First Episode Of Diverticulitis Research Articles

Outcomes of initially nonoperative management of diverticulitis with abscess formation in immunosuppressed patients. DIPLICAB study COLLABORATIVE group.

Management of diverticulitis with abscess formation in immunosuppressed patients (IMS) remains unclear. The main objective of the study was to assess short- and long-term outcomes between IMS and immunocompetent patients (IC). The secondary aim was to identify risk factors for emergency surgery. A nationwide retrospective cohort study was performed at 29 Spanish referral centres between 2015-2019 including consecutive patients with first episode of diverticulitis classified as modified Hinchey Ib or II. IMS included immunosuppressive therapy, biologic therapy, malignant neoplasm with active chemotherapy and chronic steroid therapy. A multivariate analysis was performed to identify independent risk factors to emergency surgery in IMS. A total of 1395 patients were included; 118 IMS and 1277 IC. There were no significant differences in emergency surgery between IMS and IC (19.5% and 13.5%, p = 0.075) but IMS was associated with higher mortality (15.1% vs. 0.6%, p < 0.001). Similar recurrent episodes were found between IMS and IC (28% vs. 28.2%, p = 0.963). Following multivariate analysis, immunosuppressive treatment, p = 0.002; OR: 3.35 (1.57-7.15), free gas bubbles, p < 0.001; OR: 2.91 (2.01-4.21), Hinchey II, p = 0.002; OR: 1.88 (1.26-2.83), use of morphine, p < 0.001; OR: 3.08 (1.98-4.80), abscess size ≥5 cm, p = 0.001; OR: 1.97 (1.33-2.93) and leucocytosis at third day, p < 0.001; OR: 1.001 (1.001-1.002) were independently associated with emergency surgery in IMS. Nonoperative management in IMS has been shown to be safe with similar treatment failure than IC. IMS presented higher mortality in emergency surgery and similar rate of recurrent diverticulitis than IC. Identifying risk factors to emergency surgery may anticipate emergency surgery.

Preventing acute diverticulitis. any roles for non-absorbable antibiotics? in search of evidence: a systematic review, meta-analysis, and trial sequential analysis

BackgroundHospital admissions for diverticulitis, a complication of diverticular disease, are very much on the increase. Prevention of diverticulitis could cut costs and save lives.AimsTo identify whether the risk of the first episode of diverticulitis (primary prevention) or recurrence of diverticulitis (secondary prevention) can be reduced in patients with diverticular disease using non-absorbable antibiotics (mainly rifaximin).MethodsThe studies were identified by searching PubMed and CENTRAL from 1990 to May 2022. The methodological quality of each study was also evaluated. The outcome of the meta-analysis was the occurrence of a first or subsequent episode of diverticulitis. In addition, a trial sequential analysis was performed to evaluate whether the results would be subject to type I or type II errors.ResultsPrimary prevention: the risk difference was statistically significant in favor of rifaximin (-0,019, or -1.9%, CI -0,6 to -3,3%). There was no evidence of heterogeneity (I2 0%). At one year, two years, and eight years of age, the NNT was 62, 52, and 42, respectively. The level of evidence had a moderate degree of certainty. Secondary prevention: the risk difference was statistically significant in favor of rifaximin (- 0,24, or -24%, CI -47 to -2%). There was evidence of heterogeneity (I2 92%); NNT resulted in 5. The grade level was low.ConclusionsRifaximin can lower the risk of a first episode of diverticulitis. However, the cost-benefit ratio currently appears too high. Rifaximin could also reduce the risk of a second episode, but the quality of the evidence is low.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42022379258.

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.

Computed tomography diagnosed first time diverticulitis and colorectal cancer.

Computed tomography (CT) with intravenous contrast is the gold standard for diagnosing diverticulitis. Published results concerning follow-up colonoscopy after an episode of acute diverticulitis to rule out cancer are conflicting. This study aimed to evaluate the risk of underlying colonic malignancy in patients diagnosed with a first time diverticulitis with a state of the art CT investigation with intravenous contrast. Retrospective analysis of all patients with a first episode of diverticulitis diagnosed with CT at Danderyds Hospital, Stockholm, between January 1, 2015, and November 16, 2016. Data on modified Hinchey classification, age, sex, laboratory parameters, body mass index, and colonoscopy findings were recorded. The study identified 518 patients with a CT-verified first time diverticulitis. Four hundred twenty-six (82%) of the 518 patients underwent follow-up colonoscopy and constitute our study cohort. CT showed that 402 patients had uncomplicated diverticulitis (modified Hinchey Ia), and 24 patients had complicated diverticulitis (modified Hinchey ≥Ib). Colonoscopy showed cancers in 2 (0.5%) of the 426 patients initially diagnosed as acute diverticulitis. In addition, 13 (3%) patients had advanced adenomas, and 121 (28%) patients had benign adenomas upon follow-up colonoscopy. Patients with CT-verified complicated diverticulitis (modified Hinchey ≥Ib) had a significantly higher risk for colon cancer compared with patients with an uncomplicated first time diverticulitis. Our study supports routine follow-up colonoscopy after a first episode of CT-diagnosed complicated diverticulitis. In contrast, we do not find an increased risk for neoplasia in patients with uncomplicated diverticulitis.

Critical Issues on Diverticular Disease.

In this session diverse critical issues in diverticular disease were considered, including "In or outpatient management of uncomplicated diverticulitis?", "Segmental colitis associated with diverticulosis: what is it?"and "Diverticular inflammation is a risk factor for colorectal cancer?". The conclusions drawn are outlined in the statements but in summary, outpatient management is safe in selected patients, as long as correct diagnosis and stage are assured, and this can allow a cost effective treatment. Non-antibiotic management is also safe but should be confined as an outpatient treatment in carefully selected patients. Segmental colitis associated with diverticulosis (SCAD) is a defined pathological entity (only diagnosed on biopsy) characterized by an inflammatory bowel disease-like pathology, occurring principally in the sigmoid colon, with rectal and right colon sparing. The pathogenesis is unclear but may include a genetic predisposition, microbiome alteration and ischaemia. Treatment can last months, and depends on severity, options include antibiotics, 5 ASA and probiotics for mild cases. Severe disease needs systemic steroids or even anti TNFα treatment. Whether diverticular inflammation is a risk factor for colorectal cancer was debated and the conclusion that within the first eighteen months of diagnosis of diverticular disease associations with cancer are found, likely due to similar symptoms and misclassification of disease. After that time, diverticular disease does not increase the risk of colorectal cancer. Therefore, this is recommended to exclude cancer with imaging and colonoscopy after healing of the first episode of diverticulitis.

Classification of Acute Diverticulitis for Stage-directed Therapy

In recent years, there has been a significant change in the treatment recommendations for acute diverticulitis. In order to provide the right treatment to the individual patient, it is therefore important to classify the stage of the disease accurately, after taking various aspects into consideration. Patients treated for acute diverticulitis in Würzburg University Hospital during 2010 to 2014 were included. Inclusion criteria were the presence of a computer tomography for disease classification. More than half of the patients examined (n = 135, 52.9%) had acute uncomplicated diverticulitis on admission; 112 (43.2%) had a covered perforation (small paracolic abscess n = 63, 24,3%; large abscess n = 49, 18,9%) and 12 (4.6%) a free perforation. In a total of 150 (57.9%) patients, this was the first episode of diverticulitis, with a covered (66.1%) or a free perforation (75.0%) occurring at a higher than average rate as the first manifestation. Nearly two-thirds (66.4%, n = 168) of patients underwent sigmoid resection during follow-up. Despite current trends towards more conservative therapy of acute diverticulitis, sigmoid resection remains a corner stone of successful therapy throughout all types of acute diverticulitis. The indication of sigmoid resection nowadays requires profound knowledge of the individual prognosis for recurrent diverticulitis and quality of life.

Tratamiento laparoscópico de las fístulas colovesicales: experiencia preliminar

BackgroundDiverticular disease of the colon is common in the western world. After the first episode of diverticulitis, many patients benefit from medical therapy, but 10-20% develop abscesses, obstruction, or fistula. AimTo describe the laparoscopic treatment of sigmoidovesical fistula secondary to diverticular disease. Material and methodsAn observational, retrospective study was conducted on 10 consecutive patients within the time frame of 2011-2015 that had undergone: 1) colovesical fistula resection and primary closure of the bladder and sigmoid colon or 2) laparoscopic sigmoidectomy with the NOSE technique (transanal extraction of the specimen and colorectal anastomosis with primary closure of the bladder). ResultsTen patients were operated on within the time frame of February 2011 and February 2015. The mean age of the patients was 60.7(49-71) years. Sigmoidectomy with primary anastomosis was performed on 4 patients and resection and primary closure on 6 patients. Surgery duration was 140.4 (80-210) min, blood loss was 195 (80-210) ml, and length of time before beginning oral diet was 4.3 (3–5) days. The drain was left in place in all the patients for 10 days and the transurethral catheter for 2 weeks. Up to the present time, none of the patients has presented with fistula recurrence or data consistent with intestinal anastomosis stricture. ConclusionsReports on the use of laparoscopy for the treatment of colovesical fistulas have demonstrated acceptable results. Only a few studies concentrate exclusively on colovesical fistula; in general the reports include other types of fistula (colovaginal and colocutaneous), as well. Colovesical fistula is a pathology that can be resolved safely and efficaciously through laparoscopy.

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis.

There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis. The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes. This is a population-based retrospective cohort study using administrative discharge data. This study was conducted in Ontario, Canada. All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012). Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics. There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001). There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data. There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.

To characterize the clinical course of patients with diverticulitis after nonoperative management and determine factors associated with readmission and subsequent emergency surgery. Clinical course of this disease remains poorly understood; indications for elective colectomy are unclear. This was a retrospective cohort study of patients managed nonoperatively after a first episode of diverticulitis in Ontario, Canada (2002-2012). Time-to-event analysis and Fine and Gray multivariable regression were used to characterize the risks of readmission and emergency surgery for diverticulitis, accounting for death and elective colectomy as competing events. A total of 14,124 patients were followed for a median of 3.9 years (maximum 10, interquartile range: 1.7-6.4). Five-year cumulative incidence was 9.0% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality. Patients younger than 50 years had higher incidence of readmission than patients aged 50 years and older (10.5% vs 8.4%; P < 0.001) but not emergency surgery (1.8% vs 2.0%; P = 0.52). Patients with complicated disease (abscess, perforation) were at increased risk of readmission than those with uncomplicated disease (12.0% vs 8.2%; P < 0.001), as well as increased risk of emergency surgery (4.3% vs 1.4%, P < 0.001). In multivariable regression, complicated disease and number of prior admissions were associated with increased risk of emergency surgery, yet age less than 50 years was not. Risks associated with complicated disease were nonproportional over time, being highest immediately after discharge and decreasing thereafter. Absolute risks of readmission and emergency surgery are low after nonoperative management of diverticulitis, providing evidence for the practice of deferring colectomy for patients without persistent symptoms or multiple recurrences.

Mo2048 Regulation of Intestinal Permeability by MicroRNA-29a/B Cluster

Brain-gut interaction plays a key role in pathophysiology of irritable bowel syndrome (IBS). We reported a genetic association between β3-aderenoceptor and cholinergic receptor muscarinic 3 polymorphisms in IBS (Hepato-Gastroenterol 2011;58:1474-1478). We examined the association of brain-gut peptides, such as calcitonin gene-related peptide (CGRP α, encoded by CALCA), transient receptor potential vanilloid-1 (TRPV-1) and transcription factor 7-like2 (TCF7L2) polymorphisms with IBS. Methods: DNA was obtained from 108 IBS patients; (53 diarrhea type IBS-D, 31 constipation type IBS-C, 8 mixed type IBS-M, 16 unsubtyped IBS-U) and 61 controls. For the analyses IBS-(M + U) was combined into one group (NonDNonC). CALCA, TRPV-1 and TCF7L2 polymorphisms were determined by the polymerase chain reaction (PCR)-based restriction fragment length polymorphism (RFLP) method. Results: The frequencies of the three genotypes; CALCA, TRPV-1 and TCF7L2 were not significantly different between IBS patients and controls. The distribution of the three genotypes was not significantly different between IBS-D, IBS-C and NonDNonC. The three genotypes frequencies were not significantly different between males and females in IBS. The frequencies of the three genotypes were not significantly different between under and over 3 years of disease duration in IBS. The frequencies of the TRPV-1 genotypes in IBS were significantly different between over 65 years old and under 65 years old. The frequencies of the CALCA and TCF7L2 genotypes in IBS were not significantly different between patients over 65 years old and under 65 years old. Conclusions: TRPV-1 polymorphisms are likely associated with age in IBS. TRPV-1 polymorphisms could be associated with IBS. S-727 AGA Abstracts Mo2050 Colorectal Transit During Acute Episodes of Diverticulitis Antonella Toma, Luca Bertini, Emanuele Casciani, Gianfranco Gualdi, Enrico Corazziari Background. Acute diverticulitis of the sigmoid colon presents with pain and bowel alterations: being constipation or diarrhea reported by 50% and 25%-35% of the patients respectively (Kelley MT, 2008). The colorectal mechanism leading to these opposite bowel behaviors is likely associated with a different distribution of colorectal contents as consequence of the motor activity of the large bowel. Aim. To assess distribution of colorectal contents during an episode of acute diverticulitis. Methods. Patients having the first episode of diverticulitis and no diverticulitis complications (Hinchey 1a) were recruited. CT scans of the abdomen and pelvis were performed within 4 hours from the onset of the acute diverticulitis episode in 22 patients (F=9; mean age 55.4±16.8 yrs; range 23-85) admitted to the emergency department. CT-scan datasets were scanned with a 16 MDCT scanner and image analysis was conducted on the reconstructed thin-slice portal-venous phase. Controls were 32 patients (F=12; mean age 68.5±9.4 yrs; range 50-85) with asymptomatic diverticula of the sigmoid and submitted to CT scan evaluation for not acute extra-gastrointestinal disease conditions. The large bowel was subdivided into 7 segments: ascending colon, right transverse colon, left transverse colon, proximal descending colon, distal descending colon, sigmoid and rectum. The absence/presence of contents, liquid, gas or semiquantitative (+,++,+++) amount of solid feces, were assessed and reported independently by three observers. Interobserver agreement was substantial (Cohen's Kappa=0.73). Results. In comparison to controls, patients with acute diverticulitis showed more frequently (a) gas or absence of contents in the sigmoid colon (p≤0.05), (b) less solid feces (27% vs. 56%, p ≤0.05) and more gas (45% vs. 16%, p≤0.05) in the distal descending colon, (c) equal amount of solid feces and more liquid feces in the right part of the colon, from the ascending (36% vs. 9%, p ≤0.05) to midtransverse colon (23% vs. 0%, p≤0.01) and (d) more liquid feces in the rectum (27% vs. 3%, p ≤0.01). Summary. During episode of diverticulitis the distribution of large bowel contents indicates that (a) sigmoid colon often contains gas or no content, (b) feces, solid and liquid, as well as gas are retained proximal to the sigmoid, being the solid and liquid feces mainly retained in the right part of the colon ,and the gas mainly retained in the descending colon, and (c) liquid feces are mainly present in the rectum. Conclusive hypothesis. The inflamed sigmoid may cause (a) constipation by inhibiting right to left colon transit of solid feces and being of obstacle to transit of gas and liquid contents through the sigmoid and, (b) by inhibiting the absorption of water, there is an increased amount of liquid feces in the colorectal that leads to diarrhea.

Triage of patients with acute diverticulitis: are some inpatients candidates for outpatient treatment?

Current recommendations regarding the triage of patients with acute diverticulitis for inpatient or outpatient treatment are vague. We hypothesized that a significant number of patients treated as an inpatient could be managed as an outpatient. A retrospective cohort study was carried out of 639 patients admitted for a first episode of diverticulitis. The diagnosis of acute diverticulitis was confirmed by computed tomography (CT). The endpoints included length of stay, need for surgery, percutaneous drainage and mortality. Patients were considered to have had a minimal hospitalization, defined as survival to discharge without needing a procedure, hospitalization of ≤3days and no readmission for diverticulitis within 30days after discharge. Of 639 patients, 368 (57.6%) had a minimal hospitalization. Female gender and CT scan findings of free air/fluid were negatively associated with the likelihood of minimal hospitalization. The presence of an abscess <3cm and stranding on CT did not predict the need for a higher level of care. Despite the statistical significance of several patient-level predictors, the model did not identify patients likely to need only minimal hospitalization. Most patients admitted with acute diverticulitis are discharged after minimal hospitalization. Free air/liquid in a patient admitted for acute diverticulitis indicates a more severe clinical course.

Surgical approach of complicated diverticulitis with colovesical fistula: technical note in a particular condition

Abstract Background: Diverticular disease of the colon is common in the Western world. With the first episode of diverticulitis, most patients will benefit from medical therapy, but in 10% to 20% of cases some complications will develop, such as intra-abdominal abscesses, obstructions, fistulas. In these conditions it is important to define the most appropriate surgical approach. Discussion: The management of diverticular disease has been successful owing to the advances in diagnostic methods, intensive care and surgical experience, but there is debate about the best treatment for some conditions. Fistulas complicating diverticulitis are the result of a localized perforation into adjacent viscera. In particular, the connection between the colon and the urinary tract is a serious anatomical abnormality that must be urgently corrected before a serious urinary infection results. Indications, timing and surgical procedures are determined by the severity of the disease and the patient’s general condition. Summary: Diverticular disease can lead to many complications. One of the most difficult to correct is an internal fistula, such as a colo-vesical fistula. The correct approach in cases where the disorder is clinically suspected has always been controversial, and the guidelines for sigmoid diverticulitis have not established the most appropriate method for diagnosis and treatment. At present, the surgical strategy for these cases requires interruption of the fistula and resection to remove the inflamed colonic segment, with or without primary anastomosis, focusing attention on the construction of the anastomosis to well vascularized and anatomically healthy tissues. It is clear, therefore, that establishing guidelines is difficult, because many pathological situations may be related to diverticulitis, and so, as our experience shows, the surgical approach has to be tailored to the patient’s general and local condition.

Long-Term Follow-up After an Initial Episode of Diverticulitis: What Are the Predictors of Recurrence?

The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively. We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008. Patients were identified with International Classification of Diseases, 9th Revision/Current Procedural Terminology codes. Patients were excluded if they had subsequent colectomy based on the first attack (n = 81), or if the attack they had between 2002 and 2008 was not their first attack (n = 201). We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists. These radiologists reviewed the available published literature for CT imaging characteristics thought to predict diverticulitis severity. CT variables (n = 20) were determined by prospective reevaluation of scans by blinded study radiologists. Clinical variables (n = 43) were coded based on a retrospective chart review. Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates. Multivariate analysis was performed using Cox proportional hazards modeling. Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm. The study population included 672 patients; mean age, 61 ± 15 years; mean follow-up, 42.8 ± 24 months. The index presentation of diverticulitis was most commonly located in the sigmoid colon (72%), followed by descending colon (33%), right colon (5%), and transverse colon (3%). Overall recurrence at 5 years was 36% by (95% CI 31.4%-40.6%) Kaplan-Meier estimate. Complicated recurrence (fistula, abscess, free perforation) occurred in 3.9% (95% CI 2.2%-5.6%) of patients at 5 years by Kaplan-Meier estimate. Family history of diverticulitis (HR 2.2, 95% CI 1.4-3.2), length of involved colon >5 cm (HR 1.7, 95% CI 1.3-2.3), and retroperitoneal abscess (HR 4.5, 95% CI 1.1-18.4) were associated with diverticulitis recurrence. Right colon disease (HR 0.27, 95% CI 0.09-0.86) was associated with freedom from recurrence. Although diverticulitis recurrence is common following an initial attack that has been managed medically, complicated recurrence is uncommon. Patients who present with a family history of diverticulitis, long segment of involved colon, and/or retroperitoneal abscess are at higher risk for recurrent disease. Patients who present with right-sided diverticulitis are at low risk for recurrent disease. These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy.

Outcomes after medical and surgical treatment of diverticulitis: A systematic review of the available evidence

There is still controversy regarding the appropriate management of diverticulitis of the colon in cases when both surgical and conservative treatment may be an option. We performed a systematic review of the available evidence regarding the outcomes after medical and surgical treatment of diverticulitis from studies published after 1980 and indexed in the PubMed database. We included original studies that reported comparative data for at least one outcome in medically- and surgically-treated patients with transverse or left colon diverticulitis. The main outcomes of interest were mortality, morbidity, and recurrence of diverticulitis after medical or surgical treatment. There were 21 studies fulfilling our inclusion criteria out of 1360 initially identified as possibly relevant. More patients were treated conservatively in the included studies compared to emergency surgery (24 862 vs 6504). Emergency surgery was the main option for patients with severe complications of diverticular disease, including peritonitis. In most studies, in-hospital mortality for patients treated surgically was generally higher than that of patients treated medically, whereas there were insufficient comparative data regarding mortality during follow up. However, readmission to the hospital due to diverticular disease during follow up was more common in the group of patients treated conservatively compared to those treated surgically (4358/23 446 [18.6%]vs 22/359 [6.1%]). Conservatively-treated patients, with a first or second episode of diverticulitis, required surgery for recurrent disease during follow up in a maximum of 45% of cases, with larger studies reporting percentages lower than 11%. It should be emphasized that medical and surgical treatments have not ever been compared in a randomized controlled trial in patients with diverticulitis (without generalized peritonitis that is a surgical emergency). Although medical treatment results in more readmissions due to recurrence, it may be reasonable to avoid surgical therapy in the vast majority of patients with acute diverticulitis. It is unclear what the best treatment option is for younger patients (<50 years), namely whether elective surgery should be considered with the first episode of diverticulitis.

A retrospective analysis of medical or surgical therapy in young patients with diverticulitis

Acute diverticulitis is increasingly being recognized in younger patients, but its management remains controversial. To compare long-term outcomes of young patients treated with surgery vs. medical therapy for their first episode of diverticulitis. A retrospective chart analysis at a university and an affiliated community hospital between 1991 and 2002 revealed 149 patients < or = 40 years of age with confirmed diverticulitis. Forty-nine patients (38 males, 11 females) were contacted at least 1 year after their first episode of diverticulitis. Outcomes were compared based on initial therapy--antibiotics or surgical resection. The groups were compared by outcomes, gender, age, white blood cell count, temperature and diet. Three (15%) of 20 surgical patients (mean follow-up 6.89 years), and 16 (55%) of 29 medical patients had a recurrence of diverticulitis (mean follow-up 5.72 years; P = 0.01). The treatment groups did not differ in age, white blood cell count, or temperature. (i) Surgical treatment is effective initial therapy but disease may recur in a minority of patients; (ii) medical treatment is less effective initial therapy, with recurrence in half of the patients; (iii) initial presentation is not a strong predictor of disease recurrence.

Medical versus surgical management of diverticulitis in patients under age 40

Diverticulitis in patients under age 40 is a distinct entity. We compared the medical versus surgical management of diverticulitis for complications and outcomes in these patients. A retrospective review was performed for treatment, hospitalizations, complications, and outpatient visits. Complications included readmission, recurrent symptoms after antibiotic therapy, and postoperative problems. Twenty-nine patients had a radiographic or surgical diagnosis of diverticulitis (18 surgical, 11 medical). Medically managed patients had significantly more emergency department visits (4.7 +/- 6.6 versus 0.3 +/- 0.6, P < or =0.01), and readmissions (7 versus 4, P < or =0.02). Three surgical patients (17%) had a total of 6 complications as compared with 6 medical patients (55%) with 25 complications (chi square, P < or =0.05). All medically treated patients had recurrent symptoms, and 6 required surgery. Medically managed patients had significantly more emergency department visits and complications than those managed surgically. Surgery is the indicated treatment for the first episode of diverticulitis in patients under age 40.

Acute colonic diverticulitis in the young

Colonic diverticulitis in the young has been considered to have a virulent course, high morbidity, and high operative rate. As a result, elective resection of the involved colonic segment after the first clinical episode has been the usual practice. This study presents our experience with acute diverticulitis in the young. In the last nine years, 63 patients younger than 45 years were treated for acute diverticulitis at our institution. A retrospective review was performed to determine the clinical course and outcome of these patients. Clinical presentations, radiographic tests, operative findings, and pathology results revealed that 57 patients had a pericolonic contained disease (Hinchey State I). Two patients had a large pelvic abscess (Hinchey Stage II), and four patients had a diffuse peritonitis (Hinchey Stage III). Forty-one patients (65 percent) were successfully treated medically with antibiotics and bowel rest. Of 22 patients (35 percent) who underwent emergent operations, 12 patients' diseases had been erroneously diagnosed preoperatively (9 "appendicitis"). Diverticulitis at a young age does not have a specific aggressive nature. Although, it is associated with a high rate of emergency operations, many of these are performed for a mistaken diagnosis. The recommendation for routine elective resection following the first episode of diverticulitis should be reassessed.