary for this purpose. These researchers studied 110 consecutive patients with acute or …

Imaging of colonic diverticular disease.

Diverticular disease affects approximately two thirds of the population over the age of 70. While only a small fraction of these patients will develop diverticulitis, adequate radiological evaluation of diverticulitis and its complications is imperative in determining proper medical and surgical treatment. Clinical examination and laboratory tests alone have been found to be inaccurate in defining many aspects of the disease in up to 60% of cases. Over the past 30 years, contrast enema, computed tomography, and ultrasound have all been used extensively to diagnose the complications of diverticular disease. More recently, magnetic resonance imaging has been studied in patients with complicated diverticulitis. This article reviews the use of these different radiological modalities in diagnosing acute colonic diverticulitis and its complications.

Toward therapeutic guidelines for patients with acute right colonic diverticulitis

Background At present, little information is available on the outcome of medical therapy for patients with acute right colonic diverticulitis, and this has meant a gap in constructing guidelines for its treatment. Methods The records of patients with acute right colonic diverticulitis at Nagasaki University Graduate School and affiliated hospitals were reviewed and analyzed with the goal of establishing therapeutic guidelines. The time frame of the data analyzed was from 1984 to 2002. Results Of the 81 patients included in the data, 80 patients who were suffering a first attack were successfully treated with bowel rest and antibiotics. Two of these 80 patients underwent an elective operation at the surgeon's discretion during the original hospitalization and 1 (1.2%) needed an urgent operation. Of the 78 patients who responded to medical therapy, 16 (20.5%) developed recurrent right colonic diverticulitis. All 16 patients who had a second attack were successfully treated with medical therapy. Three of the 16 patients underwent an elective operation during this rehospitalization period. Of the 13 patients who had had a second attack and had responded to medical therapy, there was a third attack in 2 patients (15.4%). Both of these patients were again successfully treated with medical therapy. There has been no morbidity and no mortality related to recurrence to date. The average time from the first attack to us contacting the patient was 35.2 months. Conclusions Unlike acute uncomplicated left colonic diverticulitis, our findings indicate that after two documented episodes, medical treatment alone rather than elective surgery may be considered as an effective guideline for the treatment of acute uncomplicated right colonic diverticulitis.

Acute diverticulitis of the colon ? current medical therapeutic management

Acute diverticulitis of the colon ? current medical therapeutic management

Surgical therapy of acute diverticulitis

Following conservative treatment of acute colonic diverticulitis at least one fourth of the patients experiences a further attack. The complication rate rises up to 60% at the recurrence. Therefore, colon resection is indicated at/following the second attack. For male patients below 50 years of age and with severe first attack, surgery is recommended already at/following the first attack. In the absence of diffuse fecal peritonitis, the one-stage colon resection with primary anastomosis is widely accepted, now. Percutaneous drainage of a peridiverticular or paracolic abscess is hazardous (success rate 70%), dangerous (consecutively delayed elimination of septic focus, 5% complication rate of drainage itself) and not necessary or helpful. Recurrent diverticulitis following sigmoid resection rarely occurs (1-11%) and is avoidable by removal of at least 20 cm colon including the rectosigmoid junction and anastomosis to the rectum. An extension of the resection towards cephalad direction to remove as much diverticula as possible seems not to decrease the risk of recurrent disease and is therefore not worthwhile.