Acute Complicated Diverticulitis Research Articles

Acute complicated jejunum diverticulitis: a case report with a short literature review

IntroductionJejunal diverticulosis is a rare condition. Most of the time, it is asymptomatic; but it can cause severe complications such as intestinal perforation, mechanical occlusion, and hemorrhage.Case presentationA patient aged 78 years, with a history of biological aortic valve prosthesis, atrial fibrillation, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, presented in the emergency department for acute abdominal pain in the lower abdominal floor, nausea, and inappetence. Abdominal computed tomography revealed an inflammatory block in the hypogastrium, agglutinated small intestinal loops, fecal stasis, and air inclusions. Pulled mesentery and associated internal hernia are suspected. Exploratory laparotomy was performed, revealing an inflammatory block in the hypogastrium, whose dissection revealed inner purulent collection and the appearance of jejunal diverticulitis, a diagnosis confirmed by histopathological examination. Segmental resection of the jejunum with double-layer terminal–terminal enteroenteric anastomosis, lavage, and drainage was performed. The evolution was favorable.ConclusionBased on our brief review, the diagnosis of complicated jejunal diverticulosis is difficult and sometimes not accurately established, even by high-resolution imaging techniques, with diagnostic laparotomy being necessary for these situations. Surgical treatment should be considered before severe complications develop.

Trends in the adoption of diverting loop ileostomy for acute complicated diverticulitis in the United States

BackgroundAcute complicated diverticulitis poses a substantial burden to individual patients and the health care system. A significant proportion of the cases necessitate emergency operations. The choice between Hartmann’s procedure and primary anastomosis with diverting loop ileostomy remains controversial. MethodsUsing American College of Surgeons National Surgical Quality Improvement Program patient user file data from 2012 to 2020, patients undergoing Hartmann’s procedure and primary anastomosis with diverting loop ileostomy for nonelective sigmoidectomy for complicated diverticulitis were identified. Major adverse events, 30-day mortality, perioperative complications, operative duration, reoperation, and 30-day readmissions were assessed. ResultsOf 16,921 cases, 6.3% underwent primary anastomosis with diverting loop ileostomy, showing a rising trend from 5.3% in 2012 to 8.4% in 2020. Primary anastomosis with diverting loop ileostomy patients, compared to Hartmann’s procedure, had similar demographics and fewer severe comorbidities. Primary anastomosis with diverting loop ileostomy exhibited lower rates of major adverse events (24.6% vs 29.3%, P = .001). After risk adjustment, primary anastomosis with diverting loop ileostomy had similar risks of major adverse events and 30-day mortality compared to Hartmann’s procedure. While having lower odds of respiratory (adjusted odds ratio 0.61, 95% confidence interval 0.45–0.83) and infectious (adjusted odds ratio 0.78, 95% confidence interval 0.66–0.93) complications, primary anastomosis with diverting loop ileostomy was associated with a 36-minute increment in operative duration and increased odds of 30-day readmission (adjusted odds ratio 1.30, 95% confidence interval 1.07–1.57) compared to Hartmann’s procedure. ConclusionPrimary anastomosis with diverting loop ileostomy displayed comparable odds of major adverse events compared to Hartmann’s procedure in acute complicated diverticulitis while mitigating infectious and respiratory complication risks. However, primary anastomosis with diverting loop ileostomy was associated with longer operative times and greater odds of 30-day readmission. Evolving guidelines and increasing primary anastomosis with diverting loop ileostomy use suggest a shift favoring primary anastomosis, especially in complicated diverticulitis. Future investigation of disparities in surgical approaches and patient outcomes is warranted to optimize acute diverticulitis care pathways.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BackgroundLiterature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.MethodsThis is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.Results564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.ConclusionsAfter 100 years since the first Hartmann’s procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment’s choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Is reassessment of Computed Tomography Reports Worthwhile in Acute Diverticulitis?

Introduction: Since the assessment of the disease severity in acute diverticulitis (AD) is of utmost importance to determine the optimal treatment and the need for follow-up investigations, we wanted to investigate whether the first CT report is compatible with daytime reassessment report and whether the value of initial report changes according to the experience of the radiologist. Methods: Consecutive patients from tertiary referral centre with AD were included. CT images done in the emergency department were initially analysed by either resident radiologists or consultant radiologists and then later reanalysed by consultant abdominal radiologists. Discrepancies between reports were noted. Results: Of total of 562 patients with AD, CT images were reanalysed in 439 cases. In 22 reports (5.0%) the final report was significantly different from the initial report and management changed in 20 cases. In reports of uncomplicated acute diverticulitis, reanalysis changed initial assessment in 4.0% of the cases and in complicated acute diverticulitis (CAD) in 9.1%. When consultant and resident radiologists were compared, there was no significant difference. Conclusion: Although no statistical difference could be noted between residents and consultants, the final report was significantly different in overall 5% of the cases when reanalysed at normal working hours by an experienced consultant abdominal radiologist. Therefore, we conclude that reassessment of CT reports is worthwhile in AD.

Non-malignant left colon emergency surgery: evaluation of factors affecting clinical outcomes and complications.

Emergency colorectal resections hold a significant position in general surgical practice, and pathologies of the left colon are relatively common. This study was conducted to assess the outcomes of isolated left colon surgeries with benign etiologies, drawing on clinicopathological and biochemical data. We carried out a retrospective review and statistical analysis of demographic, clinical, and laboratory data of patients who underwent left colon surgery at the general surgery clinic of a tertiary care hospital, excluding those with malignancy-related emergencies, from January 2017 to January 2022. The average age of the 48 patients in the study was 56.9±16.4 years. Complicated acute diverticulitis was the most frequent indication for emergency surgery (n=19, 39.6%). The Hartmann procedure was the surgical technique most often employed (n=30, 62.5%). The rates of postoperative morbidity and mortality within 30 days were 27.1% and 8.3%, respectively. Increased postoperative morbidity was linked to advanced age (mean 65.4±15.8 vs. 53.8±15.7, p=0.028), the preoperative administration of vasopressors, lower platelet counts, hypoalbuminemia (<3 mg/dl), and azotemia (blood urea nitrogen >20 mg/dl). There was no statistically significant correlation between comorbidities, American Society of Anesthesiologists (ASA) scores, surgical methods, or other clinical data and postoperative outcomes. For emergency colorectal surgery pertaining to left colon pathologies, it is critical to conduct a comprehensive evaluation in the perioperative period, especially for elderly and hypotensive patients with renal function abnormalities and for those requiring vasopressors.

The role of infectious parameters in the early prediction of complicated colonic diverticulitis.

Acute colonic diverticulitis has recently become a significant cause of hospital admissions. Complicated colonic diverticulitis, a severe form of the disease, necessitates medical and surgical intervention. Prompt diagnosis in these patients is crucial. This study aims to assess the role of infectious parameters in the early diagnosis of complicated colonic diverticulitis. This retrospective study analyzed 82 adult patients diagnosed with acute diverticulitis. Recorded data included patient demographics, hospital stay duration, disease location, and surgical procedures. Infectious parameters such as white blood cell count (WBC), C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), percentage of immature granulocytes (IG%), and systemic immune-inflammatory index (SII) were calculated and noted. Patients underwent abdominal computed tomography upon admission, and based on these results, they were categorized into uncomplicated or complicated diverticulitis groups. Statistical analysis was performed to identify differences between these groups. CRP, NLR, and SII were significantly more predictive of complicated acute colonic diverticulitis. However, no statistical differences in WBC and IG% values were observed between the groups. The study found that the percentage of immature granulocytes, previously deemed a reliable marker in many studies, did not significantly predict complicated colonic diverticulitis. Further comprehensive studies are necessary to explore inflammatory markers in colonic diverticulitis more thoroughly.

Tobacco Smoking Is a Strong Predictor of Failure of Conservative Treatment in Hinchey IIa and IIb Acute Diverticulitis-A Retrospective Single-Center Cohort Study.

Background and Objectives: Therapeutic management of patients with complicated acute diverticulitis remains debatable. The primary objective of this study is to identify predictive factors for the failure of conservative treatment of Hinchey IIa and IIb diverticular abscesses. Materials and Methods: This is a retrospective cohort study that included patients hospitalized from 1 January 2014 to 31 December 2022 at the Emergency Surgery Department of the Cagliari University Hospital (Italy), diagnosed with acute diverticulitis complicated by Hinchey grade IIa and IIb abscesses. The collected variables included the patient's baseline characteristics, clinical variables on hospital admission, abscess characteristics at the contrast-enhanced CT scan, clinical outcomes of the conservative therapy, and follow-up results. Univariable and multivariable logistic regression models were used to identify prognostic factors of conservative treatment failure and success. Results: Two hundred and fifty-two patients diagnosed with acute diverticulitis were identified from the database search, and once the selection criteria were applied, 71 patients were considered eligible. Conservative treatment failed in 25 cases (35.2%). Univariable analysis showed that tobacco smoking was the most significant predictor of failure of conservative treatment (p = 0.007, OR 7.33, 95%CI 1.55; 34.70). Age (p = 0.056, MD 6.96, 95%CI -0.18; 0.99), alcohol drinking (p = 0.071, OR 4.770, 95%CI 0.79; 28.70), platelets level (p = 0.087, MD -32.11, 95%CI -0.93; 0.06), Hinchey stage IIa/IIb (p = 0.081, OR 0.376, 95%CI 0.12; 1.11), the presence of retroperitoneal air bubbles (p = 0.025, OR 13.300, 95%CI 1.61; 291.0), and the presence of extraluminal free air at a distance (p = 0.043, OR 4.480, 95%CI 1.96; 20.91) were the other variables possibly associated with the risk of failure. In the multivariable logistic regression analysis, only tobacco smoking was confirmed to be an independent predictor of conservative treatment failure (p = 0.006; adjusted OR 32.693; 95%CI 2.69; 397.27). Conclusion: The role of tobacco smoking as a predictor of failure of conservative therapy of diverticular abscess scenarios highlights the importance of prevention and the necessity to reduce exposure to modifiable risk factors.

Risk for colorectal cancer after computed tomography verified acute diverticulitis: A retrospective cohort study with long-term follow-up.

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. 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. 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. 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.

Impact of previous diverticulitis on 5-year survival and recurrence rates in patients with colorectal cancer

Background Diverticulitis and colorectal cancer (CRC) share epidemiological characteristics, but their relationship remains unknown. It is unclear if prognosis following CRC differ for patients with previous diverticulitis compared to those with sporadic cases and patients with inflammatory bowel disease or hereditary syndromes. Aim The aim was to determine 5-year survival and recurrence after colorectal cancer in patients with previous diverticulitis, inflammatory bowel disease and hereditary colorectal cancer compared to sporadic cases. Methods Patients <75 years of age diagnosed with colorectal cancer at Skåne University Hospital Malmö, Sweden, between January 1st 2012 and December 31st 2017 were identified through the Swedish colorectal cancer registry. Data was retrieved from the Swedish colorectal cancer registry and chart review. Five-year survival and recurrence in colorectal cancer patients with previous diverticulitis were compared to sporadic cases, inflammatory bowel disease associated and hereditary colorectal cancer. Results The study cohort comprised 1052 patients, 28 (2.7%) with previous diverticulitis, 26 (2.5%) IBD, 4 (1.3%) hereditary syndromes and 984 (93.5%) sporadic cases. Patients with a history of acute complicated diverticulitis had a significantly lower 5-year survival rate (61.1%) and higher recurrence rate (38.9%) compared to sporadic cases (87.5% and 18.8% respectively). Conclusion Patients with acute complicated diverticulitis had worse 5-year prognosis compared to sporadic cases. The results emphasize the importance of early detection of colorectal cancer in patients with acute complicated diverticulitis.

Primary anastomosis with diverting loop ileostomy versus Hartmann's procedure for acute complicated diverticulitis: analysis of the National Inpatient Sample 2015-2019.

Up to 50% of patients with acute complicated diverticulitis require operative management on their index admission. There is ongoing debate as to whether primary anastomosis with diverting ileostomy versus a Hartmann's procedure is the optimal surgical approach for these patients. This study aims to compare postoperative complications in patients undergoing either Hartmann's procedure or primary anastomosis and diverting ileostomy for perforated diverticulitis using recent National Inpatient Sample data. Patients who underwent either primary anastomosis with diverting ileostomy or Hartmann's procedure for acute complicated diverticulitis from the 2015 to 2019 NIS database sample were included. Primary outcomes were postoperative in-hospital mortality and morbidity. Secondary outcomes were postoperative cause-specific complications, total admission cost, and length of stay (LOS). Univariate and multivariate regression were utilized to compare the two operative approaches. Overall, 642 patients underwent primary anastomosis with diverting ileostomy and 4,482 patients underwent Hartmann's procedure. There was no difference in in-hospital mortality (OR 0.93, 95%CI 0.45-1.92, p = 0.84) or in-hospital morbidity (OR 1.10, 95%CI 0.90-1.35, p = 0.33). Adjusted analysis suggested shorter postoperative LOS for patients undergoing Hartmann's procedure (MD 0.79days, 95%CI 0.15-1.43days, p = 0.013) and decreased total admission cost (MD $4,893.99, 95%CI $1,425.04-$8,362.94, p = 0.006). The present study supports that primary anastomosis with diverting ileostomy is safe for properly selected patients presenting with complicated diverticulitis. Primary anastomosis with diverting ileostomy is associated with greater total hospitalization costs and LOS.

P-016 INCISIONAL HERNIA AFTER ABDOMINAL EMERGENCY SURGERY. IMPACT OF PREVENTIVE SELF-ADHESIVE POLYESTER MESH PLACEMENT

Abstract Objective Analyze the results of the self-adhesive polyester mesh placement in the prevention of the postoperative evisceration and incisional hernia after median abdominal incision during an emergency digestive surgery. Material and methods A prospective observational study was done in those patients who underwent a midline abdominal incision and a self-adhesive polyester mesh was placed in onlay position, for an emergency digestive surgery between December 2020 and December 2022. Analysis was done by means of demographics, body mass index (BMI), blood tests, ASA, P-Possum score, etiology, surgical contamination, abdominal incision closure, postoperative records (≥ 90 days) categorized with Clavien-Dindo (CD) classification and 1 year of follow-up. Results Sixty patients were included, mean age 62.86, (57.6% men), 52% were ASA III, BMI&amp;gt;30 12%. Most frequent etiologies were complicated small bowel obstruction (17) and complicated acute sigmoid diverticulitis (12). Postoperative records showed a 26,6% of morbidity, 93.7% were D I- II (minor) and 6.3% CD IIIb. Neither wound evisceration nor incisional hernia was observed during the follow-up. A significative relationship (p&amp;lt;0.05) was observed between BMI, preoperative C-reactive protein and ASA classification with postoperative complications, same relationship was observed between surgical contamination but without statistical significance. Conclusions In this series, a preventive self-adhesive polyester mesh placement after abdominal midline incision during emergency digestive surgery, showed an acceptable rate of postoperative complications with a low rate of local morbidity and a good results during the follow-up

Evaluation of Clinical Assessment in Predicting Complicated Acute Diverticulitis.

Background Acute diverticulitis is a common surgical condition and one of the leadinggastrointestinal conditions that require hospital admission. The presence of complications increasesthe hospital stay and risk of requiring surgical intervention. This study aimed to investigate the clinical features that can be identified during clinical assessment and evaluate their predictive value and sensitivity in differentiating between complicated and uncomplicated diverticulitis. Methodology This retrospective case-control study was performed on patients with acute diverticulitis at Lyell McEwin Hospital, Adelaide, South Australia. Data were collected for patients presenting from January 2015 to December 2017. Patients with acute diverticulitis confirmed by computed tomography (CT) were included in the study. Multiple clinical assessment aspects were reported and compared between complicated diverticulitis and uncomplicated diverticulitis groups. Results Data from a total of 116 cases were collected, 10 of which were excluded due to lack of CT diagnosis. Forty-four cases had complicated diverticulitis (case group), and 62 cases had uncomplicated diverticulitis (control group). Twenty-three cases (52.2%) had the first episode of diverticulitis in the complicated group compared to 24 cases (38.7%) in the uncomplicated group, with an odds ratio of 1.73 (0.79-3.789). Eight cases (18.2%) had previously complicated diverticulitis in the complicated group compared to 11 cases (17.7%) in the uncomplicated group, with an odds ratio of 1.03 (0.37-2.82). Six cases (13.6%) had a fever (T > 38) in the complicated group compared to two cases (3.2%) in the uncomplicated group, with an odds ratio of 4.74 (0.9-24.7), a sensitivity of only 13.64%, and a specificity of 96.77%. Twelve cases (27.3%) had tachycardia, two cases (4.5%) had hypotension, and five cases (11.4%) had peritonism in the complicated group compared to two cases (3.2%), one case (1.6%), and one case (1.6%) in the uncomplicated group, with odds ratios of 11.25 (2.37-53.4), 2.9 (0.255-33), and 7.82 (0.88-69.5), respectively; sensitivity was 27.27%, 4.55%, and 11.36% for tachycardia, hypotension, and peritonism, whereas specificity was 96.77%, 98.39%, and 98.39%, respectively. Conclusions The study found no significant correlation between having complicated diverticulitis and previous episodes of complicated diverticulitis, immunosuppression, pain severity, or change in bowel habits. Perrectal bleeding was found to reduce the risk of having complicated diverticulitis. Our results did not demonstrate a statistically significant relationship between the first episode of diverticulitis and having complicated diverticulitis. Physical signs, when abnormal, are highly specific in predicting complicated diverticulitis. Tachycardia was found to have the highest positive predictive value and odds ratio compared to the other observed physical signs.

Association Between Coronavirus Disease 2019 and Acute Complicated Diverticulitis.

Background Gastrointestinal manifestations of coronavirus disease 2019 (COVID-19) are increasingly recognized. Through potentially overlapping pathophysiology, co-occurrence of COVID-19 and first-time acute diverticulitis has been reported. Our study aims to further characterize this association in COVID-19-positive patients within a large tertiary care academic center. Methodology Patients diagnosed with COVID-19 who subsequently developed acute diverticulitis within 30 days were identified between 2020 and 2022. COVID-19 and acute diverticulitis were diagnosed by polymerase chain reaction and computed tomography, respectively. Patients with prior history of acute diverticulitis were excluded. Patient characteristics and comorbid conditions were collected. Characterization of the COVID-19 course (treatment setting, medical/ventilatory therapy) and acute diverticulitis (treatment setting, medical/surgical therapy, complications) was performed retrospectively. Subanalysis was performed by COVID-19 vaccination status, the severity of COVID-19, and the timing of acute diverticulitis diagnosis. Results A total of 81 patients were identified, with a median duration between COVID-19 diagnosis and acute diverticulitis of 13 days (interquartile range = 2.5-21.0), with 44.4% of patients requiring hospitalization for COVID-19. The all-cause complication rate of acute diverticulitis was noted to be 59.3%, most commonly intestinal perforation (39.5%), abscess formation (37.0%), and peritonitis (14.8%). Although a trend toward increased all-cause complications (65.9%), intestinal perforation (43.9%), and peritonitis (19.5%) was noted in unvaccinated patients, this did not reach significance. Although all-cause complication rate did not differ in patients diagnosed with acute diverticulitis at the time of COVID-19 presentation, a significantly elevated incidence of intestinal perforation (55.9% vs. 27.7%, p = 0.01), peritonitis (29.4% vs. 4.3%, p < 0.01), and the need for emergent surgical intervention (38.2% vs. 10.6%, p < 0.01) was noted. Conclusions Our study indicates that patients diagnosed with first-time acute diverticulitis within 30 days of COVID-19 infection have a high complication rate, most commonly intestinal perforation. Additionally, patients diagnosed with acute diverticulitis at the same time as COVID-19 detection had a significantly elevated rate of complications and emergent surgical needs. Given the high complication rate, patients who develop diverticulitis within a short timeframe of COVID-19 infection may benefit from increased clinician vigilance and monitoring.

EUS-guided ileorectal anastomosis for relief of complete benign small-bowel obstruction (with video)

A 52-year-old man underwent an ileorectal anastomosis after a subtotal colectomy because of acute complicated diverticulitis. Seven days later, a CT scan revealed a pneumoperitoneum (A), but no clear perforation was discovered during surgery. Endoscopy disclosed a complete stenosis of the anastomosis, 15 cm from the dentate line, which prevented us from advancing a guidewire (B). A linear-array echoendoscopy (performed with EUS) was performed through the rectum, and the ileal loop with liquid inside was identified.

899 A Closed Loop Audit of Imaging Rate in Suspected Complicated Acute Diverticulitis

Abstract Aim Diverticular disease is commonly encountered in western populations, with complicated acute diverticulitis potentially leading to significant morbidity and mortality. The National Institute for Health and Care Excellence (NICE) recommend imaging these patients within 24-hours of admission, which is essential to confirm diagnosis and guide further management. We aimed to audit the imaging rate in suspected complicated acute diverticulitis within our department and identify ways to improve this. Method Data were collected from all patients admitted from January to June 2021 with suspected complicated acute diverticulitis as defined by NICE. Patients with normal inflammatory markers were excluded. Electronic records were reviewed for evidence of imaging performed within 24-hours of hospital admission and the imaging rate was compared with the previous audit cycle. Results 96 patients were admitted with suspected complicated acute diverticulitis. 83 patients had raised inflammatory markers. 76 (91.6%) of these had contrast computer tomography (CT) scans performed within 24-hours of admission. Of the 7 (8.4%) patients who did not undergo imaging within 24-hours, 3 had recent imaging suggestive of diverticular disease or diverticulitis, 2 were treated with antibiotics, 1 patient refused, and 1 had CT within 48-hours due to delays waiting for dialysis. Conclusions We have shown continued good compliance with NICE guidelines, though the imaging rate has declined slightly compared with the previous audit cycle (94.3%). In order to maintain and improve these standards, we will offer educational sessions within our department to underline the importance of timely imaging in this patient group and continue to audit our performance.

SP9.1.6 Save the scope - a 3-year analysis of follow-up methods for acute diverticulitis and the incidence of colorectal malignancy

Abstract Aims Previously, guidelines for the management of diverticular disease have recommended endoscopic evaluation following acute diverticulitis to exclude colorectal cancer (CRC). However, 2021 ACPGBI consensus guidelines recognised the sensitivity of modern CT scanning and low incidence of CRC, and suggested no routine re-imaging in CT-proven uncomplicated disease. Methods Patient were identified presenting between 2017–2019 at a single centre. Records were retrospectively reviewed to evaluate the incidence of CRC at a minimum of 18-month follow up in this patient group. Secondary outcomes included the imaging method requested, operative management, and complications following endoscopy. Results Of 486 admissions in 461 patients, 168 (35%) had CT-proven complicated disease, 225 (46%) had uncomplicated, and 93 (19%) had no imaging. 281 (59%) had follow-up investigations requested; 126 CT colonoscopy (CTC) and 150 endoscopic. 133 investigations were performed in patients with uncomplicated diverticulitis. Only 6 patients (1%) were diagnosed with CRC; 2 at endoscopy, and 4 by histology from colorectal resections during emergency admission; all had CT-proven complicated diverticulitis. No malignancy was identified in patients with uncomplicated diverticulitis. Secondary outcomes identified that 26 (24%) flexible sigmoidoscopies were poorly tolerated, necessitating further imaging. Conclusions At our centre, there was little consensus on whether patients had follow-up imaging following acute diverticulitis, and what modality was used. We identified no CRC in patients with CT-proven uncomplicated disease, with 133 potentially unnecessary investigations performed in this group. We recommend use of CTC or endoscopy following acute CT-proven complicated diverticulitis in line with ACPGBI guidelines, avoiding follow-up in uncomplicated disease.

Value of computed tomography scores in complicated acute diverticulitis.

Diverticular disease remains one of the most common conditions in the western world. Up to 25% of patients with diverticular disease require hospitalization, 15-30% of those of which require surgical intervention. CT scoring systems have been proposed as means to drive assessment and stratify patients necessitating hospital intervention. To assess and correlate CT scoring systems with clinical and surgical outcomes. Retrospective cohort analysis at a single institution. Single institutional assessment with patients presenting to emergency with a CT diagnosed episode of acute diverticulitis. One hundred and eighty-nine patients were included in the study, 61% of which were male. Patient demographics, comorbidities, medications, biochemistry and inflammatory markers, type of complication following acute diverticulitis, operative/procedural intervention, hospital outcome and mortality were measured. CT scoring systems assessed included modified Hinchey, modified Neff, World Society of Emergency Surgery (WSES) and modified Siewert scoring systems. Majority of patients had left-sided diverticulitis (91%) with localized air (88%) and pericolic abscess (49%) the most common radiological findings. 28% of patients required radiological and/or surgical management with 12% requiring intensive care unit (ICU) admission. There was a general trend for surgical/radiological intervention as the scores increased in severity. The four scoring systems were found to be statistically significant predictors of any intervention and of ICU admission with minimal statistical differences across the different scoring systems. Radiological CT scores for complicated diverticulitis are at best, moderate predictors of clinical and surgical outcomes and may serve to guide management with minimal statistical differences across different scores.

Risk factors for recurrence and complications in acute uncomplicated diverticulitis: A retrospective cohort study

IntroductionAntibiotics for acute uncomplicated diverticulitis (AUD) have been questioned in several studies. Thus, it is of value to identify risk factors for recurrence and complications to identify the best strategy for treatment. The aim was to investigate risk factors for recurrence and complications within at least 1 year after hospitalization for AUD. MethodsThis is a retrospective study, including patients hospitalized with AUD at Helsingborg Hospital and Skåne University Hospital in Sweden during January 1st, 2015–December 31st, 2017. The cohort was primarily collected via the in-patient registry. Patients with multiple registrations, acute complicated diverticulitis, ongoing antibiotics, other diagnoses, immunosuppression and non-CT-verified diagnosis were excluded. Follow-up was ≥1 year. SPSS was used for statistical analysis. ResultsOut of 596 patients, 23% experienced recurrences and 3% experienced complications. Previous diverticulitis [OR 2.86 (CI 1.85–4.55) P < 0.001] and complications [OR 1.35 (CI 1.18–1.42) P < 0.001] were independent risk factors for recurrence. A higher Charlson morbidity index (CMI) [OR 1.27 (1.0–1.61) P = 0.04] and previous diverticulitis [OR 3.68 (1.24–10.9) P = 0.013] were associated with complications. 75% of the patients received antibiotics but this did not significantly improve outcomes. ConclusionA history of previous diverticulitis or complications increases the risk for AUD recurrence. A higher CMI and a history of previous diverticulitis may be risk factors for complications but needs to be further assessed. Treatment with antibiotics does not appear to improve the outcome. Choice of treatment should therefore be individualized and based on risk factors for complications and recurrence.

Potential risks and treatment options for colonic diverticular disease Novelties based on international guidelines

The prevalence of colonic diverticulosis is growing worldwide due to dietary and lifestyle changes. Colonic diverticulosis does not cause any complaints in a significant proportion of individuals; therefore, it is usually diagnosed by accident and does not require any treatment. Diverticular disease, which constitutes about 25% of the cases, is associated with presenting symptoms, and has various forms based on the course and severity of the disease. From the early 2000s, the better understanding of the pathophysiologic pathways which play a role in the development of the diverticular disease (genetic background, low-grade chronic inflammation and intestinal dysbiosis) promoted prevention, diagnostics and finding treatment options. The main conclusions: It is a challenge to distinguish uncomplicated but symptomatic diverticular disease from irritable bowel syndrome. The prevalence of acute diverticulitis is lower than it was previously assumed. The role of diagnostic imaging, mainly abdominal computer tomography, has become more important to aid the rapid and correct diagnosis of acute diverticulitis and to determine its severity. Although a high-fiber diet may be recommended for general health purposes, there is little evidence that it benefits recovery during acute diverticulitis episodes or prevents recurrent episodes. Traditional antibiotic therapy as the mainstay of treatment of acute uncomplicated diverticulitis such as routine hospital admission has been challenged recently. In an acute episode of diverticulitis, performing colonoscopy should be avoided as it is associated with an increased risk of colonic perforation. If there was no screening colonoscopy within 3 years, it is strongly recommended at least 6 weeks after the acute episode to exclude colorectal carcinoma. Routine colonoscopy may be omitted in certain cases. Complicated acute diverticulitis should not necessarily be treated by emergency surgery. In thecase of hemodynamically stable and immunocompetent patients, resection with primary anastomosis may be preferred over a Hartmann's procedure for the treatment of perforated diverticulitis and diffuse peritonitis. With this review, the authors intend to facilitate providing up-to-date and customized treatment of diverticular disease in the daily practice.

Conservative management of complicated colonic diverticulitis: long-term results.

The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease. To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis. This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05). Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.