Acute Diverticulitis Patients Research Articles

Management of acute diverticulitis in Stage 0-IIb: indications and risk factors for failure of conservative treatment in a series of 187 patients

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.

Outcomes of Patients Hospitalized for Acute Diverticulitis With Comorbid Generalized Anxiety Disorder.

Introduction Diverticular disease and anxiety disorders are common in the general population. Prior research on diverticular disease showed that these patients have an increased frequency of anxiety and depression. The objective of this study was to explore the impact of generalized anxiety disorder (GAD) on the outcomes of adult patients admitted with acute diverticulitis. Methods Using the National Inpatient Sample database from the year 2014 and International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes, acute diverticulitis patients were selected. The outcomes of diverticulitis patients with and without GAD were explored. The outcomes of interest included inpatient mortality, hypotension/shock, acute respiratory failure, acute hepatic failure, sepsis, intestinal abscess, intestinal obstruction, myocardial infarction, acute renal failure, and colectomy. A multivariate logistic regression analysis was performed to determine if GAD is an independent predictor for the outcomes. Results Among 77,520 diverticulitis patients in the study, 8,484 had comorbid GAD. GAD was identified as a risk factor for intestinal obstruction (adjusted odds ratio (aOR) 1.22, 95% CI: 1.05-1.43, p<0.05), and intestinal abscess (aOR 1.19, 95% CI: 1.10-1.29, p<0.05). GAD was found to be a protective factor for hypotension/shock (aOR 0.83, 95% CI: 0.76-0.91, p<0.05) and acute respiratory failure (aOR 0.76, 95% CI: 0.62-0.93, p<0.05). The aORs of sepsis, inpatient mortality, myocardial infarction, acute renal failure, and colectomy were not statistically significant. Conclusions Patients with acute diverticulitis who are also diagnosed with GAD are at increased risk for intestinal obstruction and intestinal abscess, which may be due to the influence GAD has on the gut microbiota as well as the impact of GAD pharmacotherapy on gut motility. There was also a decreased risk for acute respiratory failure and hypotension/shock appreciated in the GAD cohort which may be attributable to the elevated healthcare resource utilization seen generally in GAD patients, which may allow for presentation to the emergency department, hospitalization, and treatment earlier in the diverticulitis disease course.

S967 Inflammatory Bowel Diseases Results in Worse Hospital Outcomes in Patients Admitted for Acute Diverticulitis: A Study of the National Inpatient Sample

Introduction: The association between Acute Diverticulitis (AD) and Inflammatory Bowel Diseases (IBD) is extremely rare in literature and not well studied as a result of the scarcity of reports and overlapping clinical and radiological features. In this study, we aim to investigate the clinical impact of IBD on the outcomes of patients admitted for AD. Methods: The National Inpatient Sample Database of the years 2016 to 2019 was analyzed, and patients who were hospitalized for AD, with or without a secondary diagnosis of IBD (Crohn’s Disease and ulcerative colitis) were identified using the 10th Revision of International Classification of Diseases codes. Univariates and Multivariate logistic regression analysis was performed to determine risk difference in mortality and AD-related complications. Data was considered statistically significant with p-value < 0.05. Results: A total of 313,054 adults AD hospitalizations were identified, among which 3090 (1%) had a history of IBD. AD patients baseline characteristics and comorbidities are listed in Table stratified by IBD diagnosis. IBD patients found to have 27% increase in risk of AD than IBD-free patients (adjusted odds ratio (aOR) 1.27, p< 0.001) with no difference in risk of mortality between the two groups (aOR 1.37, p=0.437). AD/IBD patients had significant increased risk of bowel perforation (aOR 3.41, p=0.04), sepsis (aOR 1.69, p=0.002), septic shock (aOR 3.16, p< 0.001), acute kidney injury (aOR 1.35, p=0.036) and undergoing colonic resection (aOR 1.28, p=0.018) than AD/non-IBD group. In term of healthcare resources utilization, IBD patients had a prolonged length of stay (adjusted mean difference (aMD) 1.39 days, p< 0.001) and increased cost of care (aMD 16993$, p< 0.001) when hospitalized for AD when compared to non-IBD patients. (Figure) Conclusion: This is the first descriptive analysis to demonstrate the effect of IBD on outcomes of patients with AD. IBD patients are at higher risk of developing AD, and IBD patients admitted for AD were found to have had higher risk of bowel perforation, sepsis, septic shock, acute kidney injury and undergoing colonic resection with significant increase in healthcare resources utilization. As such association is unique in clinical practice, misdiagnosis can occur and therefore physicians should keep high index of suspicion in this challenging scenario to primarily avoid catastrophic outcomes and decrease resources utilization.Figure 1.: Forest plot of outcomes in patient hospitalized for AD with history of IBD, compared to non-IBD patients. (AD=Acute Diverticulitis, IBD=Inflammatory Bowel Diseases) Table 1. - Baseline characteristics of AD patients stratified based on diagnosis status of IBD VARIABLE ALL AD %, NO. WITHOUT IBD %, NO. WITH IBD %, NO. P value (100.0) 313054 99.0 (309964) 1.00 (3090) Patient’s characteristics Age, mean years 58.4 58.4 60.3 0.001 Female 49.8 (155901) 49.8 (154362) 54.3 (1678) 0.028 Racial distribution < 0.001 White 76.3 (238860) 76.3 (236503) 83.4 (2577) Black 8.62 (26985) 8.65 (26812) 6.46 (200) Hispanic 11.0 (34436) 11.1 (34406) 6.29 (194) Others 2.29 (7169) 2.29 (7098) 2.65 (82) Insurance type 0.002 Medicaid 36.5 (114265) 36.5 (113137) 43.4 (1341) Medicare 11.2 (35062) 11.2 (34716) 9.43 (291) Private 45.7 (143066) 45.7 (141654) 42.7 (1319) Uninsured 6.49 (20317) 6.52 (20210) 4.38 (135) Charlson comorbidity index score 0.082 1 22.1 (69185) 22.1 (68502) 21.5 (664) 2 9.20 (28801) 9.18 (28455) 11.6 (358) ≥3 9.86 (30867) 9.85 (30531) 11.3 (349) Median annual income, us$ 0.281 1–43,999 23.9 (74820) 23.9 (74081) 23.1 (714) 44,000–55,999 26.1(81707) 26.2 (81211) 23.4 (723) 56,000–73,999 26.3 (82333) 26.3 (81521) 27.0 (834) ≥74,000 23.5 (73568) 23.4 (72532) 26.2 (810) Hospital characteristics Hospital region 0.079 Northeast 20.8 (65115) 20.8 (64473) 24.7 (763) Midwest 22.6 (70750) 22.6 (70052) 23.4 (723) South 38.0 (118961) 38.0 (117786) 35.2 (1088) West 18.4 (57602) 18.4 (57033) 16.5 (510) Hospital bed size 0.338 Small 23.3 (72942) 23.3 (72222) 22.6 (698) Medium 31.0 (97047) 31.0 (96089) 28.8 (890) Large 45.6 (142753) 45.6 (141344) 48.5 (1499) Hospital location Rural location 9.76 (30554) 9.78 (30314) 8.09 (250) 0.023 Urban location 25.0 (78264) 25.0 (77491) 21.3 (658) Teaching hospital 65.2 (204111) 65.1 (201787) 70.5 (2178) Comorbidities Hypertension 41.8 (130857) 41.8 (129565) 40.6 (1255) 0.534 Diabetes mellitus 13.9 (43515) 14.0 (43395) 11.3 (349) 0.055 Smoking history 40.0 (125222) 39.9 (123676) 42.7 (1319) 0.171 Hyperlipidemia 29.5 (92351) 29.5 (91439) 30.4 (939) 0.617 Obesity 19.5 (61046) 19.5 (60443) 16.0 (494) 0.030 Chronic kidney disease 6.45 (20192) 6.44 (19962) 8.41 (260) 0.045 Coronary artery disease 10.2 (31932) 10.2 (31616) 11.4 (352) 0.284 Peripheral vascular disease 1.07 (3350) 1.06 (3286) 2.27 (70) 0.003 Congestive heart failure 5.01 (15684) 4.99 (15467) 7.44 (230) 0.005 Chronic obstructive lung disease 8.68 (27173) 8.66 (26843) 11.0 (340) 0.039 Chronic liver disease 4.97 (15559) 4.97 (15405) 5.02 (155) 0.961 Constipation 8.46 (26484) 8.46 (26223) 8.74 (270) 0.800 AD=Acute Diverticulitis, IBD=Inflammatory Bowel Disease.

S240 Outcomes of Patients Hospitalized for Acute Diverticulitis With Comorbid Generalized Anxiety Disorder

Introduction: The prevalence of diverticulosis is as high as 50% in adults greater than 60 years old. Prior research on diverticular disease showed that these patients have an increased frequency of anxiety. Generalized anxiety disorder (GAD) is a common form of anxiety. This study explored the impact of GAD on the outcomes of patients admitted with acute diverticulitis. Methods: Adults hospitalized for diverticulitis were selected from the 2014 National Inpatient Sample database. ICD-9 codes were used to select diagnoses. Demographic data and outcomes of diverticulitis were compared between a subgroup with GAD and a subgroup without GAD. The outcomes of interest were sepsis, acute renal failure (AKI), myocardial infarction (MI), acute respiratory failure, obstruction, colectomy, hypotension/shock, gastrointestinal perforation and inpatient mortality. Chi-squared tests and independent t-tests were used to compare proportions and means respectively. A multivariate logistic regression analysis was used to establish if GAD is an independent predictor for the outcomes after adjusting for age, sex, race, and Charlson Comorbidity Index (CCI). Results: Among 77,520 diverticulitis patients in the study, 8,434 had GAD. Patients with GAD were younger (62.7 vs. 63.2 years old, p< 0.05), more likely to be female (72.6% vs. 43.5%, p< 0.05), more likely to be caucasian (83.9% vs. 75.5%, p< 0.05), and had a longer hospital stay (4.86 vs. 4.53 days, p< 0.05). There were no significant differences in total hospital charge ($40,003 vs. $39,660, p=0.54) and CCI (2.89 vs. 2.85, p=0.15). After adjusting for age, sex, race, and CCI, GAD was found to be a risk factor for obstruction (adjusted odds ratio (aOR) 1.22, 95% confidence interval (CI) 1.05-1.43, p< 0.05) and intestinal abscess (aOR 1.19, 95% CI 1.10-1.29, p< 0.05). GAD was also found to be a protective factor for acute respiratory failure (aOR 0.76, 95% CI 0.62-0.93, p< 0.05) and hypotension/shock (aOR 0.83, 95% CI 0.76-0.91, p< 0.05). The p-values for the aORs of sepsis (p=0.19), inpatient mortality (p=0.11), MI (p=0.77), AKI (p=0.76), and colectomy (p=0.07) were not statistically significant. (Table) Conclusion: In acute diverticulitis patients, GAD is a risk factor for intestinal obstruction and intestinal abscess, which may be due to GAD’s impact on motility. GAD is also a protective factor against acute respiratory failure and hypotension/shock possibly due to its association with higher healthcare utilization which may lead patients to seek out care earlier. Table 1. - Multivariate logistic regression analysis of clinical outcomes among diverticulitis patients Outcomes *Adjusted Odds Ratio 95% Confidence Interval p-Value Acute renal failure 1.02 0.93-1.11 0.76 Acute respiratory failure 0.76 0.62-.93 < 0.05 Colectomy 0.75 0.55-1.02 0.07 Hypotension/shock 0.83 0.76-.91 < 0.05 Inpatient mortality 1.34 0.93-1.92 0.11 Intestinal abscess 1.19 1.10-1.29 < 0.05 Intestinal obstruction 1.22 1.05-1.43 < 0.05 Myocardial infarction 1.05 0.78-1.40 0.77 Sepsis 1.07 0.97-1.19 0.19 *Adjusted for age, sex, race, and the Charlson comorbidity index.

Distinct changes in the colonic microbiome associated with acute diverticulitis.

The pathogenesis of acute diverticulitis (AD) remains incompletely understood, despite it being one of the most common gastrointestinal conditions worldwide. The aim of this study was to investigate the role of the colonic microbiome in the pathogenesis of AD. A prospective case-control study was performed, comparing the microbiome of AD patients with that of controls, using 16S rRNA sequencing of rectal swab samples. The microbiome of individuals with AD showed lower diversity than that of controls. There were significant compositional differences observed, with a lower abundance of commensal bacterial families and genera such as Lachnospiraceae, Ruminococcus and Faecalibacterium in AD patients compared with controls, and there was an increase in several genera with known pathogenic roles including Fusobacteria, Prevotella and Paraprevotella. This is the largest study to date to examine the microbiota of AD patients, and adds evidence to the proposed hypothesis that alterations in the colonic microbiome play a role in the pathogenesis of AD.

Development of a prediction model for clinically important outcomes of acute diverticulitis.

Acute diverticulitis (AD) is a common disease with various outcomes. When AD is diagnosed in the emergency department (ED), the ED clinician must determine the patient's treatment strategy whether the patient can be discharged, needs to be admitted to the general ward, ICU, or needs surgical consultation. This study aimed to identify potential risk factors for clinically important outcomes (CIOs) and to develop a prediction model for CIOs in AD to aid clinical decision making in the ED. Retrospective data from between 2013 and 2017 in an ED in an urban setting were reviewed for adult AD. Potential risk factors were age, sex, past medical history, symptoms, physical exams, laboratory results, and imaging results. A CIO was defined as a case with one of the following outcomes: hospital death, ICU admission, surgery or invasive intervention, and admission for 7 or more days. The prediction model for CIOs was developed using potential risk factors. Model discrimination and calibration were assessed using the area under the curve (AUC) and 95% confidence intervals (CIs) and the Hosmer-Lemeshow (HL) test, respectively. Model validation was conducted using 500 random bootstrap samples. Of the final 337 AD patients, 63 patients had CIOs. Six potential factors (age, abdominal pain (≥ 3 days), anorexia, rebound tenderness, white blood cell count (> 15,000/μl), C-reactive protein (> 10 mg/dL), and CT findings of a complication) were used for the final model. The AUC (95% CI) for CIOs was 0.875 (0.826-0.923), and χ2 was 2.969 (p-value = 0.936) with the HL test. Validation using bootstrap samples resulted in an optimism-corrected AUC of 0.858 (0.856-0.861). A prediction model for clinically important outcomes of AD visiting a single ED showed good discrimination and calibration power with an acceptable range.

Machine Learning Model for Outcome Prediction of Patients Suffering from Acute Diverticulitis Arriving at the Emergency Department-A Proof of Concept Study.

Background & Aims: We aimed at identifying specific emergency department (ED) risk factors for developing complicated acute diverticulitis (AD) and evaluate a machine learning model (ML) for predicting complicated AD. Methods: We analyzed data retrieved from unselected consecutive large bowel AD patients from five hospitals from the Mount Sinai health system, NY. The study time frame was from January 2011 through March 2021. Data were used to train and evaluate a gradient-boosting machine learning model to identify patients with complicated diverticulitis, defined as a need for invasive intervention or in-hospital mortality. The model was trained and evaluated on data from four hospitals and externally validated on held-out data from the fifth hospital. Results: The final cohort included 4997 AD visits. Of them, 129 (2.9%) visits had complicated diverticulitis. Patients with complicated diverticulitis were more likely to be men, black, and arrive by ambulance. Regarding laboratory values, patients with complicated diverticulitis had higher levels of absolute neutrophils (AUC 0.73), higher white blood cells (AUC 0.70), platelet count (AUC 0.68) and lactate (AUC 0.61), and lower levels of albumin (AUC 0.69), chloride (AUC 0.64), and sodium (AUC 0.61). In the external validation cohort, the ML model showed AUC 0.85 (95% CI 0.78–0.91) for predicting complicated diverticulitis. For Youden’s index, the model showed a sensitivity of 88% with a false positive rate of 1:3.6. Conclusions: A ML model trained on clinical measures provides a proof of concept performance in predicting complications in patients presenting to the ED with AD. Clinically, it implies that a ML model may classify low-risk patients to be discharged from the ED for further treatment under an ambulatory setting.

Trends and Outcomes of Acute Diverticulitis in Inflammatory Bowel Disease: A Propensity-matched National Study.

Patients with inflammatory bowel disease (IBD) may be at increased risk for acute diverticulitis (AD) complications due to luminal inflammation and immune modifying medications. We aimed to assess outcomes of acute diverticulitis in patients with IBD. A propensity-matched analysis of the National Inpatient Sample database was performed to assess outcomes of AD in adult patients (older than 18 years) from 2004 to 2013 with and without IBD. Outcomes included in-hospital mortality, need for percutaneous drainage, surgery, venous thromboembolism (VTE), total cost, and length of stay (LOS). A subgroup analysis comparing patients with Crohn's disease (CD) and ulcerative colitis (UC) was performed. After propensity matching, compared with non-IBD patients (n = 15,015); Patients with IBD (n = 15,106) did not have significantly higher rate of mortality and surgical intervention but had significantly higher rates of percutaneous drainage (4% vs 3.4%; P = 0.002), VTE (1.1% vs 0.7%; P < 0.001), longer LOS (P < 0.001), and total cost (P < 0.001). Compared with CD, UC was associated with significantly higher rates of surgical intervention (20.3% vs 19%; P = 0.04), in-hospital mortality (1.4% vs 0.4%; P < 0.001), VTE (1.6% vs 0.7%; P < 0.001), total cost ($41,672 ± $61,358 vs $33,951 ± $54,376; P < 0.001), and LOS (6.4 ± 6.4 vs 5.7 ± 5.3; P < 0.001). From 2004 to 2013, there was a significant increase of IBD (range 0.5% to 0.8%; P = < 0.001) in AD patients with overall stable mortality (0.5% to 1.0%; P = 0.47) of AD in patients with IBD. Patients with IBD are at increased risk of complicated diverticulitis and worse outcomes compared with matched controls. Optimal AD management strategies in IBD are needed.

S0251 Clostridioides difficile Infection Is Associated With Adverse Clinical Outcomes in Patients With Acute Diverticulitis: A Nationwide Study

INTRODUCTION: Acute diverticulitis (AD) is a common gastrointestinal disease with a significant healthcare associated burden. Patients hospitalized with AD have many risk factors for developing Clostridioides difficile infection (CDI). CDI is associated with poor outcomes in many diseases but has yet to be studied in AD. METHODS: We utilized data from the National Inpatient Sample from January 2012 to October 2015 for patients hospitalized with AD and CDI. Primary outcomes were mortality, length of stay, and hospitalization cost were compared. Secondary outcomes were complications of diverticulitis and need for surgical interventions. Risk factors for mortality in acute diverticulitis and risk factors associated with CDI in AD patients were analyzed. RESULTS: Among 767,850 hospitalizations for AD, 8,755 also had CDI. A multivariate logistic regression analysis demonstrated that CDI was associated with increased risk of inpatient mortality (OR 2.02, 95% CI 1.38–2.96), prolonged duration of hospitalization by 3.7 days (95% CI, 3.38–4.02, P < 0.001) and had higher total hospitalization charges $74525 vs $37571 (P < 0.001). Patients who required surgery for AD had greater mortality than those who did not (0.9% vs 0.3%, P < 0.001). Patient with CDI in AD who underwent surgery had greater mortality than patients with CDI who did not require surgery (4.1% vs 0.9%, P < 0.001). Predictors of CDI among patients with AD included age (1.01 OR, 95% CI 1.01–1.02) female gender (1.12 OR, 95% CI 1.01–1.24), three or more comorbidities (1.81 OR, 95% CI 1.57–2.09), admissions to teaching hospitals (1.44 OR, 95% CI 1.22–1.70), length of stay (1.08, OR 95% CI 1.07–1.09) and inflammatory bowel disease (2.26, 95% CI 1.61–3.17). A multivariate logistic regression analysis for the impact of surgery and complicated diverticulitis was performed. Patients who required surgical interventions had increased mortality including colectomy (OR 2.36, 95% CI 1.83–3.06), colostomy (OR 2.99, 95% CI 2.30–3.90) anterior resection (OR 1.9, 95% CI 1.1–3.29) and abscess drainage (OR 1.85, 95% CI 1.39–2.47). Patients with complications of diverticulitis had increased mortality including obstruction (OR 1.33, 95% CI 1.07–1.66), perforation (OR 3.90, 95% CI 2.16–7.04) and hemorrhage (OR 1.73, 95% CI 1.38–2.18). CONCLUSION: CDI in AD is associated with increased mortality, length of stay and total hospital charges. Preventative measures should be made for at-risk patients with AD to decrease infection rate and poor outcomes.Table 1.: Patient Demographics and Characteristics, Interventions, Complications and Outcomes of Acute Diverticulitis with and without CDITable 2.: Risk factors associated with In-Hospital Mortality in Acute Diverticulitis

Association of Clostridioides difficile with adverse clinical outcomes in patients with acute diverticulitis: A nationwide study.

Acute diverticulitis (AD) is a common gastrointestinal disease with a significant health care-associated burden. Patients hospitalized with AD have many risk factors for developing Clostridioides difficile infection (CDI). CDI is associated with poor outcomes in many diseases but has yet to be studied in AD. We utilized data from the National Inpatient Sample from January 2012 to October 2015 for patients hospitalized with AD and CDI compared with AD alone. Primary outcomes, which were mortality, length of stay, and hospitalization cost, were compared. Secondary outcomes were complications of diverticulitis and need for surgical interventions. Risk factors for mortality in AD and risk factors associated with CDI in AD patients were analyzed. Among 767850 hospitalizations for AD, 8755 also had CDI. A propensity score-matched cohort analysis demonstrated that CDI was associated with increased risk of inpatient mortality (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.30, 5.95), prolonged duration of hospitalization by 4.27days (P<0.0001), total hospital cost by $33271 (P<0.0001), need for surgery (OR 1.45, 95% CI 1.22, 1.71), and complications of diverticulitis (OR 1.45, 95% CI 1.21, 1.74). Predictors of CDI among patients with AD included female gender (1.12 OR, 95% CI 1.01, 1.24), three or more comorbidities (1.81 OR, 95% CI 1.57, 2.09), and admissions to teaching hospitals (1.44 OR, 95% CI 1.22, 1.70). Clostridioides difficile infection in AD is associated with increased mortality, length of stay, and hospital cost. Preventative measures should be made for at-risk patients with AD to decrease infection rate and poor outcomes.

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

Acute diverticulitis is a common gastrointestinal illness due to diverticular inflammation and focal necrosis. Diabetes mellitus has been reported to influence the outcomes of patients with diverticular disease. Our study aimed to examine the inpatient outcomes and complications of patients with acute diverticulitis and coexisting diabetes mellitus. The Nationwide Inpatient Sample was used to identify adult patients in 2014 admitted for acute diverticulitis. Primary outcomes were mortality, length of stay (LOS), and total hospitalization charges. Secondary outcomes were complications of acute diverticulitis and interventions. In total, 44 330 of patients with acute diverticulitis and diabetes mellitus were included in the analysis. Acute diverticulitis patients with diabetes mellitus had a higher rate of diverticular bleeding (P < 0.0001), but lower rates of abscess (P < 0.0001), obstruction (P < 0.0001) and colectomy (P < 0.0001) when compared to acute diverticulitis patients without diabetes mellitus. Complicated diabetes mellitus was associated with a longer LOS (P = 0.00003) and greater total hospitalization charges (P = 0.0021) compared to uncomplicated diabetes mellitus when coexisting with acute diverticulitis. Acute diverticulitis with diabetes mellitus is associated with a higher rate of diverticular bleeding, lower rates of abscess, obstruction, and colectomy compared to acute diverticulitis without diabetes mellitus. When coexisting with acute diverticulitis, complicated diabetes mellitus is not associated with higher rates of mortality or diverticulitis-related complications compared to uncomplicated diabetes mellitus.

C-reactive protein trajectory in the first 48 hours predicts the need for intervention in conservative management of acute diverticulitis.

C-reactive protein (CRP) is a useful marker for monitoring response to treatment in sepsis. The aim of this study was to examine the use of CRP trajectory in predicting the need for intervention in conservatively managed patients with acute diverticulitis (AD). A retrospective review of patients with AD who were managed conservatively was performed. They were divided into four groups based on CRP relative to the median at day 0 and 2: 'Low rise' (levels below median at day 0 and 2), 'High rise' (levels above median at day 0 and 2), 'Rapid rise' (levels below median at day 0 but above median at day 2) and 'Decline' (levels above median at day 0 but below median at day 2). Intervention was required in 64 of 456 (14%) with 30 (48%) of these performed after day 2 of admission. There were 150 patients (54%) in the 'Low rise', 76 (27%) in the 'Decline', 26 patients (9%) in the 'Rapid rise' and 25 patients (9%) in the 'High rise' groups. Within these groups 5%, 8%, 19% and 32% of patients required intervention (P = 0.001). On multivariate analysis, patients with a pelvic abscess were more likely to need intervention (odds ratio 19.1 (confidence interval 6.2-59.4), P < 0.0001). The CRP trajectory during the initial 48 h of admission can predict the need for intervention in AD patients being managed conservatively. Patients with a 'Rapid rise' or 'High rise' in CRP from day 0 to 2 are more likely to need intervention.

Validation of the Adapted Clavien-Dindo in Trauma (ACDiT) Classifications in Medical and Surgical Management of Acute Diverticulitis.

To validate the adapted Clavien-Dindo in trauma (ACDiT) tool as a novel outcome measure for patients with acute diverticulitis managed both operatively and nonoperatively. Complications following diverticulitis are difficult to classify because no traditional tools address patients managed both operatively and nonoperatively. The ACDiT grading system-graded from 0 to 5b-is applied in this manner but has not yet been validated for this patient group. We performed a 5-year observational study of patients with acute diverticulitis at a safety-net hospital. Baseline demographics and hospitalization data were collected. ACDiT scores were assigned, and validation was undertaken by comparing scores with hospital-free days, and verifying that higher scores were associated with known risk factors for poor outcomes. Inverse probability weighted propensity scores were assigned for surgical management, and inverse probability weighted regression analysis was used to determine factors associated with ACDiT ≥ grade 2. Of 260 patients, 188 (72%) were managed nonoperatively. Eighty (31%) developed a complication; 73 (91%) were grades 1 to 3b. Higher grades correlated inversely with hospital-free days (rs = -0.67, P < 0.0001) for all patients and for nonoperative (rs = -0.63, P < 0.0001) and operative (rs = -0.62, P < 0.0001) patients. Hinchey 2 to 3 and initial operative management had higher odds of having a complication of ACDiT ≥ grade 2. The ACDiT tool was successfully applied to acute diverticulitis patients managed operatively and nonoperatively, is associated with known risk factors for adverse outcomes. ACDiT may be considered a meaningful outcome measure for comparing strategies for acute diverticulitis.

Risk of colorectal cancer following CT-verified acute diverticulitis: a nationwide population-based cohort study.

Routine colonoscopy to exclude colorectal cancer (CRC) after CT-verified acute diverticulitis is controversial. This study aimed to compare the incidence of CRC in patients with acute diverticulitis with that in the general population. Patients with an emergency admission for diverticular disease to any Norwegian hospital between 1 January 2008 and 31 December 2010 were included through identification in the Norwegian Patient Registry using International Classification of Diseases (ICD-10) codes K57.1-9. To estimate the age-specific distribution of CT-verified acute uncomplicated diverticulitis (AUD) and acute complicated diverticulitis (ACD) in this nationwide study population, numbers from the largest Norwegian emergency hospital were used. Patients diagnosed with CRC within 1year following their admission for acute diverticulitis were detected through cross-matching with the Cancer Registry of Norway. Based on both Norwegian age-specific incidence of CRC and estimated age-specific distribution of CT-verified diverticulitis, standard morbidity ratios (SMRs) were calculated. A total of 7473 patients with emergency admissions for diverticular disease were identified (estimated CT-verified AUD n=3523, ACD n=1206); of these 155 patients were diagnosed with CRC within 1year. Eighty had a CT-verified diverticulitis at index admission [41 AUD (51.3%); 39 ACD (49.7%)]. Compared with the general population, the SMR was 6.6 following CT-verified AUD and 16.3 following ACD, respectively. In the first year after CT-verified acute diverticulitis, especially after ACD, the risk of CRC is higher than in the general population. This probably represents misdiagnosis of CRC as acute diverticulitis. Follow-up colonoscopy should be recommended to all patients admitted with acute diverticulitis.

National Landscape of Unplanned 30-Day Readmission Rates for Acute Non-hemorrhagic Diverticulitis: Insight from National Readmission Database.

Early readmissions are an important indicator of the quality of care. Limited data exist describing hospital readmissions inacute diverticulitis. The study aimed to describe unplanned, 30-day readmissions among adult acute diverticulitis patients and to assessreadmissionpredictors. We analyzed the 2013 and 2014 United States NationalReadmissionDatabase and identified acute diverticulitis admissions using administrative codes in adult patients older than 18years of age. Our primary outcome was a 30-day, unplannedreadmissionrate. We used Chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations with readmissions adjusting for confounders. In the cohort of 364,511 hospitalizations with acute diverticulitis, as the primary diagnosis on index admission, 31,420 (8.6%) had at least one unplanned 30-day readmission. Sixty percent of the readmissions occurred within the first 2weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to diverticulitis of the colon (41.5%), postoperative infection (4.2%), septicemia (3.6%), intestinal infection due to Clostridium difficile (3%), and other digestive system complications such bleeding or fistula (2.8%). Multivariable analysis showed advance age (> 75years), discharge against medical advice, comorbidities (renal failure, coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, diabetes, obesity, weight loss, chronic lung disease, malignancy), blood transfusion, Medicare and Medicaid insurance, and increased length of stay (> 3days) were associated with significantly higher odds for readmission. Patients who have undergone abdominal surgery during index admission were 31% less likely to get readmitted. On a national level, 1 in 11 hospitalizations for acute diverticulitis was followed by unplannedreadmissionwithin 30days with most admissions occurring in the first 2weeks. Multiple modifiable and non-modifiable factors influencing readmission rates were noted. Further studies should examine if strategies that address these predictors can decrease readmissions.

217 Post Colonoscopy Diverticulitis: How Common Is It?

INTRODUCTION: Acute Diverticulitis (AD) is a common cause of hospitalization. Colonoscopy is a commonly performed outpatient procedure. There is limited data exist regarding post colonoscopy AD. There are few single center studies which discuss about post colonoscopy AD but larger studies are lacking. Our aim is to evaluate incidence, demographic factors, clinical factors and mortality associated with post colonoscopy AD in nationwide patient population. METHODS: We used Nationwide Readmissions Database (NRD) of year 2014 to find patients admitted with AD. From that sample, we found patients who had underwent colonoscopy between one and four days prior to admission. AD patients with and without prior colonoscopy were compared by univariate and multivariate analysis. Chi-square or fisher's exact test was done for categorical variables while t test was used for continuous outcome. Multivariate logistic regression was done to compare in hospital mortality between two groups. RESULTS: There are total 235847 weighted admissions in year 2014 with AD out of which 797 (0.3%) patients had underwent colonoscopy between one and four days prior to admission. Univariate analysis showed that patients who are male and with age above 65 were significantly more associated with post colonoscopy AD. It also showed that patients with post colonoscopy AD had significantly higher mortality and total hospitalization charges (Table 1). In Multivariate analysis, patients with liver disease (Odds Ratio 1.5, P 0.02), kidney disease or electrolytes abnormalities (Odds Ratio 3.9, P &lt; 0.0001), age more than 65 (Odds Ratio 22, P &lt; 0.0001), and those who had recent weight loss (Odds Ratio 3.8, P &lt; 0.001) had higher in hospital mortality while obese patients (Odds Ratio 0.7, P 0.008) had significantly lower in hospital mortality. CONCLUSION: Incidence of AD between 1 to 4 days after colonoscopy is 0.3% (3/1000) which is more commonly seen in elderly patients. Although a rare complication, possibility of AD post procedure should be kept in mind mainly for patients who already had history of AD in the past as second episode of AD can increase their morbidity and mortality significantly. Also risk stratification becomes extremely important in high risk patients such as those who are more than 65 years of age, patients with liver and kidney diseases as they will have higher in hospital mortality and higher total hospitalization charges.

Metabolic Syndrome Exponentially Increases the Risk of Adverse Outcomes in Operative Diverticulitis

BackgroundMetabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients. MethodsWe analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m2, hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed. ResultsA total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m2. 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (β = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone. ConclusionsAdverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality. Level of EvidenceLevel III Prognostic.

Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis

PurposeSince outpatient treatment and omitting antibiotics for uncomplicated acute colonic diverticulitis have been proven to be safe in the majority of patients, selection of patients that may not be suited for this treatment strategy becomes an important topic. The aim of this study is to identify computed tomography (CT) imaging predictors for a complicated disease course of initially uncomplicated acute diverticulitis.MethodsCT imaging from a randomized controlled trial (DIABOLO study) of an observational vs. antibiotic treatment strategy of first-episode uncomplicated acute diverticulitis patients was re-evaluated. For each patient that developed complicated diverticulitis within 90 days after randomization, two patients with an uncomplicated disease course were randomly selected. Two abdominal radiologists, blinded for outcomes, independently re-evaluated all CTs.ResultsOf the 528 patients in the DIABOLO trial, 16 patients developed complications (abscess > 5 cm, perforation, bowel obstruction) within 90 days after randomization. In the group with a complicated course of initially uncomplicated diverticulitis, more patients with fluid collections (25 vs. 0%; p = 0.009) and a longer inflamed colon segment (86 ± 26 mm vs. 65 ± 21 mm; p = 0.007) were observed compared to an uncomplicated course of disease. Pericolic extraluminal air was no predictive factor.ConclusionFluid collections and to a lesser extent the length of the inflamed colon segment may serve as predictive factors on initial CT for a complicated disease course in patients with uncomplicated acute colonic diverticulitis. These findings may aid in the selection of patients not suitable for outpatient treatment and treatment without antibiotics.

Ūminio komplikuoto divertikulito gydymo protokolas

TikslasAtlikus literatūros apžvalgą ir remiantis jos duomenimis pasiūlyti ūminio komplikuoto divertikulito gydymo protokolą.MetodikaNaudojant „PubMed“, „Medline“, „Embase“, „Cochrane“, „Medscape“ elektronines duomenų bazes peržiūrėta ūminio divertikulito gydymo tematikos literatūra, publikuota 2008–2013 metais. Paieškai naudoti raktiniai žodžiai: divertikulitas, perforacija, peritonitas, Hartmano operacija, pirminė anastomozė, laparoskopinis lavažas, Hinchey. Analizei atrinkti straipsniai, kuriuose pateikti duomenys remiantis atsitiktinių imčių bei lyginamųjų studijų rezultatais. Tinkamumo kriterijai buvo nustatyti prieš pradedant literatūros apžvalgą – tirta ne mažiau kaip 100 ligonių, naudojama Hinchey klasifikacija, išvados paremtos statistiškai patikimais rezultatais. Analizuojant atrinktus straipsnius nagrinėti ir jų literatūros sąraše pateikti literatūros šaltiniai, siekiant įvertinti aktualias studijas, nepasiūlytas pirminėje paieškoje.RezultataiIš viso nagrinėta 11 straipsnių. Hinchey I–II klasių ligoniams rekomenduojamas konservatyvus gydymas – antibiotikų terapija arba perkutaninis pūlinių drenavimas, kai pūlinys didesnis negu 5 cm. Hinchey III–IV klasių ligoniams indikuojamas operacinis gydymas. Lyginant storosios žarnos rezekciją su perforacijos užsiuvimu ir drenavimu, statistiškai patikimo skirtumo negauta. Lyginant storosios žarnos rezekciją su pirmine anastomoze (PA) ir Hartmano operacija (HP), gauti statistiškai patikimi rodikliai: mirštamumas – PA 9,7 %, o HP 21,95 %, reintervencijos dažnis – PA 6,6 %, HP 15,3 %, hospitalizacijos trukmė – PA grupėje 8,65, HP grupėje 15,08 dienos. Lyginant PA su laparoskopiniu pilvo ertmės lavažu (LPD), gautas statistiškai patikimas hospitalizacijos trukmės skirtumas – po LPD 8 dienos, po PA 17 dienų. Mirčių nebuvo abiejose grupėse. Po LPD 71,43 % ligonių planine tvarka atliktos laparoskopinės rezekcinės operacijos (LR), tačiau bendra hospitalizacijos trukmė po LPD ir LR buvo mažesnė už hospitalizacijos trukmę po PA.IšvadosHinchey I–II klasės divertikulitą rekomenduojame gydyti konservatyviai plataus veikimo spektro antibiotikais arba minimaliai invazyviniais gydymo metodais – perkutaniniu pūlinio drenavimu kontroliuojant procedūrą ultragarsu (UG) ar kompiuterine tomografija (KT). Esant aukštesnės klasės komplikuotam divertikulitui tikslingas chirurginis gydymas. Hinchey III klasės divertikulito gydymui indikuojamas LPD, laparoskopinis perforacijos užsiuvimas, PA, o Hinchey IV klasės komplikuotam divertikulitui gydyti – laparotomija su PA arba HP. Ateityje tikslinga atlikti atsitiktinių imčių tyrimus įvairiems ūminio komplikuoto divertikulito gydymo metodams palyginti.

Diagnostic impact of routine colonoscopy following acute diverticulitis: A multicenter study in 808 patients and controls

The diagnosis of acute diverticulitis is mainly based on clinical, biological and computed tomography (CT)-scan findings. Elective colonoscopy is recommended after medical treatment, to rule out another diagnosis and to detect associated conditions; however, the relevance of this recommendation has been questioned. Between January 2005 and December 2011, we retrospectively identified in three referral centers the consecutive patients whom underwent a colonoscopy after the medical treatment of a CT scan-proven acute diverticulitis episode. We excluded from the analysis patients with haematochezia or recent change in bowel habits. Sex and age-matched asymptomatic patients undergoing a screening colonoscopy were chosen as a control group. We collected and compared the results of colonoscopy and histological findings in both groups. We matched 404 patients whom underwent a colonoscopy after an episode of acute diverticulitis with 404 control patients. Their mean age was 60.9 years, with 59% being women. Colorectal adenoma, advanced adenoma and cancer detection rates in acute diverticulitis patients were 12.1%, 2.7% and 0.25%, respectively; versus 14.6% (p = 0.35), 6.7% (p = 0.01) and 0.25% respectively, in control patients. Diagnosis rates for adenomas and for colorectal cancer during a colonoscopy scheduled after acute diverticulitis were similar than those of control patients undergoing a screening colonoscopy, while the detection rate of advanced adenomas was lower. We suggest that colonoscopy should be indicated only in selected patients, i.e. those presenting with reasonable doubt on initial CT-scan, those with alarm symptoms, and those with identified risk factors for colorectal cancer.