Diagnosis Of Acute Uncomplicated Diverticulitis Research Articles

Diagnosis of acute uncomplicated diverticulitis by sonography in the general practitioner's office

Diagnosis of acute uncomplicated diverticulitis by sonography in the general practitioner's office

ACUTE UNCOMPLICATED DIVERTICULITIS: Guidelines on Diagnosis and Management: is everything fine?

The transition from intravenous (IV) antibiotic therapy to oral therapy and the observation that in patients with acute uncomplicated diverticulitis (AUD), treatment with or without antibiotics gave similar results in both hospitalized and outpatients, opened the way for out-of-hospital treatment in selected patients with CT-confirmed diagnosis. Due to economic constraints and a growing demand for hospitalization, home hospital care (HAH) and other community-based services was supported to alleviate the burden on emergency departments (EDs). This resulted in significant cost savings for the National Health Service (NHS) but, in many countries, community services are not uniformly present, leading to health care inequality. Relationships between hospital and community doctors indicate poor professional communication. Shared guidelines could lead to increased adherence. Some conditional recommendations based on low-certainty evidence related to the diagnosis and management of AUD remain controversial. Even after recovery from an episode, the question of whether to pursue conservative management or elective surgery is still open for debate. The outpatient treatment is understood as referring to both patients managed by hospital doctors and those treated by general physicians in their office. On management and outcomes of patients with AUD diagnosis in primary care there is little data. AUD treatment without antibiotics encounters resistance in many countries for multiple reasons, including low implementation and uncertain dissemination of guidelines recommendations. This would require greater control and commitment on the part of Institutional bodies and scientific societies.

SP10.1.8 Acute uncomplicated diverticulitis: to scope or not to scope?

AimsTo investigate whether endoscopic follow up after a CT proven diagnosis of acute uncomplicated diverticulitis detected additional pathology, specifically colorectal cancer, and if our findings support the European Society of Coloproctology's consensus statement that “a single episode of CT verified uncomplicated diverticulitis endoscopic follow-up remains controversial and may not be necessary”.MethodsA retrospective study evaluated every General Surgical emergency admission with acute uncomplicated diverticulitis to our unit in a 5 year period (2015–2020) to assess for radiological diagnosis and endoscopic follow up.ResultsOver the 5 years there were 685 admissions with acute uncomplicated diverticulitis affecting 547 individuals. 74.3% of admissions and 80.3% of individuals underwent a Computerised Tomography (CT) during admission. 244 admissions (48%) went on to have an endoscopic examination, with 12.3% of these being inpatient investigations. 50% (122) of patients undergoing endoscopy had confirmed uncomplicated diverticulitis. Of the remaining patients undergoing endoscopy, 79.5% had no pathology detected. Only 1 malignant polyp was discovered on endoscopy with no tumours detected.ConclusionsCT has a high sensitivity and specificity in the diagnosis of acute uncomplicated diverticulitis. We suggest that it is reasonable not to utilise endoscopy as a screening tool after uncomplicated diverticulitis and the risks versus benefits must be carefully considered, especially in the era of Covid-19 where resources are tight and waiting lists ever growing. An endoscopic procedure is a costly, uncomfortable procedure that puts the patient at risk of morbidity and mortality.Our findings support the European Society of Coloproctology's statement regarding endoscopic follow-up.

Acute uncomplicated diverticulitis: key points for early management. A single-centre retrospective study.

Acute uncomplicated diverticulitis is an important clinical condition usually managed in clinical practice with antibiotic therapies and hospitalization in ward. In this setting, recent papers and guidelines suggest to limit the use of antibiotics in selected cases and encourage an early discharge in low-risk patients. The purpose of this retrospective study is to identify serological inflammatory markers and CT findings of acute uncomplicated diverticulitis (AUD) at the onset of the disease and the correlation with the need for in-patient or out-patient management. It was used a database drawn from the collection of the patients admitted to our Emergency Room from January 2016 to 2019 and undergoing urgent abdominal CT-scan for suspicious of acute diverticulitis. For each patient we considered biochemical and radiological parameters at the onset of the disease and if patients were managed as in-patients (hospitalization in ward) or as out-patient (early discharged or after observation in Short Stay Unit). Among patients with early diagnosis of AUD, 108 (65%) were hospitalized in ward with mean time of in-stay of 6.94 days, while only 58 (35%) patients with same diagnosis were managed as out-patient and early discharged from emergency room or after observation in short stay unit with a mean time of in-stay significantly shorter (3.39 days, p-value 0.0007). Higher levels of C reactive protein and the length of colon involved considered as percentage (%) in comparison with the entire colon were significantly related to the need for hospitalization (p-value 0.03). Biochemical parameters and a more advanced radiological evaluation, as the length (%) of colon involved, could allow a stratification of patients with diagnosis of AUD at the admission and help physicians in the early management.

The efficacy of a mix of three probiotic strains in reducing abdominal pain and inflammatory biomarkers in acute uncomplicated diverticulitis.

Acute Uncomplicated Diverticulitis (AUD) is defined as the inflammation of a colon diverticulum, often involving colic wall and pericolic fat. Conventional treatment of AUD includes antibiotics, usually ciprofloxacin and metronidazole, fasting, and fluid therapy. The aim of this study was to test the efficacy of a mix of three probiotic strains (Bifidobacterium lactis LA 304, Lactobacillus salivarius LA 302, Lactobacillus acidophilus LA 201; Lactibiane Iki®, Biocure [PiLeJe Groupe], Italy/PiLeJe Laboratoire, France) in association with conventional antibiotics in treating AUD compared to conventional antibiotics used alone. We enrolled 84 (25M/59F mean age 61.5 ± 11.5 years) consecutive patients who came to the Emergency Department of the Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy, with a diagnosis of AUD confirmed by CT scan. After routine blood test and dosage of C-reactive protein (C-RP), patients were randomly divided into two groups: Probiotic group (42 patients, 10M/32F mean age 32.23 ± 10.3 years) was treated with ciprofloxacin 400 mg twice a day and metronidazole 500 mg three times a day for one week and simultaneously supplemented with the probiotic mix, 1 sachet twice a day for 10 days. Control group (42 patients, 15M/27F mean age 59.01 ± 11.3 years) received the same antibiotic treatment without the probiotic mix. All patients filled a daily Visual Analog Scale (VAS) for assessment of abdominal pain, with a range value from 0 (asymptomatic) to 10, and CRP value was determined on admission and at discharge. As regards abdominal pain, on Day 3, Group A showed a significant decrease of 4.06 points (51.4%) in VAS score compared to a decrease of 2.79 points (34.9%) in Group B. On Day 5 the decrease was of 6.3 points (80%) in Group A and of 4.85 points (61%) in Group B. VAS score was reduced by 7.59 points (96%) in Group A and 6.1 points (76%) in Group B on Day 7 +, and by 7.8 points (99%) in Group A and 7.2 points (90%) in Group B on Day 10. About inflammation, Group A showed a decrease in C-RP value of 64%, compared to a decrease of only 35% in Group B. We also observed that the duration of hospitalization was significantly shorter for patients in Group A: 89 h (3.7 days) in Group A vs. 101 h (4.2 days) in Group B (p=0.03). Our results indicated showed that the supplement with the probiotic mix of Bifidobacterium lactis LA 304, Lactobacillus salivarius LA 302, and Lactobacillus acidophilus LA 201 in combination with the standard antibiotic therapy for AUD reduced abdominal pain and inflammation significantly more than antibiotic treatment used alone. These findings could be due to the anti-inflammatory activity of the probiotic mix. Larger studies are needed to validate its use in the clinical practice.

Supplementation with Lactobacillus reuteri ATCC PTA 4659 in patients affected by acute uncomplicated diverticulitis: a randomized double-blind placebo controlled trial.

Acute uncomplicated diverticulitis (AUD) is an inflammation of the colon diverticulum. We tested the efficacy of Lactobacillus reuteri 4659 (L. reuteri) in treating AUD. Primary outcome was reduced abdominal pain and inflammatory markers (C-RP). Secondary outcome was reduced hours of hospitalization. A double-blind, placebo RCT was conducted with 88 (34M/54F mean age 61.9 ± 13.9) patients with a diagnosis of AUD. Group A (44 patients, 26F): ciprofloxacin 400mg/bid and metronidazole 500mg/tid for 1week, plus L. reuteri/bid for 10days. Group B (44 patients, 28F): same antibiotic therapy for 1week, plus placebo/bid for 10days. All patients completed a daily visual analog scale (VAS) for abdominal pain. Between days 1 and 3, the group A pain decreased by 4.5 points; group B decreased by 2.36 points (p < 0.0001). Between days 1 and 5, the group A decreased by 6.6 points; group B by 4.4 points (p < 0.0001). Between days 1 and 7, the group A decreased by 7.6 points; group B decreased by 5.6 points (p < 0.0001). Between days 1 and 10, the group A decreased by 8.1 points; group B decreased by 6.7 points (p < 0.0001). For C-RP value, the mean decrease between admission and after 72h was 45.3mg/L for group A and 27.49mg/L for group B (p < 0.0001). Our RCT showed that supplementation of the standard AUD therapy with L. reuteri strain 4659 significantly reduced abdominal pain and inflammatory markers compared with the placebo group. It also resulted in a shorter period of hospitalization, and thus has economic benefits. TRIALGOV: NCT03656328.

Low risk of complications in patients with first-time acute uncomplicated diverticulitis

PurposeFirst-time acute uncomplicated diverticulitis (AUD) has been considered to have an increased risk of complication, but the level of evidence is low. The aim of the present study was to evaluate the risk of complications in patients with first-time AUD and in patients with a history of diverticulitis.MethodsThis paper is a population-based retrospective study at Västmanland’s Hospital, Västerås, Sweden, where all patients were identified with a diagnosis of colonic diverticular disease ICD-10 K57.0–9 from January 2010 to December 2014. The records of all patients were surveyed and patients with a computed tomography (CT)-verified AUD were included. Complications defined as CT-verified abscess, perforation, colonic obstruction, fistula, or sepsis within 1 month from the diagnosis of AUD were registered.ResultsOf 809 patients with AUD, 642 (79%) had first-time AUD and 167 (21%) had a previous history of AUD with no differences in demographic or clinical characteristics. In total, 16 (2%) patients developed a complication within 1 month irrespective of whether they had a previous history of diverticulitis (P = 0.345). In the binary logistic regression analysis, first-time diverticulitis was not associated with increased risk of complications (OR 1.58; CI 0.52–4.81). The rate of antibiotic therapy was about 7–10% during the time period and outpatient management increased from 7% in 2010 to 61% in 2014.ConclusionsThe risk for development of complications is low in AUD with no difference between patients with first-time or recurrent diverticulitis. This result strengthens existing evidence on the benign disease course of AUD.

Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis.

To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis. We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay. Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03). Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.

Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review

It is generally accepted that patients following an episode of diverticulitis should have additional colonoscopy screening to rule out a colorectal malignancy. We aimed to investigate the rate of CRC found by colonoscopy after an attack of uncomplicated diverticulitis. MEDLINE, Embase, and Cochrane databases were searched systematically for clinical trials or observational studies on colonic evaluation by colonoscopy after the initial diagnosis of acute uncomplicated diverticulitis, followed by hand-searching of reference lists. Nine studies met the inclusion criteria and included a total number of 2,490 patients with uncomplicated diverticulitis. Subsequent colonoscopy after an episode of uncomplicated diverticulitis was performed in 1,468 patients (59%). Seventeen patients were diagnosed with CRC, having a prevalence of 1.16% (95% confidence interval 0.72-1.9% for CRC). Hyperplastic polyps were seen in 156 patients (10.6%), low-grade adenoma in 90 patients (6.1%), and advanced adenoma was reported in 32 patients (2.2%). Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required.

Routine colonoscopy following acute uncomplicated diverticulitis

The evidence supporting current recommendations that the colon should be evaluated following an initial episode of acute diverticulitis is poor. The aim of this study was to clarify whether acute uncomplicated diverticulitis is a valid indication for subsequent colonoscopy/computed tomography (CT) colonography. This was a retrospective longitudinal study of patients with an initial presentation of acute uncomplicated diverticulitis on the basis of CT criteria, at a single institution between January 2004 and December 2008. A radiological diagnosis of acute uncomplicated diverticulitis was made in 292 patients. Some 205 patients underwent subsequent colonic evaluation or had undergone colonoscopy/CT colonography within the preceding 2 years. Colorectal polyps were present in 50 patients (24·4 per cent). Twenty patients (9·8 per cent) had hyperplastic polyps and 19 (9·3 per cent) had adenomas. Eleven patients (5·4 per cent) had advanced colonic neoplasia, including one (0·5 per cent) with a colorectal cancer. One patient had inflammatory bowel disease (IBD). The patients with colorectal cancer and IBD had clinical indicators that independently warranted colonoscopy. None of the 87 patients who did not undergo colonic evaluation had a diagnosis of colorectal cancer registered with the New Zealand Cancer Registry. The yield of advanced colonic neoplasia in this cohort was equivalent to, or less than that detected on screening asymptomatic average-risk individuals. In the absence of other indications, subsequent evaluation of the colon may not be required to confirm the diagnosis of diverticulitis.

Assessment of Three Different Therapeutic Strategies in Preventing Diverticulitis Recurrence

Background and Aim: Colonic diverticulitis shows an high recurrence rate. Since no conclusive data are available about the optimal strategy in preventing diverticulitis recurrence, aim of our study was to assess three different therapeutic strategies in preventing diverticulitis recurrence Methods: 130 patients suffering from Acute Uncomplicated Diverticulitis (AUD) (81 Males, 49 Females, mean age 64.71 years, range 40-85) were prospectively assessed during a 2-year follow-up. After obtaining remission, the patients were treatedwithmesalazine 1.6 grams every day (59 patients, group A), or rifaximin 800 mg/day for 7 days every month (52 patients, group B), or did not take any therapy (19 patients, group C). Clinical, endoscopic and histological follow-up was performed after six, 12 and therefore every 12 months after diagnosis of AUD. Results: Fifty-four patients were excluded from final evaluation (see figure 1): 17 patients died; 21 were excluded due to taking unprescribed drugs during the scheduled treatment; 16 were lost to follow-up or were excluded because not compliant. Forty-four group A patients, 23 group B patients, 9 group C patients were available for the final assessment. Sustained remission was statistically higher in group A (93.18%) than group B (56.52%) and group C (44.44%) (A vs B: p=0.01; A vs C: p=0.03; B vs C: p=0.072). Persistence of endoscopic and histological damage were the only factors affecting diverticulitis recurrence. Conclusions: Patients taking mesalazine have lower risk of diverticulitis recurrence than patients taking rifaximin or taking no therapy, thanks to lower prevalence of persisting endoscopic and histological inflammation than in patients taking rifaximin or taking no therapy

Isolated Slow Small Bowel Transit Time by Wmc: Defining Patient Population, Clinical Symptoms, and Proximal Small Bowel Pressure Profile

Background and Aim: Colonic diverticulitis shows an high recurrence rate. Since no conclusive data are available about the optimal strategy in preventing diverticulitis recurrence, aim of our study was to assess three different therapeutic strategies in preventing diverticulitis recurrence Methods: 130 patients suffering from Acute Uncomplicated Diverticulitis (AUD) (81 Males, 49 Females, mean age 64.71 years, range 40-85) were prospectively assessed during a 2-year follow-up. After obtaining remission, the patients were treatedwithmesalazine 1.6 grams every day (59 patients, group A), or rifaximin 800 mg/day for 7 days every month (52 patients, group B), or did not take any therapy (19 patients, group C). Clinical, endoscopic and histological follow-up was performed after six, 12 and therefore every 12 months after diagnosis of AUD. Results: Fifty-four patients were excluded from final evaluation (see figure 1): 17 patients died; 21 were excluded due to taking unprescribed drugs during the scheduled treatment; 16 were lost to follow-up or were excluded because not compliant. Forty-four group A patients, 23 group B patients, 9 group C patients were available for the final assessment. Sustained remission was statistically higher in group A (93.18%) than group B (56.52%) and group C (44.44%) (A vs B: p=0.01; A vs C: p=0.03; B vs C: p=0.072). Persistence of endoscopic and histological damage were the only factors affecting diverticulitis recurrence. Conclusions: Patients taking mesalazine have lower risk of diverticulitis recurrence than patients taking rifaximin or taking no therapy, thanks to lower prevalence of persisting endoscopic and histological inflammation than in patients taking rifaximin or taking no therapy

P.1.110: CLINICAL PATTERNS CAN DISTINGUISH DIVERTICULAR DISEASE FROM IRRITABLE BOWEL SYNDROME: A CASE-CASE MATCHING STUDY

Background and Aim: Colonic diverticulitis shows an high recurrence rate. Since no conclusive data are available about the optimal strategy in preventing diverticulitis recurrence, aim of our study was to assess three different therapeutic strategies in preventing diverticulitis recurrence Methods: 130 patients suffering from Acute Uncomplicated Diverticulitis (AUD) (81 Males, 49 Females, mean age 64.71 years, range 40-85) were prospectively assessed during a 2-year follow-up. After obtaining remission, the patients were treatedwithmesalazine 1.6 grams every day (59 patients, group A), or rifaximin 800 mg/day for 7 days every month (52 patients, group B), or did not take any therapy (19 patients, group C). Clinical, endoscopic and histological follow-up was performed after six, 12 and therefore every 12 months after diagnosis of AUD. Results: Fifty-four patients were excluded from final evaluation (see figure 1): 17 patients died; 21 were excluded due to taking unprescribed drugs during the scheduled treatment; 16 were lost to follow-up or were excluded because not compliant. Forty-four group A patients, 23 group B patients, 9 group C patients were available for the final assessment. Sustained remission was statistically higher in group A (93.18%) than group B (56.52%) and group C (44.44%) (A vs B: p=0.01; A vs C: p=0.03; B vs C: p=0.072). Persistence of endoscopic and histological damage were the only factors affecting diverticulitis recurrence. Conclusions: Patients taking mesalazine have lower risk of diverticulitis recurrence than patients taking rifaximin or taking no therapy, thanks to lower prevalence of persisting endoscopic and histological inflammation than in patients taking rifaximin or taking no therapy

Predictive Value of Serologic Markers of Degree of Histologic Damage in Acute Uncomplicated Colonic Diverticulitis

Acute uncomplicated diverticulitis (AUD) may show histologic and serologic signs of inflammation. To assess whether serologic markers of inflammation may be predictive of abnormal histology in AUD. Twenty-one consecutive patients affected by AUD were studied (15 Males, 6 Females, mean age 66.19 y, range 43 to 85 y). Diagnosis of AUD was based on specific endoscopic and CT scan patterns. Several serologic markers were assessed [White blood cells (WBC), Erytro-sedimentation Rate, C-reactive protein (CRP), fibrinogen, α1-acid glycoprotein]. Neutrophilic and lymphocytic inflammatory infiltrate was also scored. WBC was increased in 4/21 pts (19.4%), Erytro-sedimentation Rate in 12/21 pts (57.14%), CRP in 13/21 pts (61.9%), fibrinogen in 5/21 pts (23.8%), and α1-acid glycoprotein in 6/21 pts (28.57%). All serologic markers were related with the degree of histologic damage. In patients scoring 3 in neutrophilic infiltrate (severe active inflammation), all markers showed a statistical significant relation (ranging from P=0.004 for WBC to P=0.00001 for fibrinogen). CRP was the most sensitive marker of mild-moderate histologic damage, as it was increased in 4/10 (40%) patients scoring 0 or 1 in neutrophilic infiltrate (absence of mild active inflammation) (P=0.005). Serologic markers showed a strict relation with the degree of histologic damage in AUD. Moreover, CRP is the most sensitive marker of mild-moderate histologic damage.

A multicenter randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis (DIABOLO trial)

BackgroundConservative treatment of uncomplicated or mild diverticulitis usually includes antibiotic therapy. It is, however, uncertain whether patients with acute diverticulitis indeed benefit from antibiotics. In most guidelines issued by professional organizations antibiotics are considered mandatory in the treatment of mild diverticulitis. This advice lacks evidence and is merely based on experts' opinion. Adverse effects of the use of antibiotics are well known, including allergic reactions, development of bacterial resistance to antibiotics and other side-effects.MethodsA randomized multicenter pragmatic clinical trial comparing two treatment strategies for uncomplicated acute diverticulitis. I) A conservative strategy with antibiotics: hospital admission, supportive measures and at least 48 hours of intravenous antibiotics which subsequently are switched to oral, if tolerated (for a total duration of antibiotic treatment of 10 days). II) A liberal strategy without antibiotics: admission only if needed on clinical grounds, supportive measures only. Patients are eligible for inclusion if they have a diagnosis of acute uncomplicated diverticulitis as demonstrated by radiological imaging. Only patients with stages 1a and 1b according to Hinchey's classification or "mild" diverticulitis according to the Ambrosetti criteria are included. The primary endpoint is time-to-full recovery within a 6-month follow-up period. Full recovery is defined as being discharged from the hospital, with a return to pre-illness activities, and VAS score below 4 without the use of daily pain medication. Secondary endpoints are proportion of patients who develop complicated diverticulitis requiring surgery or non-surgical intervention, morbidity, costs, health-related quality of life, readmission rate and acute diverticulitis recurrence rate. In a non-inferiority design 264 patients are needed in each study arm to detect a difference in time-to-full recovery of 5 days or more with a power of 85% and a confidence level of 95%. With an estimated one percent of patients lost to follow up, a total of 533 patients will be included.ConclusionA clinically relevant difference of more than 5 days in time-to-full recovery between the two treatment strategies is not expected. The liberal strategy without antibiotics and without the strict requirement for hospital admission is anticipated to be more a more cost-effective approach.Trial registrationTrial registration number: NCT01111253