Predictive factors on CT imaging for progression of uncomplicated into complicated acute diverticulitis

Purpose

Since outpatient treatment and omitting antibiotics for uncomplicated acute colonic diverticulitis have been proven to be safe in the majority of patients, selection of patients that may not be suited for this treatment strategy becomes an important topic. The aim of this study is to identify computed tomography (CT) imaging predictors for a complicated disease course of initially uncomplicated acute diverticulitis.

Methods

CT imaging from a randomized controlled trial (DIABOLO study) of an observational vs. antibiotic treatment strategy of first-episode uncomplicated acute diverticulitis patients was re-evaluated. For each patient that developed complicated diverticulitis within 90 days after randomization, two patients with an uncomplicated disease course were randomly selected. Two abdominal radiologists, blinded for outcomes, independently re-evaluated all CTs.

Results

Of the 528 patients in the DIABOLO trial, 16 patients developed complications (abscess > 5 cm, perforation, bowel obstruction) within 90 days after randomization. In the group with a complicated course of initially uncomplicated diverticulitis, more patients with fluid collections (25 vs. 0%; p = 0.009) and a longer inflamed colon segment (86 ± 26 mm vs. 65 ± 21 mm; p = 0.007) were observed compared to an uncomplicated course of disease. Pericolic extraluminal air was no predictive factor.

Conclusion

Fluid collections and to a lesser extent the length of the inflamed colon segment may serve as predictive factors on initial CT for a complicated disease course in patients with uncomplicated acute colonic diverticulitis. These findings may aid in the selection of patients not suitable for outpatient treatment and treatment without antibiotics.

     

Preoperative staging of perforated diverticulitis by computed tomography scanning

Background

Treatment of perforated diverticulitis depends on disease severity classified according to Hinchey’s preoperative classification. This study assessed the accuracy of preoperative staging of perforated diverticulitis by computerized tomography (CT) scanning.

Methods

All patients who presented with perforated diverticulitis between 1999 and 2009 in two teaching hospitals of Rotterdam, the Netherlands, and in addition had a preoperative CT scan within 24?h before emergency surgery were included. Two radiologists reviewed all CT scans and were asked to classify the severity of the disease according to the Hinchey classification. The CT classification was compared to Hinchey’s classification at surgery.

Results

Seventy-five patients were included, 48 of whom (64?%) were classified Hinchey 3 or 4 perforated diverticulitis during surgery. The positive predictive value of preoperative CT scanning for different stages of perforated diverticulitis ranged from 45 to 89?%, and accuracy was between 71 and 92?%. The combination of a large amount of free intra-abdominal air and fluid was strongly associated with Hinchey 3 or 4 and therefore represented a reliable indicator for required surgical treatment.

Conclusions

The accuracy of predicting Hinchey’s classification by preoperative CT scanning is not very high. Nonetheless, free intra-abdominal air in combination with diffuse fluid is a reliable indication for surgery as it is strongly associated with perforated diverticulitis with generalized peritonitis. In 42?% of cases, Hinchey 3 perforated diverticulitis is falsely classified as Hinchey 1 or 2 by CT scanning.     

Asian patients with Hinchey Ia acute diverticulitis: a condition for the ambulatory setting?

Background

Diverticulitis in Asians is a different disease entity from Western counterparts. Few Asian studies have evaluated the management of acute Hinchey Ia diverticulitis with consideration for outpatient management. The purpose of this study was to evaluate the outcomes of Asian patients with Hinchey Ia acute diverticulitis.

Methods

A retrospective review of all patients who were treated for Hinchey Ia acute colonic diverticulitis between 2012 and 2014 was performed. All patients were diagnosed on computed tomography (CT).

Results

There were 129 patients with Hinchey Ia acute diverticulitis. Fifty-five (42.6%) patients were male, and the median age was 54 years (range, 30–86). Eighty-seven (67.4%) patients had right-sided diverticulitis.Most patients were treated empirically with intravenous ceftriaxone and metronidazole (89.1%). They were then discharged with oral antibiotics. Only 6.1% of patients had a positive blood culture. The median length of stay in the hospital was 4 (range, 3–4) days.Only three (2.3%) patients were readmitted for acute diverticulitis within 30 days. They were managed with antibiotics and discharged well. The repeated CT scans reconfirmed Hinchey Ia diverticulitis. No patients required emergency surgery, and there were no 30-day mortalities.

Conclusion

Asian patients with Hinchey Ia diverticulitis recovered well with conservative management and could be amenable to outpatient therapy. Future prospective studies should be performed amongst Asians to evaluate managing this condition in an ambulatory setting.

     

Short-term mortality,readmission, and recurrence in treatment of acute diverticulitis with abscess formation: a nationwide register-based cohort study

Purpose

The aim of the study was to investigate short-term mortality, readmission, and recurrence in a national cohort of patients with Hinchey Ib-II diverticulitis.

Methods

The retrospective cohort-investigation was conducted using a database consisting of the entire Danish population (n?=?6,641,672) in year 2000–2012, formed by linking the Danish Registers. Patients admitted with acute Hinchey Ib-II diverticulitis were identified from ICD-10 discharge codes and stratified according to treatment into an operative, drainage, and antibiotics group. The primary outcome was 30-day mortality from admission, secondary outcomes were mortality, readmission, and recurrence within 30 days post-discharge. The study was reported using RECORD guidelines.

Results

A total of 3148 eligible patients were identified. The cohort had a mean age of 65.1 year, 25.6 % had previously been admitted with diverticulitis, and 48.1 % had registered comorbidities. Within 30 days from admission, 8.7 % of the patients died. Of patients discharged, 2.5 % died, 23.8 % was readmitted, and 5.9 % was readmitted due to diverticulitis within 30 days from discharge. In multivariate analyses, increasing age was associated with mortality at odds-ratio (95 % CI) 1.10 (1.09–1.12). Previous complicated and uncomplicated diverticulitis reduced mortality with odds-ratio 0.50 (0.33–0.76) and 0.73 (0.58–0.92), while uncomplicated diverticulitis also increased risk of recurrence with odds-ratio 1.51 (1.24–1.84). Glucocorticoid usage was associated with mortality with odds-ratio 1.49 (1.23–1.81) and readmission with odds-ratio 2.91 (1.24–6.80).

Conclusion

Acute diverticulitis with abscess formation is a severe and life-threatening condition. Direct comparisons of treatment groups were not possible due to possible confounding by indication.

     

Increased faecal calprotectin predicts recurrence of colonic diverticulitis

Background and aims

Colonic diverticulitis shows a high recurrence rate, but the role of faecal markers in predicting recurrence is unknown. The aim of this study was to investigate the role of faecal calprotectin (FC) in predicting recurrence of diverticulitis.

Patients/methods

A prospective cohort study was performed on 54 patients suffering from acute uncomplicated diverticulitis (AUD) diagnosed by computerized tomography (CT). After remission, patients underwent to clinical follow-up every 2 months. After remission and during the follow-up, FC was analysed. Recurrence of diverticulitis was defined as return to our observation due to left lower-quadrant pain with or without other symptoms (e.g. fever), associated with leucocytosis and/or increased C-reactive protein (CRP). Presence of diverticulitis was confirmed by means of CT.

Results/findings

The mean follow-up was 20 months (range 12–24 months). Forty-eight patients were available for the final evaluation, and six patients were lost to follow-up. During follow-up, increased FC was detected in 17 (35.4 %) patients and diverticulitis recurred in eight patients (16.7 %). Diverticulitis recurred in eight (16.7 %) patients: seven (87.5 %) patients showed increased FC during the follow-up, and only one (12.5 %) patient with recurrent diverticulitis did not show increased FC. Diverticulitis recurrence was strictly related to the presence of abnormal FC test during follow-up.

Conclusions

In the present prospective study, increased FC was found to be predictive of diverticulitis recurrence.     

Perforated diverticulitis: is the right and left difference present here too?

Background

It is unclear if location of disease matters in perforated diverticulitis. Management guidelines for perforated diverticulitis currently do not make a distinction between right perforated diverticulitis (RPD) and left perforated diverticulitis (LPD). We aim to compare disease presentation and management outcomes between RPD and LPD.

Methods

This was a 10-year retrospective comparative cohort study of 99 patients with acute perforated diverticulitis between 2004 and 2013 in a single institution. Patients were divided into RPD and LPD groups based on location of disease and compared. Disease presentation was compared using modified Hinchey classification. Management outcomes assessed were failure of therapy, length of stay, mortality, surgical complications, and disease recurrence. Univariate analysis was performed using Student’s t test and χ² test where appropriate.

Results

RPD patients were younger (45.7?±?16.1 versus 58.3?±?14.7 years) and presented with lower modified Hinchey stage and no Hinchey IV diverticulitis when compared to LPD (14.3% Hinchey III versus 44.0% Hinchey III or IV). Conservative management of Hinchey I and II RPD and LPD was similarly successful (96.1 versus 96.5%), although RPD patients had shorter inpatient stay (4.6?±?2.2 versus 6.3?±?3.8 days) and less disease recurrence (3.1 versus 17.9%). Ten (20.4%) Hinchey I and II RPD patients were initially misdiagnosed with appendicitis and underwent surgery.

Conclusion

LPD is a more aggressive disease presenting with greater clinical severity in older patients and is associated with frequent disease recurrence when treated conservatively. Misdiagnosis of RPD as appendicitis is common and may lead to unnecessary surgery.

     

Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone

Purpose

Antibiotic treatment is the treatment of choice for uncomplicated diverticulitis (uD) and can be performed for mild complicated diverticulitis (mcD). In several cases, outpatient treatment (OT) can be undertaken. This study assessed the 1-month failure rate of OT for uD/mcD compared to inpatient treatment (IT), and identified predictive factors for treatment failure.

Methods

All consecutive patients (2006–2012) diagnosed with uD/mcD by CT scan were retrospectively analyzed. Acute uD was defined as absence of the following: abscess, fistula, extraluminal contrast, pneumoperitoneum, and need for immediate percutaneous drainage/surgery. Acute mcD was defined as complicated diverticulitis with abscess <4 cm or pneumoperitoneum <2 cm. All patients received antibiotherapy. Treatment failure was defined as (re)hospitalization the first month after treatment onset or need of drainage/surgery during hospitalization. All patients were contacted using a standardized questionnaire.

Results

Out of 540 uD/mcD, IT was offered to 369 patients (68%) and OT to 171 patients (32%). The IT group had higher median age, more women, higher median Charlson Index, more severe median Ambrosetti score, longer median time in the emergency room, and higher median CRP. Response rates to the questionnaire were 56% (IT) vs. 62% (OT), p = 0.18. Failure rates were 32% in IT vs. 10% in OT group, p < 0.01. Among the uD/mcD patients, admission/CT time between midnight and 6 AM, Ambrosetti score of 4, and free air around the colon were risk factors for failure.

Conclusions

Outpatient treatment for uncomplicated/mild complicated diverticulitis is feasible and safe. Prognostic factors of failure necessitating closer follow-up were admission/CT time, Ambrosetti score of 4, and free air around the colon.

     

Non-operative treatment of right-sided colonic diverticulitis has good long-term outcome: a review of 226 patients

Introduction

Data highlighting the long-term outcome following an initial episode of right-sided colonic diverticulitis is lacking. This study aims to evaluate and follow up on all patients with right-sided colonic diverticulitis.

Methods

A retrospective review of all patients who were discharged with a diagnosis of right-sided colonic diverticulitis from January 2003 to April 2008 was performed.

Results

A total of 226 patients, with a median age of 49 (range, 16–93)?years, were admitted for acute right-sided colonic diverticulitis. The majority of the patients (n?=?198, 87.6 %) had mild diverticulitis (Hinchey Ia and Ib). Seventy-three (32.3 %) patients underwent emergency surgery. The indications of surgery were predominantly suspected appendicitis (n?=?50, 22.1 %) and perforated diverticulitis (n?=?16, 7.1 %). Right hemicolectomy was performed in 32 (43.8 %) patients, while appendectomy, with or without diverticulectomy, was performed in the rest (n?=?41, 56.2 %). There were seven patients who underwent elective right hemicolectomy after their acute admissions.Over a median duration of 64 (12–95)?months, there were only nine patients who were readmitted 12 times for recurrent diverticulitis at a median duration of 17 (1–48)?months from the index admission. The freedom from failure (recurrent attacks or definitive surgery (right hemicolectomy)) at 60 months was 92.0 % (95 % Confidence interval 86.1 %–97.9 %).

Conclusion

Right-sided diverticulitis is commonly encountered in the Asian population and often gets misdiagnosed as acute appendicitis. If successfully managed conservatively, the long-term outcome is excellent.     

Do We Need Colonoscopy Following Acute Diverticulitis Detected on Computed Tomography to Exclude Colorectal Malignancy?

Background

Although colonoscopy verification is warranted after an acute event of diverticulitis to exclude underlying malignancy, little evidence is available to support the recommendations.

Aim

The aim of this study was to examine whether subsequent colonoscopy is warranted in patients with diverticulitis on computed tomography (CT).

Methods

The study was composed of patients diagnosed with acute diverticulitis on CT scan from January 2001 to March 2013. Patients who had subsequent colonoscopy within a year from the date of CT were included. For each diverticulitis case, two age- (±5 years) and sex-matched controls were identified from healthy individuals who had received screening colonoscopy. We evaluated the diagnostic yield of advanced colonic neoplasia in colonoscopy.

Results

One hundred and forty-nine patients underwent subsequent colonoscopy within a year from the date of CT. Among the patients, 11 (7.4 %) had colon cancer and 5 (3.4 %) had advanced adenoma. A case–control study revealed that the odds of detecting an advanced neoplasia among patients with diverticulitis on CT were approximately 8.8 times greater than in the age- and sex-matched controls [OR 8.84; 95 % CI 2.90–26.96; p < 0.001]. On analysis of the diverticulitis group, age (≥50 years) is an independent risk factor for detecting advanced colonic neoplasia.

Conclusions

The yield of advanced colonic neoplasia was substantially higher in patients with acute diverticulitis than in asymptomatic, average-risk individuals. Colonoscopy verification is warranted in patients with diverticulitis detected on CT, especially in those aged 50 years or older.     

Prediction and management of recurrent right colon diverticulitis

Purpose

While the incidence of right colonic diverticulitis (RCD) is rare in Western countries, the right colon is the most common site of diverticulitis in Asian countries. However, its recurrent pattern and management were rarely studied. This study was designed to elucidate the pattern of recurrence in RCD.

Methods

Of the 154 patients admitted as right colonic diverticulitis between February 2004 and March 2012, 104 patients were enrolled, prospectively. The recurrence rate, size, multiplicity, location, diagnostic criteria score, and predisposing factors were evaluated based on Hinchey’s classification of diverticulitis.

Results

There were 104 patients with right colonic diverticulitis in this study, and 20 patients (19.2 %) recurred after medical treatment. When the diverticula were not located in the right colon, the recurrence rate was significantly higher than the diverticula located only in the right colon (p?=?0.004). The recurrence rate of diverticulitis for a single diverticulum was significantly lower than that for multiple diverticula (p?=?0.02). Of the 20 patients with recurrence, 1 (5 %) patient underwent laparoscopic diverticulectomy due to a misdiagnosis of diverticulitis as appendicitis. The remaining 19 patients (95 %) received nonoperative management and recovered without any sequelae.

Conclusions

The recurrence rate was 19.2 %, and the predisposing factors were the location of diverticula and the multiplicity of primary diverticula. The re-recurrence rate of recurred patients was 26.3 %. The recurred lesions were controlled simply by nonoperative management. Elective surgery was also a treatment option.     

Risk Factors for Severe Diverticulitis in Computed Tomography-Confirmed Acute Diverticulitis in Korea

Background/Aims

Acute complicated diverticulitis can be subdivided into moderate diverticulitis and severe diverticulitis. Although there have been numerous studies on the risk factors for complicated diverticulitis, little research has focused on severe diverticulitis. This study was designed to identify the risk factors for severe diverticulitis in an acute diverticulitis attack using the modified Hinchey classification.

Methods

Patients were included if they had any evidence of acute diverticulitis detected by computed tomography. The patients were subdivided into severe diverticulitis (Hinchey class ≥Ib; abscesses or peritonitis) and moderate diverticulitis (Hinchey class Ia; pericolic inflammation) groups.

Results

Of the 128 patients, 25 exhibited severe diverticulitis, and 103 exhibited moderate diverticulitis. In a multivariate analysis, age >50 years (odds ratio [OR], 5.27; p=0.017), smoking (OR, 3.61; p=0.044), comorbidity (OR, 4.98; p=0.045), leukocytosis (OR, 7.70; p=0.003), recurrence (OR, 4.95; p=0.032), and left-sided diverticulitis (OR, 6.92; p=0.006) were significantly associated with severe diverticulitis.

Conclusions

This study suggests that the risk factors for severe diverticulitis are age >50 years, smoking, comorbidity, leukocytosis, recurrent episodes, and left-sided diverticulitis.     

Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis

Purpose

To date, the standard therapy used for acute episodes of uncomplicated sigmoid diverticulitis has been a 7–10-day antibiotic treatment regimen. Thanks to the development of highly potent, broad-spectrum antibiotics such as ertapenem, the question arises as to whether the duration of treatment of acute uncomplicated sigmoid diverticulitis can be reduced by using highly effective antibiotics.

Methods

To compare the efficacy of short-term therapy (4 days) versus standard therapy (7 days) for uncomplicated sigmoid diverticulitis, a prospective randomized multicenter trial was conducted. Patients were randomized to treatment groups after 4 days. Both patient groups were monitored until discharge and were followed up after 4–6 weeks and 52 months. The results were standardized and statistically evaluated.

Results

Between 16 December 2004 and 15 November 2007, 123 patients from 11 hospitals were enrolled in the study. Seventeen patients dropped out. In the remaining 106 cases, no significant differences were discerned between the two groups in terms of the basic data, apart from the mean number of diverticulitis episodes (short term 1.28?±?0.64 versus standard 1.64?±?1.07, p?=?0.037). The mean hospital stay was 8.8 days, with significant differences seen between short-term and standard therapy (7.8?±?2.8 versus 9.7?±?3.2 days; p?=?0.002). After 4 days, treatment was classified as having proved successful in 98.0% of cases and after 7 days in 98.2% of cases. An overall success rate of 95.1% (94.0% versus 96.2%, n.s.) was recorded after 1 month.

Conclusion

The results obtained with short-term ertapenem therapy (4 days) showed that this was as effective as standard therapy (7 days) for treatment of uncomplicated sigmoid diverticulitis.     

Risk factors for recurrence of right colonic uncomplicated diverticulitis after first attack

Purpose

Most patients with acute right colonic uncomplicated diverticulitis can be managed conservatively. The aim of this study was to assess the clinical and radiologic risk factors for recurrence in patients with right colonic uncomplicated diverticulitis.

Methods

The present survey included 469 patients who were successfully managed conservatively for the first episode of right colonic uncomplicated diverticulitis between 2002 and 2012 in a referral center, and records were reviewed from collected data. Patients were divided into two groups: a nonrecurrent and a recurrent group. The clinical and radiologic features of all patients were analyzed to identify possible risk factors for recurrence. The Kaplan-Meier method and Cox regression were used.

Results

Seventy-four (15.8 %) patients had recurrence, and 15 (3.2 %) received surgery at recurrence within a median follow-up of 59 months. The mean recurrence interval after the first attack was 29 months. In univariate and multivariate analyses, risk factors for recurrence were confirmed multiple diverticula (relative risk [RR], 2.62; 95 % confidence interval [CI], 1.56–4.40) and intraperitoneally located diverticulitis (RR, 3.73; 95 % CI, 2.13–6.52). Of 66 patients with two risk factors, 36 (54.5 %) had recurrence and 10 (15.2 %) received surgery at recurrence.

Conclusions

In patients with right colonic uncomplicated diverticulitis who have multiple diverticula and intraperitoneally located diverticulitis, the possibility of recurrence and surgical rate are high. Poor outcome may be cautioned in these patients.     

Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis—a proof of concept

Purpose

Perforated diverticulitis with advanced generalized peritonitis is a life-threatening condition requiring emergency operation. To reduce the rate of colostomy formation, a new treatment algorithm with damage control operation, lavage, limited closure of perforation, abdominal vacuum-assisted closure (VAC; V.A.C.®), and second look to restore intestinal continuity was developed.

Methods

This algorithm allowed for three surgical procedures: primary anastomosis ± VAC in stable patients (group I), but damage control with lavage, limited resection of the diseased colonic segment, VAC and second-look operation with delayed anastomosis in patients with advanced peritonitis or septic shock (group II), and Hartmann procedure was done for social reasons in stable patients (group III)

Results

All 27 consecutive patients (16 women; median age 68 years) requiring emergency laparotomy for perforated diverticulitis (Hinchey III/IV) between October 2006 and September 2008 were prospectively enrolled in the study. No major complications were observed in group I (n?=?6). Nine patients in group II (n?=?15) had intestinal continuity restored during a second-look operation, of whom one patient developed anastomotic leakage. The median length of stay at intensive care unit was 5 days. Considering an overall mortality rate of 26% (n?=?7), the rate of anastomosis in surviving patients was 70%.

Conclusions

Damage control with lavage, limited bowel resection, VAC, and scheduled second-look operation represents a feasible strategy in patients with perforated diverticulitis (Hinchey III and IV) to enhance sepsis control and improve rate of anastomosis.     

Severity of diverticulitis in patients with polycystic kidney disease without transplantation

Background

Patients with polycystic kidney disease (PKD) who have had a kidney transplant have an increased risk of diverticular disease and complicated diverticulitis. Literature is limited regarding the severity of diverticulitis in patients with PKD who have not had a transplant. We aim to assess whether patients with PKD, with and without renal transplant, have a similar course of diverticulitis.

Methods

A retrospective review of all adult PKD patients at our institution diagnosed with diverticulitis between 2000 and 2016 was conducted. Patients without documented PKD and diverticulitis were excluded. We compared PKD patients with and without renal transplantation.

Results

A total of 41 patients were identified. Mean age was 60 (± 12), and 56% were female. Fourteen patients had undergone renal transplantation. Five (19%) non-transplant patients had complicated diverticulitis, compared to 43% (n = 6) transplanted (p = 0.33). Fifteen (56%) non-transplant and 8 (57%) transplant patients had recurrent diverticulitis (p = 1.00). Three (11%) non-transplant and 5 (36%) transplanted patients had recurrent complicated diverticulitis. Eight (30%) non-transplant and 7 (50%) transplant patients underwent surgery (p = 0.31). All 8 non-transplant patients underwent sigmoid resection with primary anastomosis without diversion. In the transplant group, 3 Hartmann procedures and 1 sigmoid resection with and 3 without diversion were performed. There was one in-hospital death in each group.

Conclusion

In our group of patients, there was no difference in rate of recurrent diverticulitis, diverticulitis complications, or operative intervention in patients with PKD with and without renal transplant. The renal transplant group had a higher rate of recurrent, complicated diverticulitis.

     

Intermittent treatment with mesalazine in the prevention of diverticulitis recurrence: a randomised multicentre pilot double-blind placebo-controlled study of 24-month duration

Background and aim

Recurrence of diverticulitis is frequent within 5 years from the uncomplicated first attack, and its prophylaxis is still unclear. We have undertaken a multicentre, randomised, double-blind, placebo-controlled pilot study in order to evaluate the role of mesalazine in preventing diverticulitis recurrence as well as its effects on symptoms associated to diverticular disease.

Methods

Ninety-six patients with the recent first episode of uncomplicated diverticulitis were randomised to receive mesalazine 800 mg twice daily for 10 days every month or placebo for 24 months. The primary efficacy end point was the diverticulitis recurrence at intention to treat analysis. Clinical evaluations were performed using the Therapy Impact Questionnaire (TIQ) for physical condition and quality of life at admission and at 3-month intervals. Treatment tolerability and routine biochemistry parameters as well as the use of additional drugs were also evaluated.

Results

Ninety-two patients (mean age, 61.5) completed the study, 45 of whom received mesalazine, and 47, placebo. Diverticulitis relapse incidence in mesalazine-treated group was 5/45 (11 %) at the 12th month and 6/45 (13 %) at the 24th month; in the placebo-treated group, the correspondent rates were 13 % (6/47) and 28 % (13/47), respectively. Mean values of TIQ at 24 months were significantly better in mesalazine-treated group than in placebo-treated group (p?=?0.02); in addition, average additional drug consumption was significantly lower (?20.4 %, p?<?0.03) in mesalazine than in placebo.

Conclusions

Diverticulitis recurrence occurred in as many as 28 % of patients under placebo within 24 months from the initial episode. Intermittent prophylaxis with mesalazine did not significantly reduce the risk of relapse but induced a significant improvement of patients' physical conditions and significantly lowered the additional consumption of other gastrointestinal drugs.     

Emergency admissions for complicated colonic diverticulitis are increasing: a nationwide register-based cohort study

Background

Acute colonic diverticulitis is common in the Western world representing a growing burden on health care. We aimed to report the factual epidemiological and demographic characteristics in patients with acute diverticulitis in a large nationwide population.

Method

We conducted a population-based cohort study from 2000 to 2012 on the complete Danish population, which included all patients with acute colonic diverticulitis. Data were composed through two national longitudinal registries. The study main outcomes were demographic development regarding hospital admission, age, gender, geographical residency, and seasonal information.

Results

A total of 101,963 acute hospital contacts were identified from 2000 to 2012, of these 44,160 were due to acute diverticulitis. From 2000 to 2012, overall admission rates for complicated diverticulitis increased significantly with 42.7%. There was a small increase in hospital admissions due to acute diverticulitis, and uncomplicated diverticulitis accounted for 83–88% of all admissions. No significant development was seen in cases of uncomplicated diverticulitis. The majority of patients were older than 50 years (85%) and 60% were women. The male gender dominated in patients younger than 50 years (58%), whereas women dominated above 50 years (63%). Mean age and dominating age group decreased significantly from 2000 to 2012 for both genders. A significantly larger proportion of male patients had complicated diverticulitis than uncomplicated diverticulitis. Most admissions were seen during autumn.

Conclusion

We found that acute colonic diverticulitis has been progressing over the last decade with more severe cases of disease. Our findings underline the need for further research to identify the relevant risk factors and causal circumstances.

     

CT Scanning in the Evaluation of Pulmonary Hypertension

Background

Right-heart catheterization is currently the gold standard method for detecting pulmonary hypertension (PH) and grading its severity. Our study determined the utility of computerized tomography (CT) scans for detecting PH in patients with left-sided heart disease, thereby potentially avoiding the overuse of invasive right-heart catheterization.

Methods

A retrospective review was conducted on 40 patients with left-sided cardiac pathology who had undergone both right-heart catheterization and CT scanning of the chest. Mean pulmonary artery diameters (MPADs) were measured on CT scans and compared with pulmonary artery pressures measured by right-heart catheterization.

Results

Patients with mild-to-moderate PH had significantly greater CT-measured MPADs (34.89 ± 1.01) than patients without PH (controls) (27.36 ± 0.83, p < 0.001). Patients with severe PH had significantly greater MPADs (38.31 ± 0.88) than both mild-to-moderate PH patients (p < 0.01) and controls (p < 0.001). Receiver operating characteristic curve analysis showed that CT scanning predicted PH with an area under the curve of 0.95 (p < 0.0001). A cutoff MPAD of >33.3 mm had 100 % specificity and 100 % positive predictive value (N = 40, p < 0.0001), and a cutoff MPAD of <27.3 mm had 100 % sensitivity with 100 % negative predictive value (N = 40, p < 0.001).

Conclusions

CT scanning correctly identified all patients with PH with MPADs >34 mm and excluded all patients without PH when MPADs were <27 mm. We advocate that the measurement of MPAD by CT scanning can be quickly and easily performed by the clinician to screen for the presence of PH.     

Sigmoid resection with primary anastomosis and ileostomy versus laparoscopic lavage in purulent peritonitis from perforated diverticulitis: outcome analysis in a prospective cohort of 40 consecutive patients

Purpose

This prospective study aimed to compare outcomes after laparoscopic peritoneal lavage (LPL) and sigmoid resection with primary colorectal anastomosis (RPA).

Methods

From June 2010 to June 2015, 40 patients presenting with Hinchey III peritonitis from perforated diverticulitis underwent LPL or RPA. Patients with Hinchey II or IV peritonitis and patients who underwent an upfront Hartmann procedure were excluded. Primary endpoint was overall 30-day or in-hospital postoperative morbidity after surgical treatment of peritonitis.

Results

Twenty-five patients underwent RPA and 15 LPL. Overall postoperative morbidity and mortality rates were not significantly different after RPA and LPL (40 vs 67 %, p = 0.19; 4 vs 6.7 %, p = 1, respectively). Intra-abdominal morbidity and reoperation rates were significantly higher after LPL compared to RPA (53 vs 12 %, p < 0.01; 40 vs 4 %, p = 0.02, respectively). Multivariate analysis showed that LPL (p = 0.028, HR = 18.936, CI 95 % = 1.369–261.886) was associated with an increased risk of postoperative intra-abdominal septic morbidity. Among 6 patients who underwent reoperation after LPL, 4 had a Hartmann procedure. All surviving patients who had a procedure requiring stoma creation underwent stoma reversal after a median delay of 92 days after LPL and 72 days after RPA (p = 0.07).

Conclusion

LPL for perforated diverticulitis is associated with a high risk of inadequate intra-abdominal sepsis control requiring a Hartmann procedure in up to 25 % of patients. RPA appears to be safer and more effective. It may represent the best option in this context.

     

Survival after acute colon diverticulitis treated in hospital

Purpose

The aim of this study was to determine the short- and long-term relative survival as well as the causes of death in patients treated in hospital for acute colonic diverticulitis.

Materials and methods

The study included all patients treated at Levanger Hospital for acute colonic diverticulitis between 1988 and 2012. Vital statistics were complete. The median observation time was 6.95 years (range 0.28–24.66) or until death.

Results

In total, 650 different patients were hospitalized with acute colonic diverticulitis. Among these patients, there were 851 admissions for the same disease during the 25 years. The admissions had the following diagnoses: simple diverticulitis, 738; abscess formation , 44; perforation and purulent peritonitis, 47; perforation and fecal peritonitis, 9; and intestinal obstruction, 13. During the observation time, 219 were dead and 431 were still alive. After the first admission, the 100 day relative survival in patients with uncomplicated diverticulitis was 97 % (CI 95 to 99), with abscess formation 79 % (62 to 89), with purulent peritonitis 84 % (69 to 92), with fecal peritonitis 44 % (10 to 74), and with intestinal obstruction 80 % (38 to 96). After surviving the first 100 days, the estimated 5-year relative survival in the remaining 609 patients was 96 % (CI 92 to 100) and 10-year survival was 91 % (CI 84 to 97). In patients who survived the first 100 days, the different subtypes of diverticulitis yielded no significant differences in long-term relative survival. All patients who had been admitted with ASA score 4 were dead after 2 years.