History Of Diverticulitis Research Articles

The Assessment of Knowledge, Awareness and Practice Regarding Diverticulitis and Its Risk Factors Among the Population of Saudi Arabia.

Background The term "diverticula" refers to the existence of diverticula in the gastrointestinal tract but is mainly located in the sigmoid colon and is used to describe colonic diverticulosis. Diverticula, which are sac-like protrusions in the wall of the large bowel, are becoming more prevalent globally, in both developed and developing nations. This increase in occurrence is primarily attributed to changes in dietary and lifestyle patterns.Raising public awareness can potentially contribute to a decrease in the incidence of the disease and its associated complications. Aim This study aims to assess knowledge and awareness levels among the Saudi Arabian population regarding diverticulitis and its risk factors. Methods A descriptive cross-sectional study was conducted in Saudi Arabia between 1st January 2024 to 1st April 2024 using an online questionnaire for data collection. The target population consists of individuals who are between 18 years and 45, in Saudi Arabia without a history of diverticulitis. The study questionnaire covered participants' demographic (Western, Central, Southern, Eastern, Northern) regions, knowledge, awareness and practice of diverticulitis. Results A total of 548 eligible participants completed the study questionnaire, most of them (80.3%; 395) were from the Western region including Mecca, Medina and Jeddah. Participants' ages ranged from 18 to more than 40 years with a mean age of 30.5 ± 11.9 years old. A greater percentage (72.3%) of the participants were males compared to the percentage of females, which was 27.7%. The vast majority of the study participants had an inadequate knowledge level about diverticulitis (85.9%; 471) while only 31 (5.7%) had adequate knowledge and awareness about the disease. The most reported sources of information included study courses (6.4%), media (5.3%), and physicians (4.7%) while most respondents (83.6%) had no source. Conclusion In conclusion, aside from preventive strategies, the current study found that the public knew very little about diverticulitis, including its risk factors, clinical presentation, and diagnostic process. The two significant predictors of public awareness level were age and doctors as information sources.

Diverticulosis morphology is associated with risk of diverticulitis.

The size, number and distribution of diverticula vary greatly in patients with diverticulosis. We aimed to study the association between the morphology of diverticulosis assessed on colonoscopy and the risk of diverticulitis. We performed a retrospective, case-control study of cases with a history of diverticulitis and controls with diverticulosis without diverticulitis matched on sex, age (within 5 years) and year of colonoscopy. Diverticulosis characteristics were obtained from endoscopy reports and were categorized according to severity, extent, number and size. We used conditional logistic regression on matched pairs to calculate the odds of diverticulitis among patients with diverticulosis according to differing morphologic characteristics. We identified 85 cases with computed tomography-documented diverticulitis and 85 matched controls with diverticulosis without a diagnosis of diverticulitis. In cases, 60% had left-sided only diverticulosis, 2% had right-sided only and 38% had both right and left-sided diverticulosis; whereas in controls, the distribution was 53%, 18% and 29%, respectively. Cases were more likely to have large diverticula [odds ratio (OR), 3.33; 95% confidence interval (CI), 1.30-8.56 for left colon only and 1.89, 95% CI, 0.78-4.57 for both right and left]. Similarly, when the severity of diverticulosis was compared between the groups, cases were more likely to have moderate or severe diverticulosis (OR, 3.44; 95% CI, 1.51-7.84 for moderate and OR, 8.87; 95% CI, 2.98-26.37 for severe). Diverticulitis cases were more likely to have large diverticula and severe diverticulosis when compared to controls suggesting that size and severity are novel risk factors for diverticulitis.

One-year cyclic therapy with rifaximin-α is effective in the treatment of SUDD (Symptomatic Uncomplicated Diverticular Disease) also in patients with a history of complicated diverticulitis

Introduction: The treatment of diverticulosis symptoms in patients with a history of diverticulitis is a challenge in everyday clinical practice. Aim: Efficacy assessment of a cyclic, year-long treatment with rifaximin-α in patients with symptomatic uncomplicated diverticular disease (SUDD) and a history of past diverticulitis. Material and methods: This study is a multicenter, retrospective, observational study involving 48 centers. The study group included patients who reported to the outpatient clinic within a month with SUDD symptoms, who had a history of diverticulitis, and who were given a cyclic rifaximin-α treatment of 2 x 400 mg/day for 7 days and then once a month for 12 months. Epidemiological and demographic data, the course of diverticulosis, the number of inflammation episodes and their diagnoses, complications, symptoms of SUDD, and its treatment were evaluated. The efficacy of rifaximin-α therapy was assessed on a 4-point scale (0 – no symptoms, 3 – severe symptoms) every 3 months, and analyzed: pain, tenderness, bloating, bowel movements, and recurrence of inflammation during the 12-month treatment. Results: 178 patients (67% women, median age 65 years [34–92]) were included in the study. The average duration of diverticulosis was 6.4 years (3–20), and 59% of patients had more than one episode of diverticulitis during this period. In total, 87% of patients had symptoms of SUDD after or between episodes of diverticulitis. Abdominal pain was the most common symptom (92%). An inflammation episode was diagnosed using imaging in 50.5% of cases, and the rest – based on typical clinical symptoms. As many as 46.2% of patients required hospitalization, and complications were diagnosed in 44% of cases. One hundred and seventy (95%) patients completed the 12-month rifaximin-α therapy. Changes in the severity of pain, abdominal tenderness, diarrhea, constipation, and bloating were assessed every 3 months. After 12 months of treatment with rifaximin-α, there was a statistically significant reduction in the severity of symptoms overall (median from 1.5 [0–3 points] to 0.2; P<0.001) and each symptom evaluated individually. Regardless of the previous diagnostic method of diverticulitis (imaging or typical clinical presentation) or its complications (e.g. perforation, abscess), treatment with rifaximin-α was equally effective. Conclusions: Cyclic therapy with rifaximin-α is effective in treating SUDD symptoms and in preventing the recurrence of symptoms, also in patients with a history of diverticulitis – regardless of how the diagnosis was made and disease complications. The extended treatment regimen leads to a gradual resolution of symptoms during 12 months of observation. Cyclic use of rifaximin-α is necessary to maintain symptom remission.

Risk factors for readmission in patients with acute diverticulitis: a retrospective study at Auckland City Hospital.

Approximately one in five patients with acute diverticulitis (AD) will experience a recurrence. This study aimed to investigate the factors at AD admission that correlate with recurrence and test the proposed risk of recurrence-score according to Sallinen et al. method: This retrospective study followed patients for five years who were admitted with operatively or computed tomography (CT)-verified AD at Auckland City Hospital from January 2012-June 2013. Demographic, laboratory, radiological and patient-related factors at initial admission were analysed in relation to readmission with recurrent AD and to test a risk score presented by Sallinen et al. results: In the adjusted analyses, previous diagnosis of AD (OR, 7.3; 95% CI, 3.1-16.9), Māori ethnicity (OR, 5.7; 95% CI, 1.4-22.7) and complicated AD at index admission (OR, 2.5; 95% CI, 1.0-6.2), were all independent factors associated with readmission with recurrence. High-risk versus low-risk groups, according to the risk score, showed 71.4% and 18.6% recurrence rates, respectively. History of diverticulitis and complicated AD are risk factors for recurrence. The finding of higher recurrence rate in Māori requires further investigation utilising appropriate research methodologies. The risk score presented by Sallinen et al. may be a useful predictor of recurrent AD.

Pyogenic Hepatic Abscess in an Immunocompetent Patient With Poor Oral Health and COVID-19 Infection.

Pyogenic hepatic abscess (PHA) is a collection of pus in the liver caused by bacterial infection of the liver parenchyma. PHA is more common in immunosuppressed individuals and those with diabetes mellitus, cancer, and liver transplant. We present a rare case of PHA with Fusobacterium nucleatum in an immunocompetent patient with poor oral health, history of diverticulitis, and recent COVID-19 infection whose only symptoms were chest pain and a 4-week history of fever and malaise. The source of infection in this patient was likely dental caries and periodontal disease, with COVID-19 infection playing a role as a red herring in this patient's disease progression, delaying diagnosis. Diagnosis and treatment of PHA must be prompt with drainage and empiric anaerobic coverage followed by a more tailored antibiotic regimen if indicated by culture and further drainage if indicated by computed tomography.

Superior gluteal artery as a reliable back door to embolize mycotic pseudoaneurysm of an isolated Internal Iliac artery

BackgroundAntegrade access through the origin of the internal iliac and direct percutaneous access under cross-sectional imaging guidance are commonly used for embolization of internal iliac artery aneurysms, pseudoaneurysms, or endoleaks. Here, we report superior gluteal artery retrograde access to treat internal iliac artery mycotic pseudoaneurysm in a patient with failed direct percutaneous access.Case presentationWe present a 65-year-old female with a history of diverticulitis and sigmoidectomy. Post-sigmoidectomy course was complicated by left common iliac artery (CIA) iatrogenic injury which required surgical ligation of the left CIA and graft placement. However, the graft was subsequently resection due to infection. Follow up CT imaging showed a 6 cm mycotic pseudoaneurysm (PSA) of the left internal iliac artery. Initially, the PSA sac was directly accessed and embolized under direct CT-guidance using Onyx. However, enlargement of the PSA sac was noted on one week follow-up CT images. Then, superior gluteal artery was accessed under ultrasound guidance, and the PSA sac and feeding vessels were re-embolized with coil and Onyx under fluoroscopy.ConclusionRetrograde access through superior gluteal artery is a feasible and safe approach to embolize internal iliac aneurysms, pseudoaneurysms, or endoleaks, when the antegrade or direct percutaneous access is limited.

What's in a Number? Assessing the Burden of Diverticular Disease.

In this prospective observational cohort of patients with a history of diverticulitis, we assessed the correlation between the diverticulitis quality of life survey (DVQOL) and other patient-reported expressions of disease measures including work and activity impairment, and contentment with gastrointestinal-related health. Then, we assessed whether the DVQOL is better correlated with these measures than diverticulitis episode count. Our study results showed that the DVQOL has a stronger correlation with other disease measures than diverticulitis episode count, and our findings support the broader use of the DVQOL in assessing the burden of diverticulitis and monitoring response to management.

Characteristics, treatment, and outcome of diverticulitis after immune checkpoint inhibitor treatment in patients with malignancies.

Immune checkpoint inhibitors (ICIs) are efficacious for treating various malignancies. In addition to immune-related adverse events (irAEs), growing evidence suggests that ICIs might also be associated with diverticulitis. We aim to assess the clinical presentations and management of colonic diverticulitis among cancer patients after ICI treatment. A retrospective study was conducted on ICI-treated adult cancer patients between 01/2010 and 06/2020. Patients were grouped based on when diverticulitis developed relative to ICI treatment, either before (controls) or after (cases). Patient clinical characters, treatment, and outcomes were compared between both groups. 77 eligible patients were included: 63 patients developed diverticulitis after ICI exposure (46 had initial episode after ICI exposure, 17 had a history of diverticulitis prior then recurred after ICI exposure), and 14 had diverticulitis before ICI exposure. Diverticulitis occurred after a median of 129days after ICI initiation. Clinical characteristics overlapped with traditional diverticulitis. 93% of patients had symptom resolution after treatment, while 23.8% experienced complications. These patients exhibited higher rates of hospitalization (87% vs 48%, P = 0.015) and surgery/interventional radiology procedures (27% vs 0, P = 0.002), and worse overall survival (P = 0.022). History of diverticulitis was not associated with a more severe disease course. Immunosuppressants (e.g., corticosteroids) were rarely required unless for concurrent ICI-mediated colitis. Colonic diverticulitis can occur after ICI therapy at very low incidence (0.5%). Its clinical presentation, evaluation, and management are similar to traditional diverticulitis, but associated with higher complication rates requiring surgical intervention and has lower overall survival.

242 Peristomal ulcer as presenting feature of inflammatory bowel disease (IBD)

77-year-old female with a history of diverticulitis and bowel perforation with subsequent hemicolectomy presented with three weeks of abdominal pain, bloody output from ostomy and rectum, and an enlarging painful peristomal wound. She was initially seen by outpatient dermatology for a small ulcer; wound culture grew E. coli, and she was started on ciprofloxacin. Over the next week, the ulcer rapidly grew and inpatient examination revealed an 11.5 x 11 x 0.5 cm deep peristomal ulcer with violaceous borders.

Malnutrition Imparts Worse Outcomes in Patients With Diverticulitis: A Nationwide Inpatient Sample Database Study.

IntroductionStudies show that malnutrition can lead to worsening morbidity and mortality in patients. However, to our knowledge, no large database study has been conducted describing the effects of malnutrition in patients with diverticulitis. In this article, we aim to assess the impact of pre-existing malnutrition on outcomes of patients admitted for diverticulitis.MethodsData between 2008 and 2014 from the Nationwide Inpatient Sample database were extracted. Inclusion criteria for both groups included patients with a primary diagnosis of diverticulitis using the International Classification of Diseases, Ninth Revision codes. Exclusion criteria included all patients less than 18 years of age. The test group consisted of patients with a primary diagnosis of diverticulitis and a concurrent diagnosis of malnutrition. In-hospital mortality, length of stay, total cost, and complications, including various forms of sepsis, perforation, bleeding, and GI bleeding, were compared between the two groups. Univariate and multivariate analyses were used to generate odds ratios. Multivariate analysis included age, sex, race, income quartile, and calculated Elixhauser scores. Elixhauser comorbidity scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis.ResultsThere were a total of 1,520,919 patients in the study, of which 427,679 (2.8%) had a pre-existing diagnosis of malnutrition. On univariate analysis, there was a significant increase in mortality in patients with malnutrition (OR: 10.2, p < 0.01). Additionally, patients with malnutrition appeared to have longer lengths of stay (mean: 12.9, p < 0.01) and greater cost of hospitalization (mean: 194436.82, p < 0.01). Patients with malnutrition had greater rates of sepsis events (OR: 12.0, p < 0.01), perforation (OR: 2.8, p < 0.01), and GI bleed (OR: 1.84, p < 0.01). On multivariate analysis, malnutrition appeared to significantly increase mortality (OR: 3.3, p < 0.01).DiscussionPatients who present with diverticulitis with malnutrition appear to have significantly worse outcomes. We hypothesize that malnutrition leads to a shift in the gut microbiota, resulting in increased inflammation. As a result, these patients may have an increased risk of worse outcomes, such as sepsis and death. Addressing nutrition in patients with diverticulosis or those with a history of diverticulitis may improve outcomes.This abstract was previously presented at the Digestive Disease Week Conference on May 22, 2022. s accepted at the conference were published in supplements of the journals Gastroenterology and GIE: Gastrointestinal Endoscopy.

Risk Factors Associated with the Development of Colorectal Anastomotic Strictures Prior to Diverting Loop Ileostomy Reversal.

Anastomotic strictures represent a major source of morbidity in colorectal surgery with an incidence reported up to 30%. Despite this, the mechanism by which strictures develop remains unclear. This study aims to determine the incidence of colorectal anastomotic strictures and associated risk factors among a series of diverted patients. A retrospective chart review was conducted of 142 patients over a 7-year period at a single institution after colorectal resection with anastomosis and diverting ileostomy creation re-examined with postoperative endoscopy. One patient was removed due to anastomotic tumor recurrence. Patient and technical factors were examined for significance using chi-square analysis. Logistic regression was used to perform multivariate analysis to estimate odds ratio (OR) and 95% confidence intervals (CI). Among 141 patients, 14.1% (20 patients) developed strictures detected on endoscopy. Strictures were observed in a greater percentage of women than men (21.2% vs 8%, P = .025). 30.6% of patients who underwent resections for diverticulitis developed strictures while those with neoplastic lesions and other indications had stricture rates of 6.8% and 17.6%, respectively (P = .002). Anastomoses performed during a colostomy reversal were associated with a higher stricture rate (OR 4.23, 95% CI 1.37-13.40, P = .012). Anastomoses performed with a 28/29mm EEA circular stapler demonstrated a significantly higher stricture rate versus a 31/33mm stapler (OR 7.21, 95% CI 1.23-155.58, P = .045). Our data reveal that female sex, history of diverticulitis, anastomoses performed in the setting of colostomy reversal, and smaller stapler size are associated with a higher rate of anastomotic stricture.

Incidental Colonic Ganglioneuroma on Surveillance Colonoscopy.

CASE REPORT A 73-year-old man with a history of diverticulitis after left hemicolectomy and an end-to-end colo-colonic anastomosis underwent a screening colonoscopy with resection of 4, 2-10-mm tubular adenomas. A 10-mm semipedunculated polyp with a normal mucosal pit pattern under narrow-band imaging was found in the splenic flexure (Figure 1). The polyp was resected using a hot snare and submitted for histopathological diagnosis, which demonstrated colonic mucosa with distorted crypt architecture. The lamina propria was expanded by collection of spindle cells within fibrillary matrix, and irregular nests and groups of ganglion cells indicated a ganglioneuroma (GN) (Figure 2). No clinical symptoms were associated with this finding, and a prior colonoscopy revealed no evidence of GN. Surveillance colonoscopy was recommended in 3 years, given the presence of an adenoma of ≥10 mm in size.Figure 1.: (A) A semipedunculated polyp under white-light imaging in the splenic flexure. (B) A semipedunculated polyp with a normal mucosal pit pattern under narrow-band imaging in the splenic flexure.Figure 2.: (A) An (H&E original magnification 20×) image of the colonic polyp consisting of abnormal appearing ganglion cells (single arrow) and spindled Schwann cells (double arrows). (B) An (H&E original magnification 10×) image of the colonic polyp consisting of abnormal appearing ganglion cells and spindled Schwann cells. H&E, hematoxylin & eosin.Ganglioneuromas of the gastrointestinal tract are rare tumors composed of ganglion cells, nerve fibers, and supporting cells. Gastrointestinal GNs are usually confined to the large intestine and are morphologically classified into 3 categories, namely, polypoid GNs, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis.1 Polypoid GNs are mostly solitary and small (measuring <20 mm), with a sessile or pedunculated appearance. Colonic GNs are characterized by a normal colonic pit pattern under narrow-band imaging. These lesions produce no characteristic symptoms and are usually found incidentally during endoscopy. Rarely, they present with abdominal pain, obstruction, ileus, appendicitis, or weight loss depending on their size and anatomical location.2 Ganglioneuromatous polyposis and diffuse ganglioneuromatosis are associated with genetic syndromes, such as neurofibromatosis 1, multiple endocrine neoplasia 2B syndrome, and juvenile polyposis. Solitary GNs are generally not associated with familial syndromes, although they have been reported in cases of Cowden disease, tuberous sclerosis, polyposis coli, and juvenile polyposis.1 Gastrointestinal GNs are usually treated with endoscopic resection. Currently, no guidelines exist on the management of solitary GNs or recommendations for interval surveillance colonoscopy. Repeat colonoscopy is not necessary because of the benign nature of these lesions, which tend not to recur.3 DISCLOSURES Author contributions: S. Agarwal and Y. Wang designed and drafted the article and acquired data. PG Iyer drafted and revised the article for intellectual content. CL Leggett designed and drafted the article , acquired data, revised the article for important intellectual content, and is the article guarantor. Financial disclosure: None to report. Informed patient consent was obtained for this case report.

680. Month Long Fungemia due to Candida auris Endocarditis

Background Candida auris (C. auris) is a multidrug resistant Candida species, reported to cause persistent fungemia along with a multitude of invasive fungal infections. We report the first case of C. auris fungemia due to endocarditis.Methods61 year old man with a history of diverticulitis that required sigmoid resection and was complicated by abdominal abscesses due to multi drug resistant organisms warranting heavy antibiosis. Prolonged hospitalisation for that surgery was followed by a stay at a long term acute care hospital. He was readmitted at an outside hospital with sepsis where blood cultures grew C.auris. Upon evaluation, was found to have aortic valve endocarditis. Per patient’s preference, surgery was initially deferred. Despite escalation of therapy with a combination of antifungals, he remained fungemic for five weeks with repeat blood cultures showing changing antifungal susceptibility patterns. Patient eventually underwent surgical intervention at our facility, with valve cultures being positive for C.auris. After the surgery he was treated with 6 weeks of intravenous combination antifungal therapy.Results C.auris’s pathogenicity stems from multiple mechanisms with multi drug resistance being most pertinent. What adds to the complexity of the management is the absence of C.auris specific minimum inhibitory concentration breakpoints. Therefore treatment is based on Center for Disease Control’s (CDC) proposed breakpoints that have been extrapolated from other Candida spp. It is further complicated by lack of C.auris specific data showing essential agreement among different commercially available antifungal susceptibility testing (AFST). Heteroresistance of the microbial population is an issue that must be considered in such protracted fungemia. ConclusionInvasive infections due to Candida auris presents as a diagnostic and therapeutic challenge to clinicians. Disclosures All Authors: No reported disclosures

S218 Characteristics, Treatment, and Outcome of Diverticulitis Related to Immune Checkpoint Inhibitors in Patients With Malignancies

Introduction: Immune checkpoint inhibitors (ICIs) are an efficacious treatment for various malignancies. In addition to immune related adverse events (irAEs), there is growing evidence that ICIs might induce colonic diverticulitis. The aim of this study was to assess the clinical spectrum and management of diverticulitis among cancer patients after ICI treatment. Methods: A retrospective chart review was conducted on cancer patients who were exposed to ICIs between January 2010 and June 2020. Patients were divided into two groups: those who developed diverticulitis after ICI treatment (cases) and those who had diverticulitis before ICI treatment (controls). Patient clinical characters, treatment, and outcomes were compared between the two groups. Results: Among 502 cancer patients with a diagnosis of diverticulitis in the study window, 77 eligible patients were included in our final analysis where-in: 63 patients with a diverticulitis event after ICI and 14 as controls with diverticulitis only before ICI. Among 63 cases after ICI exposure, 46 had an initial episode, and 17 had recurrent episodes from pre-ICI era. Diverticulitis occurred after a median of 129 days (range: 32-277) after ICI initiation with anti-PD1/L1 monotherapy more frequently (75%). Clinical characteristics overlapped with traditional acute diverticulitis, with 93% of patients achieving symptom resolution with oral antibiotics alone. Diverticulitis complication rate in this ICI cohort is higher than traditional diverticulitis (23.8% vs 12%). Those with complicated ICI related diverticulitis more frequently needed hospitalization (87% vs 48%, P=0.015) and surgery/interventional radiology procedures (27% vs 0%, P=0.002), and had worse overall survival (P=0.022). Regarding recurrence after the first diverticulitis episode post ICI therapy, history of diverticulitis does not appear to contribute to more severe disease course. Immunosuppressants (e.g., corticosteroids) were rarely required unless concurrent ICI colitis was identified. Conclusion: Diverticulitis appeared to be more frequent after ICI therapy, particularly anti-PD-1/L1 therapy. Clinical presentation, evaluation, and management is similar to traditional diverticulitis, although it has higher complication rates requiring surgical intervention and impairing overall survival.

History of Diverticulitis and Risk of Incident Cardiovascular Disease in Men: A Cohort Study.

Diverticulitis and cardiovascular disease (CVD) are two highly prevalent disorders sharing common risk factors which are hypothesized to have an inflammatory basis. To examine the association between history of diverticulitis and risk of incident CVD. We conducted a prospective cohort study of 43,904 men aged 40 to 75years without a history of CVD (fatal or nonfatal myocardial infarction and stroke) at enrollment who were followed up from 1986 to 2012 in the Health Professionals Follow-Up Study. Lifestyle factors, dietary intake, and disease information were self-reported biennially or quadrennially. Incident diverticulitis and CVD were confirmed by review of medical records. We used Cox proportional hazard models to calculate age- and multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI) of incident CVD. We conducted a stratified analysis according to the presence or absence of CVD risk factors (smoking, hypertension, hyperlipidemia, and diabetes). We identified 3848 incident cases of CVD during 856,319 person-years of follow-up. Men with diverticulitis had higher incidence of CVD (727 cases per 100,000 person-years) compared to men without diverticulitis [446 cases per 100,000 person-years, multivariate HR of 1.35 (95% CI 1.07-1.70)]. The association of diverticulitis and subsequent CVD appeared more evident among men without known CVD risk factors (HR 4.06, 95% CI 2.04-8.08) compared to those with one or more CVD risk factors (HR 1.27, 95% CI 0.98-1.63). Diverticulitis may be an independent risk factor of incident CVD, suggesting possible common etiopathogenic mechanisms. Diagnosis of diverticulitis underscores the importance of preventive measures to reduce future CVD.

S1807 Diverticular Abscess Causing Bowel Obstruction

INTRODUCTION: Emergency room visits for acute diverticulitis have increased 21% in the last few years. Although most of them are uncomplicated, an estimated 15% of all cases present with acute abdomen resulting in emergent surgery. The most common cause of complicated diverticulitis is bowel perforation which is usually diagnosed via computerized tomography (CT). A rare but more severe complication can include complete colonic obstruction secondary to diverticular abscess formation. CASE DESCRIPTION/METHODS: A 59 year-old female with a past medical history of recurrent diverticulitis presented with a three-day history of diffuse abdominal pain and distention associated with non-bloody emesis and non-bloody diarrhea. Her last diverticulitis flare was one year prior to presentation and resolved with antibiotics and supportive management. The patient denied prior colonoscopy and first-degree family members with colon cancer. On arrival, patient was afebrile and hemodynamically stable. Abdominal physical exam demonstrated a distended abdomen and diffuse tenderness along with decreased bowel sounds. Laboratory tests showed mild leukocytosis but were otherwise unremarkable. CT of the abdomen and pelvis with contrast demonstrated a 3 × 5 cm irregular mass at the junction of the descending colon and sigmoid colon suspicious for a malignant neoplasm along with colonic obstruction and sigmoid diverticulosis without fat stranding. Exploratory laparotomy found complete obstruction of the long segment of the thickened colon from which biopsies were obtained and she underwent left hemicolectomy with end-to-end anastomosis. Biopsy results showed diverticulitis with abscess, which was the etiology of the large bowel obstruction. The patient was placed on antibiotics and was discharged once she was able to have a bowel movement. DISCUSSION: Patients with known diverticulosis have a 10–25% chance of developing diverticulitis. Mortality from diverticular abscess is as high as 32% and can occur in remote areas via hematogenous spread of microorganisms through colonic mucosal defects. Severe bowel obstruction as with our patient, is rarer than partial obstruction which occurs due to wall edema and peripheral inflammation. Exploratory laparotomy is necessary and biopsy is crucial to definitively exclude colon cancer as CT imaging findings cannot solely include or exclude malignancy. It is important to evaluate for diverticular abscess in a patient with a history of diverticulitis in the setting of complete bowel obstruction.Figure 1.: 3 × 5cm Irregular mass seen at the junction of the Descending Colon and Sigmoid Colon.Figure 2.: Obstructing mass at the junction of the Sigmoid and Descending Colon.

Clinical Difference between Acute Appendicitis and Acute Right-Sided Colonic Diverticulitis.

Background Clinical presentations of acute appendicitis (AA) and acute right-sided colonic diverticulitis (ARCD) are similar. However, the usual treatment for each disease differs between surgical and conservative management. The aim of this study was to identify clinical differences between AA and ARCD. Method We performed a single-center retrospective study on adult patients, with uncomplicated AA and ARCD confirmed by computed tomography, who visited an emergency department between March 2018 and August 2019. Clinical variables including past medical history, presented symptoms and signs, and laboratory findings were compared between the two groups. A logistic regression analysis was subsequently performed to differentiate ARCD from AA based on results of univariate analyses. Results A total of 212 (79.1%) and 56 (20.9%) patients were enrolled in AA and ARSD groups, respectively. Logistic regression analysis revealed that a past history of diverticulitis [OR: 102.679 (95% CI: 9.964–1058.055), p < 0.001] was associated with ARCD, while ketonuria [OR: 2.907 (95% CI: 1.091–7.745), p=0.033], anorexia [OR: 21.544 (95% CI: 3.905–118.868), p < 0.001], and neutrophilia [OR: 3.406 (95% CI: 1.243–9.336), p=0.017] were associated with AA. Conclusion Anorexia, neutrophilia, and ketonuria were predictors of AA while a history of diverticulitis was a predictor of ARCD.

Epidemiology of Diverticulitis and Prevalence of First-Ever Colorectal Cancer Postdiverticulitis in Adults in the United States: A Population-Based National Study.

The incidence of acute diverticulitis is increasing, and previous studies showed a wide range of prevalence of colorectal cancer after diverticulitis. There is a lack of high-quality evidence to support performing colonoscopy after diverticulitis. We aimed to describe the incidence of first-ever diverticulitis and prevalence of first-ever colorectal cancer postdiverticulitis in the United States. This is a retrospective cohort study. We queried a national database that contains data from 26 major integrated healthcare systems in the United States. We identified an aggregated patient cohort aged ≥18 years with a diagnosis of first-ever diverticulitis from February 2015 to February 2020, followed by first-ever colorectal cancer diagnosis, at least 1 day after and within 1 year of diverticulitis. The incidence of first-ever diverticulitis was calculated. The prevalence and OR of first-ever colorectal cancer after diverticulitis were analyzed. Among 31,778,290 individuals, we found the incidence of first-ever acute diverticulitis to be 2.9%. The prevalence of colorectal cancer within 1 year of first-ever acute diverticulitis was 0.57%, whereas the prevalence of colorectal cancer without a history of diverticulitis was 0.31% (OR = 1.8 (95% CI, 1.76-1.86)). The majority (92.3%) of the postdiverticulitis colorectal cancer were diagnosed within the first 6 months. The risk of colorectal cancer postdiverticulitis was higher in women (OR = 1.9), African Americans (OR = 2.0), and adults aged 18 to 65 years (OR = 2.3). We are unable to validate the diagnostic code because patient information in our database is deidentified. Individuals are twice as likely to be diagnosed with colorectal cancer within 1 year of their first episode of acute diverticulitis compared with individuals without diverticulitis. We advocate for colonoscopy after the first occurrence of acute diverticulitis to screen for colorectal cancer, particularly for patients without a recent colonoscopy. See Video Abstract at http://links.lww.com/DCR/B412.

Is mesalazine treatment effective in the prevention of diverticulitis? A review.

Diverticulitis is the most severe form of Diverticular disease (DD). An effective treatment strategy for its prevention has not yet been defined. This review aimed to provide a viewpoint on the role of mesalazine, also note as 5-aminosalicylic acid (5-ASA), in the prevention of diverticulitis. A systematic electronic search of relevant articles was performed using PubMed, Embase, Scopus, and Cochrane. Randomized controlled trials (RCTs), open trials, and retrospective studies, published between January 1999 and January 2020, were identified. Twelve eligible studies that analyzed primary or secondary outcomes of diverticulitis were included. The population included patients with symptomatic uncomplicated diverticular disease (SUDD), or patients with a history of diverticulitis. All studies compared 5-ASA to placebo, rifaximin, or other treatments. Two studies, including 359 patients, assessed the efficacy of 5-ASA in preventing the first appearance of diverticulitis in patients with SUDD. Of these, one showed that 5-ASA was effective, and one did not. Ten studies, including 2.995 patients, assessed the efficacy of 5-ASA treatment in preventing the recurrence of diverticulitis in patients with a history of diverticulitis. Four studies showed that 5-ASA had a certain degree of efficacy. All four RCTs demonstrated that 5-ASA did not significantly reduce the rate of diverticulitis recurrence. In a retrospective trial, 5-ASA was less effective than rifaximin in preventing diverticulitis recurrence. In an open trial, there was no difference between 5-ASA and probiotic treatment. Overall, there is currently conflicting evidence regarding the efficacy of 5-ASA treatment in the prevention of diverticulitis and further RCTs are needed.

Selectivity of Janus Kinase Inhibitors in Rheumatoid Arthritis and Other Immune-Mediated Inflammatory Diseases: Is Expectation the Root of All Headache?

Janus kinase (JAK) is a signal transducer and activator of a protein transcription system that transduces signals from cell surface cytokine and growth factor receptors to the nucleus. Recently developed JAK inhibitors (JAKinibs) inhibit JAKs non-selectively or selectively and down-regulate the effects of corresponding ligands (i.e. cytokines and growth factors). JAKinibs are efficacious against rheumatoid arthritis and other immune-mediated inflammatory diseases and are being increasingly prescribed clinically. Regarding safety, JAKinib use is associated with common or unique changes in laboratory parameters; however, incidence rates of serious adverse drug reactions (ADRs) associated with these changes are low. Opportunistic and other infections, including tuberculosis, are the most critical ADRs of treatment with JAKinibs, and screening and monitoring of patients should be carefully performed. Incidence rates of herpes zoster (HZ) in patients receiving JAKinibs are high in Japan and Korea, and modestly high in other countries. Filgotinib may not be associated with an elevated risk for HZ, but long-term safety data are lacking. Data from clinical development programmes and post-marketing surveillance have indicated no increased risk for malignancy or serious cardiac events; however, long-term observational studies are necessary. Despite the non-elevated risk of gastrointestinal perforations, patients with older age and/or a history of diverticulitis or receiving non-steroidal anti-inflammatory drugs should be carefully evaluated to determine the risk-benefit balance. The incidence rates of venous thromboembolism with all approved doses are similar to that expected in the population, although there are discrepancies in the placebo-controlled portion of the baricitinib clinical development programmes. Regulatory agencies in the USA and Europe suggested a higher risk for thrombotic events in patients receiving JAKinibs. Pharmacokinetic studies demonstrated that dose adjustment should be considered for JAKinib use in patients with moderate-to-severe renal or hepatic dysfunction, depending on the metabolism of each drug. Long-term observational studies enrolling patients with diverse clinical backgrounds are required to strike a risk-benefit balance in clinical settings.Electronic supplementary materialThe online version of this article (10.1007/s40265-020-01349-1) contains supplementary material, which is available to authorized users.