Treatment Of Diverticulitis Research Articles

Development of intestinal colonic drug delivery systems for diverticular disease: A QbD approach

This study aimed to advance the development of intestinal colon-coated sustained-release matrix tablets of metronidazole for diverticulitis treatment, employing the Quality by Design (QbD) methodology. Comprehensive Risk analysis and Risk evaluation were conducted to assess the potential risks associated with Critical Material Attributes (CMA) and Critical Process Parameters (CPP). Ishikawa diagram, color-coded risk classification and the Risk Priority Number (RPN) were used as tools for risk evaluation. A Design of Experiments (DoE) was executed using a fractional factorial design, incorporating five key factors derived from the Risk analysis and Risk evaluation. Two levels and a central point were established for each factor, resulting in 28 batches of coated tablets. The manufacturing process involved direct compression, followed by a coating process using pH-dependent or time-dependent polymers. Characterization and dissolution studies were conducted on all batches, and the obtained results underwent analysis of variance (ANOVA).The findings demonstrated the robustness and reproducibility of both the direct compression and coating processes. Statistical analysis identified HPMC/chitosan ratio, blending time, coating polymer, and coating weight gain as factors significantly impacting drug release. A Design Space was established to delineate the interplay of these factors, offering insights into various combinations influencing drug release behavior. Thus, the design space for 10 % weight gain formulations includes a range of HPMC/CH ratios between 2.7–3 and mixing times between 10 and 12 min; for 20 % weight gain formulations it includes a range of HPMC/CH ratios up to 2 and mixing times between 10 and 16 min. Multiple Linear Regression between technological and biopharmaceutical variables were optimized facilitating scale-up operations. Batches with a 10 % weight increase and varied HPMC viscosity grades and coating polymers achieve ∼50 % drug release at 24 h; however, batches with a 20 % weight increase along, with either high proportions of HPMC and short blending times or low proportions of HPMC and longer blending times, achieve slow release of metronidazole. This study contributes to optimizing metronidazole colonic delivery systems, enhancing their potential efficacy in diverticulitis treatment.

The Emerging Role of the Microbiota and Antibiotics in Diverticulitis Treatment

AbstractDiverticular disease is the leading cause of elective colon surgery. With a rising incidence in younger populations, it continues to pose a significant burden on the health care system. Traditional etiopathogenesis implicated an infectious mechanism, while recent challenges to this theory have demonstrated the microbiome playing a significant role, along with genetic predispositions and associations with obesity and diet. Therefore, the role of antibiotics in uncomplicated disease merits reconsideration. In this review, we aim to outline the current knowledge regarding antibiotics for diverticulitis treatment, broadly define the microbiome components, functions, and modifiability, and discuss newly proposed pathogenetic mechanisms for diverticular disease that incorporate information regarding the microbiome. Analytic techniques for microbiota characterization and function continue to advance at a rapid pace. As emerging technology advances, we will continue to elucidate the role of the microbiome in diverticular disease development.

Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study.

Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure. A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30days after admission. Ninety-three patients (61% male, mean age 57 ± 17years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002). Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.

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.

Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails?

IntroductionDiverticulitis and appendicitis are common emergency general surgical conditions. Both can be treated with antibiotics alone; however, no antibiotic regimen has been identified as superior to others. In this study, we review different antibiotic regimens and their rates of failure. MethodsRetrospective cohort study of patients treated empirically with antibiotics for diverticulitis or appendicitis from January 1, 2018, to December 31, 2020, at an independent academic hospital in the Midwest. ResultsA total of 587 (appendicitis, n = 43; diverticulitis, n = 544) patients were included in the cohort. They were equally male (49%) and female (51%) with a median age of 59 y. Three major antibiotic classes were compared: cephalosporin + metronidazole (C + M), penicillins, and quinolone + metronidazole. Appendicitis patients were more likely to receive C + M for empiric treatment (73%, P < 0.001), while diverticulitis patients were more likely to receive quinolone + metronidazole (45%, P < 0.001). Patients empirically treated with antibiotics for appendicitis were more likely than those treated for diverticulitis to require additional antibiotics or procedure within 90 d (33% versus 13%, respectively; P = 0.005). Empiric treatment with C + M for diverticulitis was more likely to be associated with the need for additional antibiotics or procedures within 90 d than treatment with other regimens (P = 0.003). Choice of antibiotic for empiric treatment did not correlate with death at 90 d for appendicitis or diverticulitis. Diverticulitis patients who were initially treated as inpatients and were prescribed C + M at hospital discharge had a higher rate of death than those who were prescribed the other antibiotics (P = 0.04). ConclusionsEmpiric antibiotic treatment of appendicitis is more likely to be associated with additional antibiotics or procedure when compared with diverticulitis; however, antibiotic choice did not correlate with any of the other outcomes. Empiric treatment with a C + M for diverticulitis was more likely to be correlated with the need for additional antibiotics or procedure within 90 d.

Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey.

International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change. A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change. The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%). Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.

Recurrence patterns of acute colonic diverticulitis among patients admittedto Benghazi Medical Center, Benghazi, Libya: A retrospective and hospital-based study

Background: The normal pattern of acute colonic diverticulitis is still unknown, and prophylactic surgery after conservative treatment of diverticulitis is a topic of growing debate. The aim of this study was to investigate the patterns and frequency of recurrences and the likelihood of complications in conservatively treated uncomplicated and complicated diverticulitis in our epidemiological setting. Methods: This retrospective study was conducted to investigate 98 inpatients admitted to Benghazi Medical Center with acute colonic diverticulitis, between February 2021 and August 2022. Acute diverticulitis discharge summaries were reviewed to identify eligible patients, and their medical records were meticulously reviewed retrospectively to confirm that their clinical presentation was consistent with colonic diverticulitis. Results: A retrospective study of 98 patients with acute colonic diverticulitis found that uncomplicated diverticulitis was associated with younger age, better 2-year survival rates, and more conservative management. Recurrence rates were almost similar between uncomplicated and complicated diverticulitis (23% vs. 25%) and typically occurred within 12 months of the initial attack. Surgical intervention was necessary for patients with perforations, while conservative management was used for other cases. Complications included abscesses in 44% of cases and perforations in 38% of cases. Conclusion: This study found that acute diverticulitis has a low recurrence rate and a limited propensity for progression into complications. It is recommended that elective surgery is used as a preventive measure against recurrences and associated complications. These findings have implications for clinical practice.

Conservative treatment of diverticulitis

Conservative treatment of diverticulitis

Acute epiploic appendagitis - a rare differential diagnosis of acute abdomen.

Acute epiploic appendagitis is a rare differential diagnosis of unclear or acute abdomen. To describe - by means of a scientific case report - the extraordinary diagnosis of acute epiploic appendagitis along with contained diverticulitis and incarcerated herniation of the greater omentum into the hernial sac of a former trocar site (medical history, significant for laparoscopic ovarian cyst removal) in a 29-year-old female based on experiences obtained in the successful clinical case management, and on selective references from medical scientific literature. Medical history: A 29-year-old female was admitted with abdominal pain in the lower left quadrant. She reported a laparoscopic ovarian cyst removal 3 years prior. Physical examination of the abdomen revealed tenderness in the lower left quadrant without a palpable mass.Leading diagnoses were found using transabdominal ultrasound and confirmed by an abdominal CT scan; namely, incarcerated trocar hernia, diverticulitis of sigmoid colon, and acute epiploic appendagitis. Therapeutic approach was comprised of an explorative laparoscopy (because of the incarcerated hernia), adhesiolysis, removal of a tip of the greater omentum out of the hernial sac, closure of the hernial orifice, and removal of an unclear, inflamed, and bloody fatty tissue from the wall of the descending colon (histopathological investigation confirmed acute epiploic appendagitis). This was flanked by conservative treatment of diverticulitis of the sigmoid colon.Further clinical course was uneventful, with discharge on the 3rd postoperative day with favorable long-term outcome, characterized by no further complaints for 15 months. Acute epiploic appendagitis is an inflammatory, usually self-limiting condition of the epiploic appendages of the colon. It typically manifests with abdominal pain in the lower left quadrant. Imaging is an important diagnostic tool to determine whether the patient has, in fact, acute epiploic appendagitis, so recognizing the characteristic oval lesions with the surrounding inflammation and central fat attenuation on CT, as well as the hyperechoic oval lesions with a hypoechoic peripheral band on ultrasound images is crucial. Nevertheless, it is often overlooked in patients and confused with other differential diagnoses, such as appendicitis or diverticulitis. Although the condition appears infrequently, it is essential to be proficient in the diagnostic evaluation, as a misdiagnosis may lead to unnecessary treatment and even surgical intervention. , the patient was initially diagnosed with an incarcerated abdominal hernia, and therefore subsequently underwent surgery. The inflamed epiploic appendage was discovered in laparoscopic exploration, removed, and confirmed through the histopathology report. This is an approach to be performed with great caution so as not to 1. : misinterpret an inflamed diverticula or covered perforation of it as well as not 2. : overlooking a peritoneal tumor lesion.

Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails?

Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails?

Antibiotic treatment duration in diverticulitis, complicated urinary tract infection, and endocarditis: a retrospective, single-center study

ObjectivesDespite the availability of international guidelines advocating shorter treatment durations, nonadherence to them is common. We assessed duration of antibiotic treatment for diverticulitis, complicated urinary tract infection (UTI), and endocarditis. MethodsMedical records of patients hospitalized with the previously stated diseases in 2017 and 2018 were randomly selected at a Swiss tertiary care hospital. The appropriateness of antibiotic treatment duration was assessed according to international and local guidelines. ResultsA total of 243 patients were included in the study: 100 with diverticulitis, 200 with complicated UTI, and 43 with endocarditis. The dherence to local and international guidelines was 11% and 18% in diverticulitis, 39% and 40% in complicated UTI, and 84% and 86% in endocarditis, respectively. Nonadherence was primarily due to the prolonged treatment in diverticulitis and complicated UTI with a median duration of antibiotic treatment of 11 days (interquartile range 10-13) and 14 days (interquartile range 10-15), respectively. When pooling diverticulitis and complicated UTI cases, the identification of a pathogen in any microbiological sample was associated with an improved adherence to local guidelines in addition to hospitalization in a medical ward and infectious diseases consultation. ConclusionProlonged courses of antibiotic treatment were common and the treatment adherence to guidelines were poor in diverticulitis, moderate in complicated UTI, and excellent in endocarditis.

Indications for surgical treatment of diverticulitis: factors that influence surgical decision-making for patients and surgeons.

Indications for surgical treatment of diverticulitis: factors that influence surgical decision-making for patients and surgeons.

Efficacy of a new Nutraceutical Formulation in preventing acute intestinal inflammation: New therapeutic opportunities for the treatment of diverticulitis?

Acute diverticulitis is a painful, relatively sudden condition, characterized by the presence of low-grade inflammation in the colonic mucosa. Recent clinical trials supported the use of nutraceutical compounds in the treatment of patients with gastrointestinal disorders, including diverticulitis. To verify the hypothesis that nutraceutical ingredients my prevent diverticulitis development, we tested a combination of different natural active supplements, in a mouse model of acute intestinal inflammation. A nutraceutical formulation was administered daily in a prevention setting, by intrarectal enema. Inflammation severity was monitored using a Disease Activity Index (DAI) score, histological and endoscopic analysis, and quantification of Fecal Calprotectin (FC). Results showed that a combination of cranberry juice, pomegranate extract fruit in ellagic acid and inulin Fibruline®, prevented the development of experimental acute intestinal inflammation. This was confirmed endoscopically, in terms of reduced colon thickness and granularity of mucosal surface. Results were also confirmed histologically, not only by significant reduction of ulcerations, compared to control groups, but also by significant prevention of flogosis and inflammatory infiltration. Nutraceutical ingredients were also able to significantly reduce FC levels, confirming the anti-inflammatory properties of these dietary supplements. Our study supports the potential use of nutraceutical ingredients as a novel therapeutic approach to prevent acute diverticulitis.

EP.FRI.451 Laparotomy rates and factors influencing treatment modality for diverticulitis during the COVID-19 lockdown

BackgroundInfection control measures during the COVID-19 crisis modified diverticulitis treatment. Here we present the treatment applied in three large UK centres compared to the same timeframe in 2019. MethodsThis was a multicentre, comparative study, whereby diverticulitis cases from March 23rdto May 11th2019 acted as historical controls for cases during lockdown. Severity at presentation (SD), comorbidities, treatment modality, Length of Stay (LOS), complications and COVID-19 status (CS) were recorded. Chi-squared, ANOVA, Mann-Whitney test and linear regression were used for analyses. Results59 patients presented with diverticulitis in 2020 compared to 130 in 2019 (M:F 27/32, 56/74 and 64vs.62 y.o.). Laparotomy was performed in 6/59 and 12/130 respectively. Comparing 2019 to 2020, there was no statistical difference for severity (p = 0.643), treatment modality (0.946), comorbidities (0.313), LOS (0.602). Linear regression demonstrated statistically significant association between treatment employed (p < 0.001) and SD, while there was no association with age, comorbidities or CS. LOS was associated with severity only (p < 0.001), whilst CS, treatment, age and comorbidities yielded no statistical difference. ConclusionDiverticulitis cases during 2020 lockdown reduced noticeably (59vs.130). There was no difference in severity, treatment, comorbidities or LOS between 2019 and 2020. Laparotomy was performed in 6/59 and 12/130 respectively. Decision about treatment and LOS in 2020 was associated with severity of disease only. There was no association with COVID status. These findings should be interpreted with caution due to small COVID positive numbers and not including ambulatory units, however, they are consistent with findings from our sister Spanish group.

Actual issues of diagnosis and treatment of diverticulitis

The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.

Emerging evidence and recent controversies in diverticulitis: a 5-year review.

Diverticulitis is a common gastrointestinal disease that still garners significant attention and study because of its heterogeneity in presentation and outcome. We provide a review of the newest and most controversial topics in diverticulitis. Recent discoveries on the influence of diet and other environmental risk factors are discussed, showing how the epidemiology of the disease process is shifting away from what was previously felt to be a disorder primarily limited to older western populations. Interestingly, as has long been suspected, genetic mutations and variations associated with the development of diverticulitis are being discovered and are summarized here. The data for non-operative and outpatient management of diverticulitis are reviewed, as are pharmacologic agents studied for use in the secondary prevention of diverticulitis. Lastly, we present controversies in the surgical treatment of diverticulitis. This review will provide a synopsis of the last 5 years of literature relating to diverticulitis.

236. Incorporating Clinical Guidance into Computerized Prescriber Order Entry May Reduce Fluoroquinolone Utilization for the Treatment of Diverticulitis at a Rural Community Health System

BackgroundFluoroquinolones are associated with many adverse effects. As a result, many hospitals are investigating methods to reduce fluoroquinolone use. Computerized prescriber order entry (CPOE) provides an opportunity to develop and implement clinically guided order sets that discourage the use of fluoroquinolones. To date, there are few studies investigating the effect of clinically guided order sets on medication utilization. This study aims to investigate the hypothesis that incorporating clinical guidance and leveraging antimicrobial stewardship into a CPOE diverticulitis order set would reduce fluoroquinolone use in the treatment of diverticulitis.MethodsA diverticulitis order set was revised to provide guided antibiotic selection based on a patient’s penicillin allergy. Patients were split into two groups based on admission date relative to the implementation date of the revised order set. Fluoroquinolone use was compared between both groups. The primary outcome was the percentage of patients who were ordered a fluoroquinolone-containing regimen during their stay. The secondary outcome was the percentage of regimens that contained a fluoroquinolone. A subgroup analysis was conducted exclusively on patients whose antibiotics were ordered with the diverticulitis order set.Results494 patients were included in the study. 316 patients in the pre-order set group, 178 patients in the post-order set group. 56% of patients in the pre-group received a fluoroquinolone in their regimen versus 46% of patients in the post-group (RR=0.82; 95% CI 0.68–0.99, p = 0.028). 49% of regimens in the control group contained a fluoroquinolone versus 39% of regimens in the experimental group (RR=0.78; 95% CI 0.64–0.95; p = 0.012). 77.5% of patients in the control subgroup received a fluoroquinolone in their regimen versus 42.4% of patients in the experimental subgroup (RR=0.55; 95% CI 0.36–0.84, p = 0.0062). Fluoroquinolone days of therapy decreased from 90.6 to 58.6 from 2018–2019. Clostridioides difficile infections also decreased during this time frame.Table 1: Average fluoroquinolone days of therapy per 1000 patient days Figure 1: Percentage of Diverticulitis Orders by Antibiotic Regimen: Pre- and Post-Order Set Change. CFP=cefepime, Metro=metronidazole, PIP-TZ=piperacillin-tazobactam, AM-SB=ampicillin-sulbactam, CIP=ciprofloxacin, Levo=levofloxacin, FQ=fluoroquinolone Figure 2: Fluoroquinolone days of therapy per 1000 patient days from 2016–2020. ConclusionOur findings support the hypothesis that incorporating clinical guidance into a CPOE order set would reduce fluoroquinolone use for the treatment of diverticulitis.Figure 3: Indicence of Clostridioides difficile infection per 1000 patient days Disclosures All Authors: No reported disclosures

Risk of colectomy after conservative treatment of diverticulitis of the left hemicolon complicated by abdominal or pelvic abscess: protocol of a systematic review and meta-analysis

IntroductionAcute diverticulitis of the sigmoid colon is increasingly treated by a non-operative approach. The need for colectomy after recovery from a flare of acute diverticulitis of the left colon, complicated...

Elective surgery for diverticulitis – What does the surgeon need to consider?

Despite less stringent indications, elective colectomy is still commonly performed in the treatment of diverticulitis. Rather than focusing on age-based criteria and number of diverticulitis episodes, current guidelines recommend an individualized approach to elective colectomy for diverticulitis, taking into consideration several patient and disease factors. Given the low risk for complicated recurrences or emergency surgery requiring an ostomy with long-term conservative management, quality of life should be the primary determinant of surgery. Pharmacologic therapies have proven ineffective in reducing the risk of diverticulitis recurrence; however, they may reduce chronic abdominal symptoms associated with diverticular disease. Furthermore, elective colectomy for diverticulitis carries a non-trivial risk for major morbidity, and as with other elective operations, proper patient selection is key. Immunosuppressed patients are a unique, high-risk subgroup with worse diverticulitis and postoperative outcomes, rendering the decision for surgery even more complex.

Technical considerations for elective colectomy for diverticulitis

Colectomy is the definitive treatment of diverticulitis, consisting of surgical resection of the pathophysiologic origin of the disease process. The decision to proceed with elective colectomy is often a nuanced decision. The data and consensus recommendations have evolved over time and no longer simply advocate for surgery after the first episode of complicated or second episode of uncomplicated diverticulitis.