Outcomes Of Acute Diverticulitis Research Articles

FTP6.4 Management and Outcomes of Acute Diverticulitis in Immunosuppressed Patients

Abstract Aims Previous studies have suggested that immunosuppressed patients with acute diverticulitis are at high risk of failing conservative management and many will require urgent surgical intervention. Some series have shown mortality rates as high as 39% and 56% with medical and surgical management respectively. The aim of this study was to analyse the management and outcomes of immunosuppressed patients presenting with acute diverticulitis. Methods Data were collected on patients admitted as an emergency with acute diverticulitis over a 2-year period (1st January 2018 to 31st December 2019). Immunosuppressed patients were identified and divided into 5 groups according to the cause: group 1, chronic corticosteroid use; group 2, transplant patients; group 3, malignant neoplasm; group 4 chronic kidney disease; group 5, other immunosuppressant treatments. Outcomes were recorded. Results Sixty-one patients with immunosuppression were admitted with acute diverticulitis. The number of patients in groups 1-5 were 23, 2, 11, 16 and 9 respectively. Fifty-one patients (83.6%) had a CT during their admission and thirteen (21.3%) presented with complicated diverticulitis. Two patients (3.3%) underwent emergency surgery, both of whom were on chronic corticosteroid therapy and were alive at 1-year post-op. All fifty-nine patients (96.7%) managed conservatively survived admission. Conclusions This study has shown a lower rate of emergency surgery than previously observed and lower mortality with both medical and surgical management. Conservative management appears to be safe for the majority of immunosuppressed patients with acute diverticulitis.

Epidemiology, Management, and Outcomes of Acute Diverticulitis in King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia.

Acute diverticulitis is considered one of the most common emergencies presenting with acute abdomen. There is a paucity of literature on the epidemiology and clinical picture of acute diverticulitis among the Middle Eastern population. Thus, this study aimed to describe the epidemiology, complications, and outcomes in addition to the management of acute diverticulitis in King Abdul-Aziz University Hospital (KAUH), Jeddah, Saudi Arabia. This retrospective study was conducted from 2009 to 2019, using data extracted from an electronic medical system. Data obtained included demographics, clinical presentation, and patient management. Quantitative variables were described as mean and standard deviation, whereas qualitative variables were described as numbers and percentages. The Mann-Whitney U test was used for non-parametric variables, and correlation analysis was done using Spearman's test. Forty-five patients with a median age of 53 years had acute diverticulitis. Twenty-eight patients (62.2%) were Saudi Arabians, and 27 (60%) were male. The majority of patients (n=32, 71.1%) had only left-sided disease, and abdominal pain was the most frequently reported symptom (n=35, 77.8%). Computed tomography revealed that 21 (72.4 %) patients had Hinchey classification stage IA disease. The recurrence rate was 24.4% (N =11). Four patients required 30-day readmission (8.9%). The most commonly used inpatient antibiotic was metronidazole, and the most common surgical procedure was Hartmann's procedure. The 30-day mortality rate was 6.7% (n=3). This study found that acute diverticulitis is more prevalent in men, has a high recurrence rate, and is predominantly seen in the left colon. Most patients have an uncomplicated form of the disease. Given the lack of previous studies in Saudi Arabia, future research should include population-based studies to identify the prevalence, complications, and outcomes of acute diverticulitis in the country.

Predictors of Clinical Course and Outcomes of Acute Diverticulitis: The Role of Age and Ethnicity

Background and Objectives: Acute diverticulitis (AD) is the leading and most burdensome complication of colonic diverticulosis. However, risk factors for its development and predictors of its course are still poorly defined. In this regard, the association of a young age with a complicated course and worse outcome are still controversial. Moreover, little research has addressed the effect of ethnicity on the course of AD. The current study aimed to evaluate the impact of these variables on AD’s course and outcome in the diverse and unique ethnic landscape of Israel. Materials and Methods: We performed a retrospective review of the charts of patients with a radiologically confirmed diagnosis of AD. Patients’ outcomes and disease course, including hospitalization duration, complications, and recurrent episodes, were documented and compared among different age and ethnic groups. Multivariate analysis was performed to identify predictors of complicated AD. Results: Overall, 637 patients with AD were included, the majority (95%) had distal colon AD, and almost one quarter of them were aged less than 50 years. The majority of patients in the young age (<50) group were males (69.7%). Nonetheless, the rate of recurrent episodes (35.3% vs. 37.3%, p = 0.19), hospitalization duration (5 ± 4.7 vs. 6 ± 3.2, p = 0.09) and complications rate (17.3% vs. 13.7%; p = 0.16) were similar for both age groups. In the ethnicity group analysis, Arab minority patients had a first episode of AD at a significantly younger age compared to their Jewish counterparts (51.8 vs. 59.4 years, p < 0.001). However, factors such as a complicated course (16% vs. 15%; p = 0.08) and relapsing episode rates (33% vs. 38%; p = 0.36) did not differ significantly between groups. None of the variables, including young age and ethnic group, were predictors of complicated AD course in the multivariate analysis. Conclusion: AD is increasingly encountered in young patients, especially in ethnic minority groups, but neither ethnicity nor young age was associated with worse outcomes.

Far from black and white: Role of race, health literacy, and socioeconomic factors in the presentation of acute diverticulitis

BackgroundRacial discrepancies in treatment and outcomes of acute diverticulitis have been observed, yet underlying factors are poorly understood. We aimed to identify racial inequalities in health literacy among patients hospitalized with acute diverticulitis and characterize factors associated with more severe presentation. MethodsWe performed a retrospective cohort analysis of 947 Black or White patients admitted with acute diverticulitis at a quaternary referral center from January 2009 through September 2019. Health literacy was determined by the validated Brief Health Literacy Screening, and socioeconomic status was defined by the area deprivation index, a composite of multiple neighborhood socioeconomic deprivation measures. The primary outcome was severity of disease presentation represented by systemic inflammatory response syndrome criteria; secondary outcomes included intensive care unit admission, length of stay, and invasive interventions. ResultsAmong all study participants, 121 (12.8%) self-identified as Black. Overall, 140 (14.8%) patients had inadequate health literacy, and 495 (52.3%) had area deprivation index greater than the national median. There was no association between race or area deprivation index and health literacy. A total of 340 (35.9%) patients met criteria for systemic inflammatory response syndrome, and 88 (9.3%) underwent an intervention; median length of stay was 3.5 days. Race, health literacy, and area deprivation index were not significantly associated with outcomes (P > .05). ConclusionAmong patients with acute diverticulitis, no difference in severity of presentation by race, health literacy, or area deprivation index was observed. These findings suggest that differences in presentation of acute diverticulitis may not be driven by these social factors. Future studies should include considerations of clinical characteristics of acute diverticulitis, such as the role of access and underuse of healthcare resources.

S0251 Clostridioides difficile Infection Is Associated With Adverse Clinical Outcomes in Patients With Acute Diverticulitis: A Nationwide Study

INTRODUCTION: Acute diverticulitis (AD) is a common gastrointestinal disease with a significant healthcare associated burden. Patients hospitalized with AD have many risk factors for developing Clostridioides difficile infection (CDI). CDI is associated with poor outcomes in many diseases but has yet to be studied in AD. METHODS: We utilized data from the National Inpatient Sample from January 2012 to October 2015 for patients hospitalized with AD and CDI. Primary outcomes were mortality, length of stay, and hospitalization cost were compared. Secondary outcomes were complications of diverticulitis and need for surgical interventions. Risk factors for mortality in acute diverticulitis and risk factors associated with CDI in AD patients were analyzed. RESULTS: Among 767,850 hospitalizations for AD, 8,755 also had CDI. A multivariate logistic regression analysis demonstrated that CDI was associated with increased risk of inpatient mortality (OR 2.02, 95% CI 1.38–2.96), prolonged duration of hospitalization by 3.7 days (95% CI, 3.38–4.02, P < 0.001) and had higher total hospitalization charges $74525 vs $37571 (P < 0.001). Patients who required surgery for AD had greater mortality than those who did not (0.9% vs 0.3%, P < 0.001). Patient with CDI in AD who underwent surgery had greater mortality than patients with CDI who did not require surgery (4.1% vs 0.9%, P < 0.001). Predictors of CDI among patients with AD included age (1.01 OR, 95% CI 1.01–1.02) female gender (1.12 OR, 95% CI 1.01–1.24), three or more comorbidities (1.81 OR, 95% CI 1.57–2.09), admissions to teaching hospitals (1.44 OR, 95% CI 1.22–1.70), length of stay (1.08, OR 95% CI 1.07–1.09) and inflammatory bowel disease (2.26, 95% CI 1.61–3.17). A multivariate logistic regression analysis for the impact of surgery and complicated diverticulitis was performed. Patients who required surgical interventions had increased mortality including colectomy (OR 2.36, 95% CI 1.83–3.06), colostomy (OR 2.99, 95% CI 2.30–3.90) anterior resection (OR 1.9, 95% CI 1.1–3.29) and abscess drainage (OR 1.85, 95% CI 1.39–2.47). Patients with complications of diverticulitis had increased mortality including obstruction (OR 1.33, 95% CI 1.07–1.66), perforation (OR 3.90, 95% CI 2.16–7.04) and hemorrhage (OR 1.73, 95% CI 1.38–2.18). CONCLUSION: CDI in AD is associated with increased mortality, length of stay and total hospital charges. Preventative measures should be made for at-risk patients with AD to decrease infection rate and poor outcomes.Table 1.: Patient Demographics and Characteristics, Interventions, Complications and Outcomes of Acute Diverticulitis with and without CDITable 2.: Risk factors associated with In-Hospital Mortality in Acute Diverticulitis

Clinical presentation and outcomes of acute diverticulitis in a Middle Eastern population

Background and study aimsThere is lack of literature describing the presentation of diverticulitis in the Middle East population. The aim of this study is to provide an analysis of the epidemiological indicators, patterns of presentation and outcomes of acute diverticulitis in a Middle Eastern population. Patients and methodsA retrospective review of all adult patients over the age of 17 who were admitted to the surgical service with a diagnosis of acute diverticulitis between January 2010 and May 2018 at a major university affiliated government hospital in the state of Kuwait. Data collected included patients’ demographics, clinical presentation, management and outcome. ResultsBetween January 2010 and May 2018 there were 132 patients admitted with a diagnosis of acute diverticulitis. The mean age was 49.2 [±14.3] years. There were 89 (67.4%) men and 43 (32.6%) women. One-hundred and fifteen patients (87.1%) were Arabs, of which Kuwaiti citizens represented 58.3%. Most patients (76.5%) presented with uncomplicated diverticulitis. One hundred and twelve patients (84.8%) had sigmoid colon diverticulitis. There were nine patients that were readmitted within thirty days. The mean length of hospital stay was 5.3 days [±4.5]. The median follow-up period was 15.6 weeks (IQR 1.8, 118.4), during which time recurrent attacks occurred in 25 patients (18.9%). ConclusionsIt appears that there is a low prevalence of acute diverticulitis in Arabs living in Kuwait, and that when they do present with acute diverticulitis the majority present at a relatively younger age with uncomplicated disease.

The Effect of Surgical Training and Operative Approach on Outcomes in Acute Diverticulitis: Should Guidelines Be Revised?

Current guidelines accept partial colectomy and primary anastomosis with proximal diversion for select patients with perforated diverticulitis based on low-quality evidence. This study aimed to compare the effect of operative approach and surgeon training on outcomes following urgent/emergent colectomy for diverticulitis. This is a statewide retrospective cohort study. Data were obtained from the New York State all-payer sample from 2000 to 2014. All patients who underwent an urgent/emergent sigmoid colectomy for diverticulitis with creation of an end colostomy or primary anastomosis with proximal diversion were included. We excluded all patients age <18 years, with IBD, colorectal cancer, ischemic colitis, or elective operations. The main outcomes measured were postoperative in-hospital mortality and complications, RESULTS:: A total of 10,780 patients underwent urgent/emergent colectomy for diverticulitis: 10,600 (98.3%) received a Hartmann procedure and 180 (1.7%) received primary anastomosis with proximal diversion. Colorectal surgeons performed 6.0% of all operations. Utilization of primary anastomosis with proximal diversion was greater among colorectal surgeons but remained low overall (4.2% vs 1.5%; p < 0.001). Postoperative mortality was 2-fold greater when noncolorectal surgeons performed primary anastomosis vs Hartmann procedure (15% vs 7.4%; p < 0.001) and 1.4 times greater among noncolorectal surgeons than among colorectal surgeons (7.5% vs 5.3%; p = 0.04). On multivariable logistic regression (adjusting for patient demographics/characteristics, year, hospital academic status, and surgeon training) primary anastomosis with proximal diversion remained associated with increased mortality (OR, 2.7; 95% CI,1.7-4.4; p < 0.001), complications (OR, 1.8; 95% CI, 1.3-2.5; p < 0.001), and reoperation (OR, 3.4; 95% CI, 1.8-6.3; p < 0.001), whereas colorectal board certification was associated with decreased mortality (OR, 0.66; 95% CI, 0.46-0.95; p = 0.03). Selection bias secondary to retrospective nature and absence of disease severity were limitations of this study. Despite current recommendations for primary anastomosis with proximal diversion for perforated diverticulitis, this operation in New York State was associated with increased postoperative morbidity and mortality when performed by general surgeons. Given that the majority of urgent/emergent colectomies for diverticulitis are not performed by colorectal surgeons, guidelines for operative management of perforated diverticulitis should be reevaluated. See Video Abstract at http://links.lww.com/DCR/A772.

Colonoscopy-induced acute diverticulitis: myth or reality?

Colonoscopy in patients with diverticulosis can be technically challenging and limited data exist relating to the risk of post-colonoscopy diverticulitis. Our aim was to evaluate the incidence, management, and outcomes of acute diverticulitis following colonoscopy. Study design is retrospective cohort study. Data were gathered by conducting an automated search of the electronic patient database using current procedural terminology and ICD-9 codes. Patients who underwent a colonoscopy from 2003 to 2012 were reviewed to find patients who developed acute diverticulitis within 30 days after colonoscopy. Patient demographics and colonoscopy-related outcomes were documented, which include interval between colonoscopy and diverticulitis, colonoscopy indication, simultaneous colonoscopic interventions,and follow-up after colonoscopy. From 236,377 colonoscopies performed during the study period, 68 patients (mean age 56years) developed post-colonoscopy diverticulitis (0.029%; 2.9 per 10,000 colonoscopies). Incomplete colonoscopies were more frequent among patients with a history of previous diverticulitis [n = 10 (29%) vs. n = 3 (9%), p = 0.03]. Mean time to develop diverticulitis after colonoscopy was 12 ± 8 days, and 30 (44%) patients required hospitalization. 34 (50%) patients had a history of diverticulitis prior to colonoscopy. Among those patients, 14 underwent colonoscopy with an indication of surveillance for previous disease. When colonoscopy was performed within 6weeks of a diverticulitisattack, surgical intervention was required more often when compared with colonoscopies performed after 6weeks of an acute attack [n = 6 (100%) vs. n = 10 (36%), p = 0.006]. 6 (9%) out of 68 patients receivedemergency surgical treatment. 15 (24%) out of 62 patients who had non-surgical treatment initially underwent an elective sigmoidectomy at a later date. Recurrent diverticulitis developed in 16 (23%) patients after post-colonoscopy diverticulitis. Post-colonoscopy diverticulitis is a rare, but potentially serious complication. Although a rare entity, possibility of this complication should be kept in mind in patients presenting with symptoms after colonoscopy.

How to use administrative data for surgical outcomes in acute diverticulitis

&lt;p&gt;The measurement of quality outcomes is crucial in surgical care. Administrative data are increasingly used but their ability to provide clinically useful information is reliant on how closely the coding can define a particular cohort. In acute admissions for diverticular disease, it is important to differentiate between complicated and uncomplicated diverticulitis, and between diverticulitis and diverticular bleeding. We aim to develop a method to define clinically relevant cohorts of patients from an administrative database in acute diverticulitis. Codes for acute diverticulitis were found from the ICD-10-AM (Australia and New Zealand) coding system, and the accuracy was established with retrospective chart review and cross-referenced with a clinical database at a single institution. Coding of non-diverticular and missed diverticular cases was examined to determine non-diverticular codes that could differentiate these cases. These were combined into logic algorithms designed to differentiate between uncomplicated and complicated diverticulitis admissions derived from an administrative database. Specific K57 diverticular codes possessed sensitivity and positive predictive values of 0.92 and 0.69 for uncomplicated diverticulitis, respectively, with 0.61 and 0.92 for complicated diverticulitis, respectively, based on 153 cases. Most of the missing cases were usually complicated diverticulitis whilst some cases coded incorrectly as uncomplicated diverticulitis were often found as undifferentiated abdominal pain. Diagnostic codes combined into algorithms that accounted for predictable variations improved cohort definition. In conclusion, algorithms with combined codes improved definitions of clinically relevant cohorts for acute diverticulitis from an Australian or New Zealand administrative database. This method may be used to develop logic algorithms for other surgical conditions and enable widespread measurement of relevant surgical outcomes.&lt;/p&gt;

Laparoscopic Colon Resections in Geriatric Patients: Improving Outcomes in Acute Diverticulitis

Laparoscopic Colon Resections in Geriatric Patients: Improving Outcomes in Acute Diverticulitis

Differing Outcomes in Acute Diverticulitis Between Internists and Gastroenterologists

Differing Outcomes in Acute Diverticulitis Between Internists and Gastroenterologists