Management Of Diverticulitis Research Articles

Acute diverticulitis requiring hospitalization according to regional discrepancies in France between 2013 and 2022: a nationwide study

PurposeThe prevention of colon diverticulitis tends to be tailored according to the patients. In order to improve the public health policy to prevent diverticulitis, the influence of regional parameters at a department scale has to be assessed.ObjectiveThis analysis aimed to assess the occurrence of acute diverticulitis in France in general and according to environmental factors suspected to affect such diseases.MethodsAll patients above 18 years old admitted to a general hospital with a diverticulitis diagnosis between 2013 and 2022 in France were included. Data were extracted from the French national hospital discharge database. The primary outcome was the occurrence of diverticulitis according to French territories and known risk factors.ResultsIn this nationwide cohort study, the 10-years cumulative occurrence of diverticulitis in France was 3.45% (n = 2 0.248.099 patients). Diverticulitis was influenced by older age and male gender but was not significantly associated with ecological parameters (obesity, alcohol consumption, smoking or economic discrepancies) at a departmental scale. Of all patients diagnosed with diverticulitis, 5% had at least one surgical intervention. The surgical management of diverticulitis was associated with an increased number of surgeons in the department, even after adjustment for age and sex.ConclusionsExcept for smoking, the frequency of diverticulitis requiring an hospitalization was independent of regional parameters (nor alcohol intake, nor obesity nor the economic discrepancies).

Emerging Topics in the Management of Diverticulitis.

Emerging Topics in the Management of Diverticulitis.

A Multimodal Approach to the Management of Diverticular Abscess with Paraesophageal Hernia Complication

This study aims to evaluate the management of acute diverticulitis complicated by hernia and the role of electroacupuncture in managing postoperative ileus. The case involved a 51-year-old male patient who presented with left lower abdominal pain, fever, and defecation disorder. Physical examination showed signs of infection with localized peritonitis, while laboratory tests revealed neutrophilia. CT scan showed diverticulitis with abscesses in the descending and sigmoid colon, as well as free air around the colon and perihepatic region, and paraesophageal hernia. The patient underwent left hemicolectomy with Hartmann's procedure. Postoperatively, the patient developed ileus which was treated using electroacupuncture. The results showed that the relationship between diverticulosis and hernia is due to connective tissue changes. Approximately 10-20% of diverticulosis cases progress to acute diverticulitis. CT scan is the gold standard for diagnosis, staging and management of diverticulitis. In cases of Hinchey III diverticulitis, laparoscopic washing does not give better results compared to colonic resection. The Hartmann procedure is recommended for patients with multiple comorbidities. Electroacupuncture proved to be an effective adjunctive therapy in managing postoperative ileus. The conclusion of this study is that a multimodal approach, including surgery and complementary therapies such as electroacupuncture, is essential in the management of diverticulitis and its complications. The implication of this study is the need for a holistic approach in managing patients with acute diverticulitis, especially in cases with multiple comorbidities and risk of postoperative complications.

Diverticulitis Management in Complex Medical Contexts

AbstractDiverticulitis is a prevalent medical issue, particularly among elderly individuals in the Western world. Management is nuanced and is influenced by both disease presentation and patient factors, especially those that affect risk of septic and surgical complications. This paper reviews existing literature to explore the incidence, presentation, and management of diverticulitis in complex medical contexts—immunocompromised populations, specifically highlighting those undergoing chemotherapy, HIV/AIDS patients, transplant recipients, and individuals with autoimmune and connective tissue diseases. Not surprisingly, management of diverticulitis in these complex patient populations is associated with increased morbidity. However, even taking into consideration the risk of septic and surgical complications, more recent data and treatment recommendations suggest that both nonoperative and operative management strategies may be appropriate based on individual patient presentations, mirroring the treatment paradigm of immunocompetent patients. In addition, in discussing operative management of complex medical patients, immunosuppression alone should not be considered a contraindication to primary anastomosis. Overall, there are limited existing data on diverticulitis in immunocompromised populations and, especially, patients with autoimmune and connective tissue disorders. Further research is warranted to better understand the impact of these chronic diseases on diverticulitis severity and to best inform evidence-based practices in this complex clinical scenario.

Success in Diverticulitis Management: What Outcomes Really Matter?

AbstractAchieving optimal outcomes is a universal goal among health care providers. However, disagreement often arises when selecting and measuring endpoints as markers of care performance. In diverticulitis, this task is complicated by variability in clinical presentation and existence of multiple evidence-based therapeutic options. The aim of this review is to summarize trends and challenges in outcomes measurement for diverticulitis. We discuss historical origins and compare existing frameworks for classifying outcomes. Next, focus is directed to an exploration of important outcomes through clinical controversies: antibiotics for acute uncomplicated diverticulitis, colectomy with primary anastomosis for acute complicated diverticulitis, and elective colectomy for recurrent diverticulitis. Finally, we review recommendations supporting case-by-case decision-making and implications for clinicians, in addition to ongoing international efforts to standardize outcomes that matter for common diseases.

Acute diverticulitis management: evolving trends among Italian surgeons. A survey of the Italian Society of Colorectal Surgery (SICCR).

Acute diverticulitis (AD) is associated with relevant morbidity/mortality and is increasing worldwide, thus becoming a major issue for national health systems. AD may be challenging, as clinical relevance varies widely, ranging from asymptomatic picture to life-threatening conditions, with continuously evolving diagnostic tools, classifications, and management. A 33-item-questionnaire was administered to residents and surgeons to analyze the actual clinical practice and to verify the real spread of recent recommendations, also by stratifying surgeons by experience. CT-scan remains the mainstay of AD assessment, including cases presenting with recurrent mild episodes or women of child-bearing age. Outpatient management of mild AD is slowly gaining acceptance. A conservative management is preferred in non-severe cases with extradigestive air or small/non-radiologically drainable abscesses. In severe cases, a laparoscopic approach is preferred, with a non-negligible number of surgeons confident in performing emergency complex procedures. Surgeons are seemingly aware of several options during emergency surgery for AD, since the rate of Hartmann procedures does not exceed 50% in most environments and damage control surgery is spreading in life-threatening cases. Quality of life and history of complicated AD are the main indications for delayed colectomy, which is mostly performed avoiding the proximal vessel ligation, mobilizing the splenic flexure and performing a colorectal anastomosis. ICG is spreading to check anastomotic stumps’ vascularization. Differences between the two experience groups were found about the type of investigation to exclude colon cancer (considering the experience only in terms of number of colectomies performed), the size of the peritoneal abscess to be drained, practice of damage control surgery and the attitude towards colovesical fistula.

Treatment preferences in diverticulitis are common and rarely change after a clinic visit

With the increasing prevalence of diverticulitis, professional guidelines encourage the individualization of treatment. However, the frequency of treatment preferences of both surgeons, and patients, and the resultant impact of that preference on diverticulitis management is underexplored. We reviewed 27 consecutive patient visits of 3 colorectal surgeons at our institution to evaluate factors that drove their treatment, as well as their equipoise for patient randomization into medical or surgical treatments. Using standardized pre- and post-visit questionnaires, we investigated the impact of the clinic visit on treatment recommendations. Our results demonstrate that our surgeons have a practice bias towards complicated disease, and have a preference towards operative management of diverticulitis, in both complicated and uncomplicated disease. This preference was frequently unchanged after clinic visit, which has implications for guiding truly shared decision making, as it continues to be the recommendation.

Open Versus Minimally Invasive Emergent Colectomy for Diverticulitis.

The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes. Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO). Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; β -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (β -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open. Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.

Diverticulitis in the Under-40 Population.

As obesity and lifestyle factors become more prevalent in younger populations, we are diagnosing and treating diverticulitis in younger patients. In this study, the demographics, risk factors for the development, and treatment of acute diverticulitis were assessed focusing on patients under the age of 40. A retrospective review of the electronic medical records of a cohort of subjects diagnosed with diverticulitis was performed. Inclusion criteria included patients aged 18-40 who were treated for acute diverticulitis with or without any complications. Of the 109 patients, 40 patients required surgery, and 69 patients were managed conservatively. Analysis showed that the Hinchey classification (p<0.001) was the strongest predictor of treatment modality. As the incidence of diverticulitis has increased in recent decades, so too has the frequency with which elective surgical procedures are performed as treatment. While these procedures are vital components in the management of diverticulitis, the majority of research comparing conservative versus surgical treatments has been done in patients over 50 years old. Although diverticulitis has been classically thought of as a disease of the elderly, it has become more prevalent in younger populations due to the rise of obesity and lifestyle modification in the under-40 population. Although the prevalence of treatment and diagnosis of acute diverticulitis in younger patients has risen, there is a paucity of data surrounding treatment protocols for diverticulitis in association with patient symptoms for patients under the age of 40 years old. Our study has found that there is a higher incidence of complications in diverticulitis inpatients under the age of 40.Additionally, when considering the pattern of complication presentation in younger patients with complicated diverticulitis, surgical intervention might not be appropriate. The current treatment algorithm relates diverticulitis complications with surgical interventions. However, our data suggest that patients under the age of 40 presenting with abscesses or strictures may not need surgical intervention. This information could be particularly helpful in guiding physicians and younger patients in selecting the best choice of care and minimizing complications.Additionally, further research should help guide treatment protocol in this specific population of patients, as there is a lack of established guidelines pertaining to diverticulitis surrounding younger patients.

Operative versus nonoperative management for diverticulitis complicated by abscess

A clinical decision report using: You K, Bendl R, Taut C, et al. Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively. Br J Surg. 2018;105(8):971-979. https://doi.org/10.1002/bjs.10868 for a patient with a recurrent diverticulitis complicated by abscess formation.

Contemporary management of diverticulitis

The treatment of diverticulitis is experiencing a shift in management due to a number of large scale clinical trials. For instance, clinicians are beginning to recognize that avoidance of antibiotics in uncomplicated diverticulitis is not associated with worse outcomes. Additionally, while the decision to proceed with elective surgical resection for recurrent uncomplicated disease is less conclusive and favors a patient-centric approach, complicated disease with a large abscess denotes more aggressive disease and would likely benefit from elective surgical resection. Lastly, in patient with acutely perforated diverticulitis who require urgent surgical intervention, laparoscopic lavage is generally not recommended due to high re-intervention rates and the preferred surgical procedure is primary anastomosis with or without diversion due to high morbidity and low rates of Hartmann reversal.

Jejunal diverticulum perforation leading to extra intestinal faecolith formation: a case report

A 54-year-old woman with a history of jejunal diverticulitis presented with vague abdominal pain and underwent a laparotomy for a suspected foreign body perforation based on CT imaging. Surprisingly, no foreign body was found, but rather a chronic jejunal diverticulum with perforation and early-stage faecolith formation within the contained site. This rare case challenges assumptions about jejunal diverticulitis management and suggests that premature faecolith formation can occur post-perforation. We proposed revising treatment strategies to consider conservative measures for stable patients with contained perforations, emphasizing accurate diagnosis and individualized management, and promoting further research to establish evidence-based guidelines specific to jejunal diverticulitis.

Prescription Practice Protocol of Antibiotics in A&amp;E for Acute Diverticulitis in DGH: A Closed Loop Audit

Abstract Aim of the study To examine the level of adherence, of local antibiotics prescription practice, for Diverticulitis to NICE guidelines 2019. Introduction Acute diverticulitis is an inflammation of a diverticulum, a sac-like protrusion from the colon wall, due to micro-perforation. Based on clinical and radiological findings they are classified as complicated and uncomplicated diverticulitis. As per nice guidelines, diverticulitis can be managed on the basis of classification, Method Retrospect data collection for 3 months, for each cycle, was done from the surgical on-call take list and reviewed the management of diverticulitis. Patients with a confirmed diagnosis of acute diverticulitis by Ct scan were only included in the study. Results In our 1st cycle of study, we found that our practice was not competent with NICE guidelines and 98% of patients were treated with antibiotics despite their requirement. We made a local guideline in association with NICE guidelines for the management of acute diverticulitis and organized teaching sessions and did templates presentation in various wards. In 2nd cycle of the study 71% of the patient was treated with antibiotic and 71% were in need of antibiotics as per NICE guideline. Conclusion We are now 100% compliant with NICE guidelines in antimicrobial prescription in acute diverticulitis.

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.

Diverticulitis patient care during the Covid-19 pandemic in Germany—a retrospective nationwide population-based cohort study

PurposeCoronavirus disease 2019 (COVID-19) impacted health care systems around the world. Despite a decrease in emergency admissions, an increased number of complicated forms of diverticulitis was reported. It was the aim of this study to analyze the pandemic impact on diverticulitis management in Germany.MethodsThis is a retrospective population-wide analysis of hospital billing data (2012–2021) of diverticulitis in Germany. Patients were identified based on diagnosis (ICD10) and procedural codes to stratify by conservative and operative management. Primary outcome of interest was admission rates, secondary outcomes were rates of surgical vs conservative treatment and fraction of complicated clinical courses during the pandemic.ResultsOf a total of 991,579 cases, 66,424 (6.7%) were admitted during pandemic lockdowns. Conservative treatment was the most common overall (66.9%) and higher during lockdowns (70.7%). Overall admissions and population adjusted rates of surgically treated patients decreased, the latter by 12.7% and 11.3%, corrected to estimated rates, in the two lockdowns. Surgery after emergency presentation decreased by 7.1% (p=0.053) and 11.1% (p=0.002) in the two lockdowns with a higher rate of ostomy and/or revision (+5.6%, p=0.219, and +10.2%, p=0.030). In-hospital mortality was increased in lockdown periods (1.64% vs 1.49%). In detail, mortality was identical in case of conservative treatment during lockdown periods (0.5%) but was higher in surgically treated patients (4.4% vs 3.6%).ConclusionDuring lockdowns, there was an overall decrease of admissions for diverticulitis, especially non-emergency admissions in Germany, and treatment was more likely to be conservative. In case of surgery, however, there was increased risk of a complicated course (ostomy, re-surgery), possibly due to patient selection.

Diverticulitis, surgery, evidence-based medicine, and the Steve Jobs' dots: a narrative review.

Emergency treatment of acute diverticulitis remains a hazy field. Despite a number of clinical studies, randomized controlled trials (RCTs), guidelines and surgical societies recommendations, the most critical hot topics have yet to be addressed. Literature research from 1963 until today was performed. Data regarding the principal RCTs and observational studies were summarized in descriptive tables. In particular we aimed to focus on the following topics: the role of laparoscopy, the acute care setting, the RCTs, guidelines, observational studies and classifications proposed by literature, the problem in case of a pandemic, and the importance of adapting treatment /place/surgeon conditions. In the evaluation of these points we did not try to find any prospective evolution of the concepts achievements. On the contrary we simply report the individuals strands of research from a retrospective point of view, similarly to what Steve Jobes said: "you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future". We have finally obtained what can be defined "a narrative review of the literature on diverticulitis". Not only evidence-based medicine but also the contextualization, as also the role of 'competent' surgeons, should guide to novel approach in acute diverticulitis management.

Diverticulitis with abscess formation: Outcomes of non-operative management and nomogram for predicting emergency surgery: The Diplicab Study Collaborative Group

BackgroundTo assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery. MethodsThis nationwide retrospective cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib–II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed. ResultsOverall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 [0.37–0.96]). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001–1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04–4.44), Hinchey II (odds ratio: 2.15; 1.42–3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06–3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08–6.32), and use of morphine (odds ratio: 3.68; 2.29–5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77–0.85). ConclusionPercutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.

Presentation, Outcomes, and Non-elective Surgical Management of Diverticulitis: Is There an Ethnic Divide?

Presentation, Outcomes, and Non-elective Surgical Management of Diverticulitis: Is There an Ethnic Divide?

Risk Factors and Management of Diverticulitis

Diverticulitis is a type of gastrointestinal disorder that develops when the mucosa herniates through the muscular wall of the colon forming a sac like pouch known as diverticula. Development of diverticula can present as asymptomatic, known as diverticulosis or symptomatic, known as diverticulitis. Within the gut, the flora plays an essential role in in providing a barrier to pathogenic organisms. Scientists believe that the chronic inflammation related to diverticulitis is a result of an imbalance in the normal gut flora. There are many risk factors associated with diverticulitis including genetic predisposition, dietary and lifestyle factors. Individuals aged sixty-five and older have a significantly higher risk of developing a diverticular disease, however new research has shown that the greatest increase in percentage of individuals diagnosed with diverticulitis are individuals age 50 years and younger. With irreversible damage being done on the gut microbe, scientists have developed several possible treatments of diverticulitis with antibiotics, anti-inflammatory and probiotic drugs. A combination of these treatments helps to eliminate recurrence of diverticulitis.

Tips for the Medical Management of Diverticulitis.

1University of Washington, Seattle, Washington, USA; 2University of North Carolina, Chapel Hill, North Carolina, USA. Correspondence: Anne F. Peery, MD, MSCR. E-mail: [email protected].