Management Of Acute Uncomplicated Diverticulitis Research Articles

Outpatient Management Protocol for Uncomplicated Diverticulitis: A 3-Year Monocentric Experience in a Tertiary Hospital.

Background/Objectives: The management of acute uncomplicated diverticulitis (AUD) has shifted towards outpatient care in the last decade, challenging the traditional inpatient approach. We aimed to analyze the safety and feasibility of a structured outpatient treatment pathway for AUD in a tertiary hospital. Methods: We conducted a retrospective observational cohort analysis of patients who underwent outpatient management for AUD at the Geneva University Hospitals from 2019 to 2021. Patient demographics, selection criteria, treatment protocols, and outcomes were analyzed. Results: Two-hundred and twenty patients were included in the outpatient cohort. Four patients (1.8%) required hospitalization due to the failure of outpatient management, whereas the majority of patients (116 patients, 98.2%) experienced a successful resolution of their symptoms without hospitalization. In a univariate analysis, factors associated with treatment failure included elevated white blood cell counts at admission (14 G/l vs. 10.6 G/l, p = 0.049) and the first follow-up appointment, (10.7 G/l vs. 7.4 G/l, p = 0.011) and the presence of free air on their CT scan (25% vs. 2,3%, p = 0.033). In a multivariate analysis, the presence of free air was the only identified risk factor for unsuccessful outpatient management (p = 0.05). We observed high rates of follow-up compliance (99.1%). Conclusion: Under the condition of a warranted outpatient follow-up appointment and with adequate selection criteria, outpatient management appears to be an effective approach for most patients with AUD, emphasizing the importance of tailored therapeutic interventions and vigilant clinical assessments for optimal outcomes.

From evidence to practice: real-world insights into outpatient management of acute uncomplicated diverticulitis.

Diverticulitis is experiencing a significant increase in prevalence and its widespread in-hospital management results in a high burden on healthcare systems worldwide. This study compared inpatient and outpatient approach of acute non-complicated diverticulitis using a non-selected population in a real-world setting. This observational retrospective study included all consecutive patients from two Portuguese institutions diagnosed between January 2017 and December 2021 with non-complicated diverticulitis according to the modified Hinchey Classification. The primary endpoints were to identify criteria for inpatient treatment and compare the outcomes on the basis of the treatment regimen. The secondary endpoints were to determine the predictive factors for clinical outcomes, focusing on treatment failure, pain recurrence, and the need for elective surgery following the initial episode. A total of 688 patients were included in this study, 437 treated as outpatients and 251 hospitalized. Inpatient management was significantly associated with higher preadmission American society of anesthesiologists (ASA) score (p = 0.004), fever (p = 0.030), leukocytosis (p < 0.001), and elevated C-reactive protein (CRP) (p < 0.001). No significant association was found between failure of conservative treatment and patient's age, ASA score, baseline CRP, presence of systemic inflammatory response syndrome (SIRS), and inpatient or outpatient treatment regimen. Pain recurrence was significantly associated with higher CRP levels (p = 0.049), inpatient treatment regime (p = 0.009) and post index episode mesalazine prescription (p = 0.006). Moreover, the need for elective surgery was significantly associated with the presence of previous episodes (p = 0.004) and pain recurrence (p < 0.001). The majority of patients with uncomplicated diverticulitis of the left colon experience successful conservative approach and can be safely managed in an ambulatory setting. Neither treatment failure, recurrence of pain, or need for posterior elective surgery are associated with outpatient treatment regimen.

SP5.3 - Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis: Time to change the traditional practice

Abstract Background To evaluate comparative outcomes of outpatient versus inpatient treatment and antibiotics versus no antibiotics approach in the treatment of uncomplicated (Hinchey 1a) acute diverticulitis. The protocol of this review was registered in PROSPERO (CRD42023488826). Methods A systematic online search was conducted using electronic databases. Comparative studies of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey 1a) acute diverticulitis were included. The primary outcome was diverticulitis recurrence. Emergency surgical resection, elective surgical resection, development of complicated diverticulitis, mortality rate, and length of hospital (LOS) were the other evaluated secondary outcomes. Results The literature search identified 14 studies (n=3,875) comparing NABX (n=2,008) versus ABX (n=1,867). The NABX group showed a lower disease recurrence rate and shorter LOS compared with the ABX group (P=0.01) and (P=0.004). No significant difference was observed in emergency resections (P=0.33), elective resections (P=0.73), development of complicated diverticulitis (P=0.65), hospital re-admissions (P=0.65) and 30-day mortality rate (P=0.91). Twelve studies (n=2,286) compared OP (n=1,021) versus IP (n=1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P=0.10), emergency surgical resection (P=0.40), elective resection (P=0.30), diverticulitis recurrence (P=0.22), and mortality (P=0.61). Conclusion Compared with the use of ABX, the NABX approach seems to provide similar clinical outcomes and shorter LOS. Moreover, OP treatment of Hinchey 1a acute diverticulitis is comparable with IP management and presumably leads to cost savings in depleted healthcare systems

Management of acute uncomplicated diverticulitis and adherence to current guidelines-a multicentre SNAPSHOT study.

To explore whether previous participation in clinical studies increases adherence to management guidelines in acute uncomplicated diverticulitis (AUD). This retrospective cohort study was designed to give a SNAPSHOT of the management of AUD at six hospitals, three of which had participated in the AVOD trial comparing antibiotic versus non-antibiotic treatment of AUD. Patients with AUD were included from March 2019 through June 2020 and followed for 90days. The primary outcome was treatment of AUD categorised by antibiotic treatment and inpatient or outpatient management compared between AVOD and non-AVOD hospitals. Descriptive statistics were compiled, and differences between hospitals were assessed with Pearson's chi-squared test. The cohort included 449 patients with AUD of which 63% were women and the median age was 63 (IQR: 52-73) years. Patient characteristics were comparable across the hospitals. Antibiotics were administered to 84 (19%) patients and 113 (25%) patients were managed as inpatients. Management varied significantly between AVOD and non-AVOD hospitals. The mean proportion of patients treated with antibiotics was 7% at AVOD hospitals compared to 38% at non-AVOD hospitals (p < 0.001). The mean proportion of in-hospital management was 18% at AVOD hospitals versus 38% at non-AVOD hospitals (p < 0.001). Most patients with AUD were managed according to current guidelines. However, the management varies between hospitals and previous participation in clinical studies may increase knowledge of and adherence to guidelines.

Systematic review and meta-analysis of the management of acute uncomplicated diverticulitis: time to change traditional practice

BackgroundTo evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis.MethodsA systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters.ResultsThe literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61).ConclusionObservation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis.

138 Overview of the management of acute uncomplicated diverticulitis in a District General Hospital

Abstract Aims Acute diverticulitis is a condition where diverticula, which is the outpouching of the large intestinal mucosa; becomes inflamed or infected. We took recommendations from ACPGBI, WSES and NICE guidelines on the management of acute uncomplicated diverticulitis and compared our practice with them in a district general hospital. Methods Retrospective data collection of 50 consecutive patients presented to A&amp;E with CT-proven acute uncomplicated diverticulitis was performed. Data included demographic distribution, clinical, laboratory and radiological features on presentation, treatment history and follow-up plans. Results All 30 patients being admitted with antibiotics, had modified Hinchey type 1a or 1b diverticulitis. However, 12 of these patients were over the age of 65 and another four had CRP &amp;gt;150. In the discharged group, all 20 patients had type 1a or 1b diverticulitis and almost all were discharged with antibiotics. However, 2 of these patients had CRP &amp;gt;150 and another five of them were over the age of 65. A request for the endoscopic procedure was placed for all 50 patients however 36 of them are still on the waiting list. Almost half of these patients were discharged without any written advice on discharge about the diverticular disease. Conclusions After analysing the data, more than half of these admitted patients could have been managed in ambulatory care without antibiotics. Conservatively managed diverticulitis patient doesn’t need routine endoscopic evaluation. All patients should have written advice given about their condition. We are in the process of making a pathway to ensure safe and cost-effective management for patients with acute diverticulitis.

ThTP7.3 Do patients receive written information? An overview of the management of acute uncomplicated diverticulitis

Abstract Background The management of acute uncomplicated diverticulitis was audited in compliance with NICE, the World of Society of Emergency Surgery and the Association of Coloproctology of Great Britain and Ireland guidelines. Included was the advice for appropriate written information. The initial cycle found no consistency in written advice if given at all. This audit analysed the compliance of providing written information to patients with acute diverticulitis. Following the initial cycle identifying significant discrepancies between patients, a secondary aim was formed to publish a standardised patient information leaflet. Method 50 consecutive patients presenting to A&amp;E with CT-proven uncomplicated acute diverticulitis were included. If any, advice on discharge was assessed for topics and consistency. Other factors were considered including if discharged directly from A&amp;E or antibiotic administration. Results The mean age of patients was 58.4 years. 30 patients were admitted, 20 were discharged from A&amp;E. 41 patients received antibiotics. All patients were Modified Hinchey Classification 1a or 1b. 21 patients had no documented written advice on discharge. Most commonly, the advice given was to seek medical attention or return to hospital if increasingly unwell (eight) or dietary advice while in acute infection (12). Conclusion Almost half of patients had no written advice and there was no consistency in the other half. A standardised approach was required hence the need for the patient information leaflet to be created. This includes all topics recommended by guidelines and ensures no information is missed for patients. The leaflet is now published.

Management of acute uncomplicated diverticulitis without antibiotics: compliance and outcomes -a retrospective cohort study

MethodsRecent randomized control trials (RCTs) have confirmed that antibiotics in acute uncomplicated diverticulitis (AUD) neither accelerate recovery nor prevent complications or recurrences.A retrospective cohort study was conducted, including all consecutive AUD patients hospitalized 2015- 2018 at Helsingborg Hospital (HH) and Skåne University Hospital (SUS), Sweden. HH had implemented a non-antibiotic treatment protocol in 2014 while SUS had not. Main outcomes were proportion of patients treated with antibiotics, complications, recurrences, and adherence to routinely colon evaluation.ResultsA total of 583 AUD patients were enrolled, 388 at SUS and 195 at HH. The diagnosis was CT-verified in 320 (83%) vs. 186 (95%) patients respectively (p < 0.001). Forty-three (11%) and 94 (48%) of patients respectively did not receive antibiotics during hospitalization (p < 0.001). CRP was higher in the antibiotic group compared to the non-antibiotic group, both at admission and peak (90 mg/L vs 65 mg/L; p = 0.016) and (138 mg/L and 97 mg/L; p < 0.001). There were no significant differences in recurrences (22.0% vs. 22.6%; p = 0.87) and complications (2.5% vs. 2.9%; p = 0.77) between the antibiotic/non-antibiotic groups.ConclusionThe structured treatment protocol led to reduced antibiotic use and a higher standard of care in terms of CT-verification. Clinicians’ compliance to the treatment protocol and best clinical practice was poor and warrants further studies.

727 Ambulatory Management of Acute Uncomplicated Diverticulitis During COVID-19 Pandemic

IntroductionAcute diverticulitis remains a common acute presentation to the emergency department(ED). During the COVID-19 pandemic, surgical services have been adapted to reduce hospital admissions. Our aim is to assess the safety and efficacy of the surgical ambulatory service in the management of acute diverticulitis.MethodData was retrospectively collected on consecutive patients referred to the surgical team with a suspected diagnosis of diverticulitis between 30.04.20-16.08.20. Unsuccessful ambulation was determined by representation at 30 days.Results83 patients presented with suspected diverticulitis. 36 patients were deemed clinically stable and suitable for ambulation. 21 of these patients underwent a CT abdomen in the ED, confirming uncomplicated diverticulitis and were discharged with oral antibiotics as per trust guidance. 4 patients were discharged from ED for an ambulatory CT abdomen, with a median waiting time of 3 days. 11 patients received no imaging prior to discharge, all of whom had known diverticular disease. 86% of ambulated patients underwent a telephone review within 72 hours of acute presentation. 8.3% of ambulated patients represented within a 30 day window, 0 of which required surgical management.ConclusionsPatients presenting with uncomplicated acute diverticulitis can be safely managed in an ambulatory setting. Access to imaging early can facilitate successful discharge.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis.

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

Hospital in the home-based management of acute diverticulitis: a safe and effective alternative to inpatient care.

The traditional approach to management of acute uncomplicated diverticulitis involves admission to hospital, antibiotic therapy, gut rest and monitoring for the development of complications. Despite evidence to suggest this can safely be performed in an outpatient setting, inpatient care remains standard practice in Australia potentially due to a variety of factors (van Dijk et al. 2018; Cirocchi et al. 2019). Hospital in the home (HIH) allows patients requiring complex care including intravenous antibiotics, intravenous fluids and complex pain relief to be managed at home. This study examined the safety and efficacy of HIH-based care for acute diverticulitis over a 16-year period. A retrospective review of cases of acute diverticulitis managed under our HIH service from the period of 1st of January 2004 to 20th of October 2020 was completed. Baseline descriptive data relating to age, co-morbidities and severity of diverticulitis was collected. Details of medical treatment provided and subsequent complications were also collected. During the study period, 23 patients with acute diverticulitis were treated under the HIH unit. Among the study population, the median age was 60 (interquartile range 15) with a slight female predominance (n= 13, 56.5%). This represented the first presentation in 60.9% of patients. Average length of stay was 3.6 days (SD=1.0) with no acute complications recorded in the study period. Two patients (8.7%) had further episodes of acute diverticulitis within 60 days. In this study, the lack of complications demonstrated indicates that HIH-based management of acute diverticulitis may be a viable and safe alternative to inpatient care.

Impact of the COVID-19 pandemic on surgical services: early experiences at a nominated COVID-19 centre.

Impact of the COVID-19 pandemic on surgical services: early experiences at a nominated COVID-19 centre.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

The management of acute uncomplicated diverticulitis in the community; results of a single centre study and review of the literature

The management of acute uncomplicated diverticulitis in the community; results of a single centre study and review of the literature

The Use of Biochemical Markers in Complicated and Uncomplicated Acute Diverticulitis

ObjectiveDiverticulosis is extremely common in western society. A recent study has shown that outpatient, nonantibiotic management of acute uncomplicated diverticulitis may be a feasible and safe option. However, the ability to identify these patients is still difficult. This study explores the ability of white cell count, C-reactive protein, and bilirubin in differentiating patients with complicated and uncomplicated diverticulitis, as well as progression to surgical intervention.MethodsThis is a retrospective study of patients admitted with acute diverticulitis over a 5-year period (2009–2014) at a single institution in Australia. Patients were classified into 3 groups; uncomplicated diverticulitis, complicated diverticulitis without surgery, and complicated diverticulitis with surgery. Analysis of variance (ANOVA) and Bonferroni's post hoc analyses were used to compare markers across the groups.ResultsA total of 541 patients met the inclusion criteria for this study. One-way ANOVA showed a significant difference in white cell count (P &amp;lt; 0.0001), C-reactive protein (P &amp;lt; 0.0001), and bilirubin (P = 0.0006) between all 3 groups. Post hoc analyses showed a significant difference in white cell count, C-reactive protein, and bilirubin when comparing uncomplicated diverticulitis against complicated diverticulitis without surgery (P &amp;lt; 0.05) and complicated diverticulitis with surgery (P &amp;lt; 0.05). White cell count also showed a significant difference when comparing complicated diverticulitis without surgery and complicated diverticulitis with surgery (P &amp;lt; 0.05).ConclusionsWhite cell count, C-reactive protein, and bilirubin can distinguish between uncomplicated and complicated diverticulitis.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings

Purpose: Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics.Methods: The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model.Results: In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469).Conclusions: The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Do antibiotics improve outcomes in the management of acute uncomplicated diverticulitis?

Do antibiotics improve outcomes in the management of acute uncomplicated diverticulitis?

Therapeutic management of acute uncomplicated diverticulitis.

Acute diverticulitis is a painful disease of the colon characterized by peridiverticular inflammation and/or infection. The spectrum of acute diverticulitis ranges from isolated peridiverticular inflammation all the way to free perforation with purulent or feculent peritonitis. Among gastrointestinal disorders, acute diverticulitis is one of the most common diagnoses in the ambulatory setting and principal hospital discharge diagnoses. Acute diverticulitis accounts for substantial utilization of healthcare resources and is a detriment to patients' quality of life. In the last decade, several cohort studies and trials have significantly improved our understanding of acute diverticulitis. This paper will review the current literature on acute uncomplicated diverticulitis with a focus on therapeutic management.

Management of acute uncomplicated diverticulitis without antibiotics: a single-centre cohort study.

This study aimed to evaluate the implementation of nonantibiotic management of acute uncomplicated diverticulitis at a large university hospital in Norway with regard to management failure, disease recurrence and complications. On 1 January 2013 we implemented a new policy for the management of acute uncomplicated diverticulitis without antibiotics. Antibiotic treatment was only provided in the case of defined criteria. All patients admitted from 1 January 2013 to 30 June 2014 with a CT-verified, left-sided, acute uncomplicated diverticulitis were included in the study and evaluated retrospectively, with 12months' follow-up. Of 244 admissions with acute uncomplicated diverticulitis, 177 (73%) were managed without antibiotics. Among these there were seven (4%) management failures, including five patients in whom a deteriorating clinical picture prompted antibiotic treatment and two readmissions within 1month due to persisting symptoms. The only complication in this group was one fistula (<1%). Eight (5%) patients had a recurrence of acute diverticulitis requiring hospital care and two (1%) underwent elective surgery within the first year. Twenty (8%) patients met predefined exemption criteria and received antibiotics from admission, six (30%) of whom developed complications. The recurrence rate in this group was 10% and none had surgery performed. The 47 (20%) policy violators treated with antibiotics from admission had no complications. Their recurrence rate was 11% and one (2%) patient underwent elective surgery. This study confirms that nonantibiotic management of acute uncomplicated diverticulitis is safe and feasible. Most complications occurred in a small group of high-risk patients treated with antibiotics.

Systematic review: outpatient management of acute uncomplicated diverticulitis.

Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach. Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion. Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %. Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.