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Ortenzi M, Williams S, Haji A, Ghiselli R, Guerrieri M. Acute Diverticulitis. EMERGENCY LAPAROSCOPIC SURGERY IN THE ELDERLY AND FRAIL PATIENT 2021:163-180. [DOI: 10.1007/978-3-030-79990-8_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 PMCID: PMC7575828 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent. To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether. The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables. Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing. Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known. The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy. After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy. For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”. Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary. For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents. Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance. Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key. Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease. While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined. Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Rook JM, Dworsky JQ, Curran T, Banerjee S, Kwaan MR. Elective surgical management of diverticulitis. Curr Probl Surg 2020; 58:100876. [PMID: 33933211 DOI: 10.1016/j.cpsurg.2020.100876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/17/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Jordan M Rook
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jill Q Dworsky
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Thomas Curran
- Medical University of South Carolina, Charleston, SC
| | - Sudeep Banerjee
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Mary R Kwaan
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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A systematic review and meta-analysis of disease severity and risk of recurrence in young versus elderly patients with left-sided acute diverticulitis. Eur J Gastroenterol Hepatol 2020; 32:547-554. [PMID: 31972659 DOI: 10.1097/meg.0000000000001671] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Young patients are thought to have a more severe disease course and a higher rate of recurrent diverticulitis. However, these understandings are mainly based on studies with important limitations. This review aimed to clarify the true natural history of acute diverticulitis in young patients compared to elderly patients. PubMed and MEDLINE were searched for studies reporting outcomes on disease severity or recurrences in young and elderly patients with a computed tomography-proven diagnosis of acute diverticulitis. Twenty-seven studies were included. The proportion of complicated diverticulitis at presentation (21 studies) was not different for young patients (age cut-off 40-50 years) compared to elderly patients [risk ratio (RR) 1.19; 95% confidence interval 0.94-1.50]. The need for emergency surgery (11 studies) or percutaneous abscess drainage (two studies) yielded comparable results for both groups with a RR of 0.93 (95% confidence interval 0.70-1.24) and 1.65 (95% confidence interval 0.60-4.57), respectively. Crude data on recurrent diverticulitis rates (12 studies) demonstrated a significantly higher RR of 1.47 (95% confidence interval 1.20-1.80) for young patients. Notably, no association between age and recurrent diverticulitis was found in the studies that used survival analyses, taking length of follow-up per age group into account. In conclusion, young patients do not have a more severe course of acute diverticulitis. Published data on the risk of recurrent diverticulitis in young patients are conflicting, but those with the most robust design do not demonstrate an increased risk. Therefore, young patients should not be treated more aggressively nor have a lower threshold for elective surgery just because of their age.
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Abstract
PURPOSE OF REVIEW While few diseases are limited solely to the elderly, diverticular disease is clearly more prevalent with increasing age and therefore the aim of this review is to focus on the clinical implications of diverticular disease in the elderly. RECENT FINDINGS Diverticulitis in the elderly is best managed with an individualized treatment approach including considerations for selective antibiotic usage even in uncomplicated disease. Furthermore, due to the increased prevalence of ischemic colitis in the elderly and the similarities in presentation with diverticular hemorrhage, there needs to be a high index of suspicion and appropriate evaluation for ischemic colitis in patients with hematochezia, particularly if they have abdominal pain. The elderly are a vulnerable population where the index of suspicion for complications of diverticular disease should be high.
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Affiliation(s)
- Mona Rezapour
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Neil Stollman
- Alta Bates Summit Medical Center, East Bay Center for Digestive Health, 300 Frank H Ogawa Plaza, Suite 450, Oakland, CA, 94612, USA.
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Abstract
Diverticulitis has become increasingly more common in the 20th century and is now one of the most frequent indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical presentation can vary widely from mild, uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically, all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid "Hartmann's" stump. However, the treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore, the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and complicated left-sided diverticulitis in 2017.
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Affiliation(s)
- Sarah E Deery
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, WAC 4-460, Boston, MA, 02114, USA
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, WAC 4-460, Boston, MA, 02114, USA.
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Perisigmoid Abscess Leading to a Diagnosis of Ehlers-Danlos Syndrome Type IV. ACG Case Rep J 2016; 3:104-6. [PMID: 26958560 PMCID: PMC4748196 DOI: 10.14309/crj.2016.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of connective tissue disorders characterized by triad of joint hypermobility, skin extensibility, and tissue fragility. Ehlers-Danlos syndrome type IV places patients at risk for life-threatening, spontaneous, vascular or visceral rupture due to reduced or abnormal secretion of type III collagen. We present an adolescent male who was found to have a perisigmoid abscess with a fistula connecting to adjacent sigmoid colon secondary to undiagnosed EDS type IV. Conservative management with antibiotics and bowel rest was pursued to allow for elective resection for his acute complicated diverticulitis at a safer time.
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De Cecco CN, Ciolina M, Annibale B, Rengo M, Bellini D, Muscogiuri G, Maruotti A, Saba L, Iafrate F, Laghi A. Prevalence and distribution of colonic diverticula assessed with CT colonography (CTC). Eur Radiol 2016; 26:639-645. [PMID: 26105021 DOI: 10.1007/s00330-015-3866-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 05/20/2015] [Accepted: 05/27/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study aimed to evaluate the prevalence of colonic diverticula according to age, gender, distribution, disease extension and symptoms with CT colonography (CTC). METHODS The study population included 1091 consecutive patients who underwent CTC. Patients with diverticula were retrospectively stratified according to age, gender, clinical symptoms and colonic segment involvement. Extension of colonic diverticula was evaluated using a three-point quantitative scale. Using this data, a multivariate regression analysis was applied to investigate the existence of any correlation among variables. RESULTS Colonic diverticula were observed in 561 patients (240 men, mean age 68 ± 12 years). Symptomatic uncomplicated diverticular disease (SUDD) was present in 47.4% of cases. In 25.6% of patients ≤40 years, at least one diverticulum in the colon was observed. Prevalence of right-sided diverticula in patients >60 years was 14.2% in caecum and 18.5% in ascending colon. No significant difference was found between symptomatic and asymptomatic patients regarding diverticula prevalence and extension. No correlation was present between diverticula extension and symptoms. CONCLUSION The incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding, with their prevalence increasing with patient age. SUDD does not seem to be related to diverticula distribution and extension. KEY POINTS Incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding. SUDD does not seem to be related to diverticula distribution and extension.
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Affiliation(s)
- Carlo Nicola De Cecco
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy
- Department of Radiology & Radiological Sciences, Medical University of South Carolina, 25 Courtenay Drive, Charleston, SC, 29425, USA
| | - Maria Ciolina
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy
| | - Bruno Annibale
- Department of Digestive and Liver Disease, University of Rome "Sapienza" - Sant'Andrea Hospital, Via di Grottarossa 1035, Rome, Italy
| | - Marco Rengo
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy
| | - Davide Bellini
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy
| | - Giuseppe Muscogiuri
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy
| | - Antonello Maruotti
- Department of Public Institutions, Economy and Society, University "Roma Tre", Rome, Italy
- Southampton Statistical Sciences Research Institute & School of Mathematics, University of Southampton, Southampton, UK
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Franco Iafrate
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, University of Rome "Sapienza" - Polo Pontino, Via Franco Faggiana, 34, 04100, Latina, Italy.
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Vather R, Broad JB, Jaung R, Robertson J, Bissett IP. Demographics and trends in the acute presentation of diverticular disease: a national study. ANZ J Surg 2015; 85:744-8. [PMID: 25925134 DOI: 10.1111/ans.13147] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diverticular disease (DD) is a major health problem in the Western world. The aim of this study was to describe demographics and trends in acute DD admissions in New Zealand. METHODS Information pertaining to acute hospital admissions between January 2000 and June 2012 for a primary diagnosis of large bowel DD was retrieved from a national database. RESULTS There were 25,167 admissions for acute DD. Mean age of presentation decreased from 65.9 years in 2000 to 64.1 years in 2012 (P < 0.001). Mean age was lower in men than women (61.4 versus 67.4 years, P < 0.001). Although men comprised 45.2% of the cohort they were over-represented in the 18-44 years stratum (68.6 versus 31.4%; P < 0.001). Europeans accounted for 84.8% of admissions and presented at an older age (65.8 years) than Māori (56.2 years), Pacific Islanders (58.4 years) or Asians (58.9 years) (P < 0.001). Acute DD admissions were higher in more deprived populations (P < 0.001). Mean length of hospital stay (LOS) reduced from 5.8 days in 2000 to 4.1 days in 2012 (P < 0.001). LOS increased with age (P < 0.001) and deprivation (P = 0.013), but did not differ between ethnicities (P = 0.088). Computed tomography scanning of acute admissions doubled from 2000 to 2012 (29.7-59.2%; P < 0.001) with a halving in the use of acute in-patient colonoscopy (26.1-13.2%; P < 0.001) and emergent surgery (14.8-7.2%; P < 0.001). Percutaneous drain use increased from 0.6% in 2000 to 1.1% in 2012 (P = 0.003). CONCLUSION Acute DD is a source of considerable morbidity in New Zealand and there have been significant changes in its admission demographics and trends over the last decade.
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Affiliation(s)
- Ryash Vather
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Joanna B Broad
- Freemasons' Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Rebekah Jaung
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Jason Robertson
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Park SM, Kwon TS, Kim DJ, Lee YS, Cheung DY, Oh ST, Kim JG, Lee IK. Prediction and management of recurrent right colon diverticulitis. Int J Colorectal Dis 2014; 29:1355-60. [PMID: 24997717 DOI: 10.1007/s00384-014-1938-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Sun Min Park
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, #62 Yeouido-dong, Yeongdeungpo-gu, Seoul, 150-713, Korea
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Peery AF, Sandler RS. Diverticular disease: reconsidering conventional wisdom. Clin Gastroenterol Hepatol 2013; 11:1532-7. [PMID: 23669306 PMCID: PMC3785555 DOI: 10.1016/j.cgh.2013.04.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/24/2013] [Accepted: 04/24/2013] [Indexed: 02/07/2023]
Abstract
Colonic diverticula are common in developed countries and complications of colonic diverticulosis are responsible for a significant burden of disease. Several recent publications have called into question long-held beliefs about diverticular disease. Contrary to conventional wisdom, studies have not shown that a high-fiber diet protects against asymptomatic diverticulosis. The risk of developing diverticulitis among individuals with diverticulosis is lower than the 10% to 25% proportion that commonly is quoted, and may be as low as 1% over 11 years. Nuts and seeds do not increase the risk of diverticulitis or diverticular bleeding. It is unclear whether diverticulosis, absent diverticulitis, or overt colitis is responsible for chronic gastrointestinal symptoms or worse quality of life. The role of antibiotics in acute diverticulitis has been challenged by a large randomized trial that showed no benefit in selected patients. The decision to perform elective surgery should be made on a case-by-case basis and not routinely after a second episode of diverticulitis, when there has been a complication, or in young people. A colonoscopy should be performed to exclude colon cancer after an attack of acute diverticulitis but may not alter outcomes among individuals who have had a colonoscopy before the attack. Given these surprising findings, it is time to reconsider conventional wisdom about diverticular disease.
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Affiliation(s)
- Anne F. Peery
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Robert S. Sandler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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Song ME, Jung SA, Shim KN, Song EM, Kwon KJ, Kim HI, Yoon SY, Cho WY, Kim SE, Jung HK, Moon IH. [Clinical characteristics and treatment outcome of colonic diverticulitis in young patients]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 61:75-81. [PMID: 23458984 DOI: 10.4166/kjg.2013.61.2.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS The clinical course and the most appropriate management of colonic diverticulitis in young patients are currently unresolved. This retrospective study was designed to compare young patients (≤40 years) with older patients (>40 years) regarding clinical characteristics of acute colonic diverticulitis and to determine whether differences exist in treatment outcome. METHODS Three-hundred sixty eight patients presenting with acute colonic diverticulitis from March 2001 through April 2011 at Ewha Womans University Mokdong Hospital were reviewed retrospectively. The differences in clinical characteristics, treatment modality and recurrence between each group were analyzed. RESULTS Two-hundred and six patients were aged 40 years or younger and 162 patients were older than 40 years. The older group was diagnosed more frequently with severe diverticulitis. Surgical treatment was significantly more frequent in the older group than in the younger group (15.4% vs. 4.4%, p<0.001). No significant difference was found in preatment modality between the two groups in patients with recurrence. The difference in recurrence between groups was not statistically significant. In multivariate analysis, left colonic diverticulitis was significantly associated with severe diverticulitis (OR, 14.651; 95% CI, 4.829-44.457) and emergency surgery (OR, 13.745; 95% CI, 4.390-43.031). CONCLUSIONS When patients with colonic diverticulitis are treated conservatively, young age is no longer an independent risk factor for subsequent poor outcome. Diverticulitis in young patients does not have a particularly aggressive or fulminant course. Therefore, we recommend that diverticulitis management should be based on the severity and location of the disease, and not on the age of the patient.
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Affiliation(s)
- Myung Eun Song
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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van de Wall BJM, Poerink JA, Draaisma WA, Reitsma JB, Consten ECJ, Broeders IAMJ. Diverticulitis in young versus elderly patients: a meta-analysis. Scand J Gastroenterol 2013; 48:643-51. [PMID: 23330633 DOI: 10.3109/00365521.2012.758765] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare patients younger and older than 50 years with diverticulitis with regard to complications, disease recurrence and to the need for surgery. MATERIAL AND METHODS A literature review and meta-analysis was conducted according to the PRISMA guidelines. MEDLINE, Embase and the Cochrane databases were searched for longitudinal cohort studies comparing patients younger and older than 50 years with diverticulitis. RESULTS Eight studies were included with a total of 4.751 (male:female 1:0.66) patients younger and 18.328 (male:female 1:1.67) older than 50 years of age. The risk of developing at least one recurrent episode was significantly higher among patients younger than 50 years (pooled RR 1.73; 95% CI 1.40-2.13) with an estimated cumulative risk of 30% compared with 17.3% in older patients. The risk of requiring surgery during hospitalization for a primary episode of diverticulitis was equal in both age groups (pooled RR 0.99; 95% CI 0.74-1.32) and estimated at approximately 20%. Patients younger than 50 years more frequently required urgent surgery during hospitalization for a subsequent recurrent episode (pooled RR 1.46; 95% CI 1.29-1.66); the cumulative risk was 7.3% in younger and 4.9% in patients older than 50 years. CONCLUSION Patients younger than 50 years only differ substantially in risk for recurrent disease from patients older than 50 years of age. Although the relative risk for requiring urgent surgery for recurrent disease was higher in younger patient, one should consider that the absolute risk difference is relatively small (7.3% vs. 4.9%).
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Gonzales ER, Alavi K. Evaluation and Treatment of Uncomplicated Diverticular Disease. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, Marcello PW, Schoetz DJ. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011; 54:283-8. [PMID: 21304297 DOI: 10.1007/dcr.0b013e3182028576] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of our study was to determine the clinical and CT predictors of recurrent disease after a first episode of diverticulitis that was successfully managed nonoperatively. METHODS We retrospectively analyzed 954 consecutive patients who presented to our institution with diverticulitis from 2002 to 2008. Patients were identified with International Classification of Diseases, 9th Revision/Current Procedural Terminology codes. Patients were excluded if they had subsequent colectomy based on the first attack (n = 81), or if the attack they had between 2002 and 2008 was not their first attack (n = 201). We evaluated CT variables chosen by a panel of expert gastrointestinal radiologists. These radiologists reviewed the available published literature for CT imaging characteristics thought to predict diverticulitis severity. CT variables (n = 20) were determined by prospective reevaluation of scans by blinded study radiologists. Clinical variables (n = 43) were coded based on a retrospective chart review. Univariate analysis of variables in relation to recurrent disease was performed by a log-rank test of Kaplan-Meier estimates. Multivariate analysis was performed using Cox proportional hazards modeling. Variables with P < .2 on univariate analysis were included in a stepwise selection algorithm. RESULTS The study population included 672 patients; mean age, 61 ± 15 years; mean follow-up, 42.8 ± 24 months. The index presentation of diverticulitis was most commonly located in the sigmoid colon (72%), followed by descending colon (33%), right colon (5%), and transverse colon (3%). Overall recurrence at 5 years was 36% by (95% CI 31.4%-40.6%) Kaplan-Meier estimate. Complicated recurrence (fistula, abscess, free perforation) occurred in 3.9% (95% CI 2.2%-5.6%) of patients at 5 years by Kaplan-Meier estimate. Family history of diverticulitis (HR 2.2, 95% CI 1.4-3.2), length of involved colon >5 cm (HR 1.7, 95% CI 1.3-2.3), and retroperitoneal abscess (HR 4.5, 95% CI 1.1-18.4) were associated with diverticulitis recurrence. Right colon disease (HR 0.27, 95% CI 0.09-0.86) was associated with freedom from recurrence. CONCLUSION Although diverticulitis recurrence is common following an initial attack that has been managed medically, complicated recurrence is uncommon. Patients who present with a family history of diverticulitis, long segment of involved colon, and/or retroperitoneal abscess are at higher risk for recurrent disease. Patients who present with right-sided diverticulitis are at low risk for recurrent disease. These findings should be taken into consideration when counseling patients regarding the potential benefits of prophylactic colectomy.
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Affiliation(s)
- Jason F Hall
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA, USA.
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Patients with less than three episodes of diverticulitis may benefit from elective laparoscopic sigmoidectomy. World J Surg 2010; 33:2444-7. [PMID: 19641950 DOI: 10.1007/s00268-009-0162-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND This study was designed to asses the predictive factors of postoperative complications in patients who underwent a laparoscopic elective approach for recurrent diverticulitis and to determine the relationship between the number of acute episodes and surgical morbidity. METHODS A retrospective analysis was performed on patients with colonic diverticular disease treated by an elective laparoscopic approach between July 2000 and November 2007. The variables studied were age, sex, BMI, ASA, number of previous acute episodes, local severity, abdominal surgery history, comorbidity, and laparoscopic training of the surgeon. Logistic regression analysis was used to establish significant results. RESULTS A total of 137 patients were analyzed; 87 (63.5%) were men with a mean age of 56.7 (range, 27-89) years. Intraoperative and postoperative complications occurred in 2.9% (n = 4) and 12.4% (n = 17) of the patients respectively. Conversion rate was 9.4% (n = 13). Local severity (odds ratio (OR), 16.34; 95% confidence interval (CI), 4.1-64.5, p = 0.00007), history of abdominal surgery (OR, 3.02; 95% CI, 0.8-11.5; p = 0.02), and the training of the operating surgeon (OR, 4.8; 95% CI, 1.02-22.7; p = 0.001) were significant risk factors related to surgery conversion. A history of three or more acute episodes was significantly associated with a high severity of local process and was a risk factor related to conversion (OR, 2.6; 95% CI, 0.5-12.3; p = 0.22). The severity of the local process seems to be a risk factor for perioperative complications. A significant association (chi2, 4.45; p = 0.03) between conversion and postoperative complications also was observed (OR: 3.79, 95% CI, 1.02-14.07; p = 0.04). CONCLUSIONS A history of three or more acute episodes of diverticulitis with conservative treatment is associated with a high severity of the local process during laparoscopic sigmoidectomy and increases the rate of conversion and perioperative complications.
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Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010; 47:680-735. [PMID: 20684920 DOI: 10.1067/j.cpsurg.2010.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jason Hall
- Department of Colon and Rectal Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA. Patterns of recurrence in patients with acute diverticulitis. Br J Surg 2010; 97:952-7. [DOI: 10.1002/bjs.7035] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Background
The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following conservatively managed diverticulitis increasingly controversial. This study investigated recurrence rates, patterns and complications after conservatively managed diverticulitis.
Methods
This was a retrospective chart review of all patients admitted with diverticulitis between June 1997 and June 2002. Demographic data, management, recurrence rates, complications and subsequent surgery were recorded.
Results
Some 502 patients were identified, 337 with uncomplicated and 165 with complicated diverticulitis. Median follow-up was 101 (range 60–124) months. Of 320 patients with uncomplicated diverticulitis managed conservatively, 60 (18·8 per cent) had one episode of recurrence, whereas 15 (4·7 per cent) had two or more episodes. After an initial attack of uncomplicated diverticulitis, only 5·0 per cent developed complicated disease. Complicated disease recurred in 24 per cent, compared with a recurrence rate of 23·4 per cent in those with uncomplicated diverticulitis (P = 0·622). When recurrence occurred, it usually did so within 12 months of the initial episode.
Conclusion
Acute diverticulitis has a low recurrence rate and rarely progresses to complications. Any recurrence is usually early, in a pattern more consistent with failure of the index episode to settle. Subsequent elective surgery to prevent recurrence and the development of complications should be used sparingly.
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Affiliation(s)
- T Eglinton
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - T Nguyen
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - S Raniga
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - L Dixon
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - B Dobbs
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - F A Frizelle
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
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Hall JF, Roberts PL, Ricciardi R, Marcello PW, Scheirey C, Wald C, Scholz FJ, Schoetz D. Colonic diverticulitis: does age predict severity of disease on CT imaging? Dis Colon Rectum 2010; 53:121-5. [PMID: 20087085 DOI: 10.1007/dcr.0b013e3181c18d64] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of our study was to determine whether young patients with diverticulitis were more likely to present with abdominal CT evidence of severe disease. METHODS We analyzed the abdominal CT scans of 932 patients who presented to our institution with CT scan findings consistent with diverticulitis from January 2002 through June 2007. Radiologists retrospectively reviewed all abdominal scans for the presence of imaging findings consistent with diverticulitis (bowel wall thickness, extraluminal air, free perforation, abscess, or fistula). The cohort was divided into 2 groups; patients <or=50 years of age and patients >51 years of age. RESULTS Two hundred forty-three patients were <or=50 years and 689 patients were >51 years. Young patients were more likely to be male (63% vs 42%, P < .0001). Young patients had a higher proportion of scans with extraluminal air than older patients (19.7% vs 12.6%, P < .008). Young patients were more likely to present with severe disease found by CT than older patients (19.3% vs 11.5%). When we adjusted for gender, young males had a higher proportion of scans with extraluminal air than older males (22.4% vs 13.1%, P = .014). Young males were also more likely to present with severe disease (22% vs 12%). CONCLUSION Young patients were more likely to have extraluminal air and severe disease found by CT. Young male patients presented more commonly with evidence of severe disease. They did not differ from older patients in rates of free perforation, abscess, or fistula formation.
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Affiliation(s)
- Jason F Hall
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA
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20
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Santin BJ, Prasad V, Caniano DA. Colonic diverticulitis in adolescents: an index case and associated syndromes. Pediatr Surg Int 2009; 25:901-5. [PMID: 19711089 DOI: 10.1007/s00383-009-2472-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2009] [Indexed: 11/27/2022]
Abstract
Diverticular disease of the colon, a common problem among adults, is diagnosed rarely in children. We report an adolescent patient with sigmoid diverticulitis who required operative treatment. Pediatric patients with the complications of diverticula typically have conditions that result in genetic alterations affecting the components of the colonic wall. Our patient had Williams-Beuren syndrome, although Ehlers-Danlos syndrome, Marfan syndrome, and cystic fibrosis may also be associated with colonic diverticula in adolescence. Pediatric patients with these disorders who experience abdominal pain should be evaluated for the presence of colonic diverticular complications.
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Affiliation(s)
- Brian J Santin
- Division of Pediatric Surgery, Department of Surgery, The Ohio State University College of Medicine and Nationwide Children's Hospital, 700 Children's Drive, ED 379, Columbus, OH 43205, USA
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Janes S, Meagher A, Faragher IG, Shedda S, Frizelle FA. The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature. Dis Colon Rectum 2009; 52:1008-16. [PMID: 19502872 DOI: 10.1007/dcr.0b013e3181a0a8a9] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age
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Affiliation(s)
- Simon Janes
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
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Abstract
Diverticulitis is classified as uncomplicated or complicated, i.e., associated with perforation, fistula, or obstruction. CT allows more reliable characterization of an acute attack of diverticulitis. Medical management is reserved for uncomplicated diverticulitis and the initial phase of treatment of diverticulitis associated with abscess formation. Percutaneous abscess drainage is a major advance, which permits one-stage resection in a majority of cases. Diverticulitis associated with free perforation can be selectively managed with resection and primary anastomosis, although a Hartmann resection is likely to be performed. A fistula associated with diverticulitis can usually be managed with a one-stage resection. Obstruction can be managed selectively with resection with on-table bowel preparation, primary anastomosis, and proximal diversion. Laparoscopic techniques permit successful performance of elective resections most of the time. Hand assistance is of particular value when the patient has dense fibrosis.
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Affiliation(s)
- Michael H. Mccafferty
- Division of Colorectal Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Leslie Roth
- Division of Colorectal Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jeffrey Jorden
- Division of Colorectal Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky
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Buc E, Mabrut JY, Génier F, Berdah S, Deyris L, Panis Y. [Not Available]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2007; 31:35-46. [PMID: 24928748 DOI: 10.1016/s0399-8320(07)91950-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Young patients with diverticular disease: A preliminary quality of life study. Int J Surg 2007; 5:244-9. [DOI: 10.1016/j.ijsu.2006.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 09/24/2006] [Accepted: 09/24/2006] [Indexed: 11/22/2022]
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Abstract
The timing and appropriateness of surgical treatment of sigmoid diverticular disease remain a topic of controversy. We have reviewed the current literature on this topic, focusing on issues related to the indications and types of surgery. Current evidence would suggest that elective surgery for diverticulitis can be avoided in patients with uncomplicated disease, regardless of the number of recurrent episodes. Furthermore, the need for elective surgery should not be influenced by the age of the patient. Operation should be undertaken in patients with severe attacks, as determined by their clinical and radiological evaluation.
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Affiliation(s)
- Liliana Bordeianou
- Department of Surgery, Massachusetts General Hospital, ACC 460, 15 Parkman Street, Boston, MA 02114 USA
| | - Richard Hodin
- Department of Surgery, Massachusetts General Hospital, ACC 460, 15 Parkman Street, Boston, MA 02114 USA
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Pautrat K, Bretagnol F, Huten N, de Calan L. Acute diverticulitis in very young patients: a frequent surgical management. Dis Colon Rectum 2007; 50:472-7. [PMID: 17164966 DOI: 10.1007/s10350-006-0787-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The natural history of sigmoid diverticulitis in terms of the virulence and management in young patients is an ongoing controversy. This retrospective study was designed to assess the severity and early management of acute diverticulitis according to age. METHODS From 2000 to 2004, 284 patients were admitted for acute diverticulitis. Fifty-two patients (18 percent) were aged 50 years or younger and were divided in two groups: aged 40 years or younger (Group 1, n = 20), and patients older than aged 40 years (Group 2, n = 32). The diagnosis was confirmed by computed tomography in 49 patients (94 percent). RESULTS Radiologic findings showed that the rate of complicated lesions (i.e., diverticular perforation and/or abscess) was significantly higher for patients younger than aged 40 years than patients older, respectively 72 and 35 percent (P = 0.02). The risk of requiring immediate surgical treatment was significantly more frequent in Group 1 than Group 2 (40 vs.13 percent; P = 0.04). There was a trend toward a higher risk of "major surgery" (i.e., Hartmann's procedure) in Group 1 than Group 2 (15 vs. 0 percent; P = 0.05). CONCLUSIONS Diverticulitis in patients younger than aged 40 years seems to have a particularly aggressive and fulminant course and requires early surgical procedures for complications (associated abscess, colonic perforation) in 40 percent of cases. The use of "major procedure" (i.e., stoma) is more frequent in these patients.
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Affiliation(s)
- Karine Pautrat
- Department of Digestive Surgery, Trousseau Hospital, Tours, France
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Constantinides VA, Tekkis PP, Senapati A. Comparison of POSSUM scoring systems and the surgical risk scale in patients undergoing surgery for complicated diverticular disease. Dis Colon Rectum 2006; 49:1322-31. [PMID: 16680607 DOI: 10.1007/s10350-006-0522-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the accuracy of the Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale for the treatment of patients with complicated diverticular disease. METHODS Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity variables were prospectively recorded for 324 patients undergoing colorectal resections in 42 hospitals in the United Kingdom from January to December 2003. The accuracy of each model was evaluated by measures of discrimination, calibration, and subgroup analysis. RESULTS The overall operative mortality was 10.8 percent (Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 21.9 percent; Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10.5 percent; colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10 percent; Surgical Risk Scale-estimated mortality rate, 38.2 percent). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale over-predicted mortality in young patients (P < 0.001) and Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity underpredicted mortality in elderly patients (P < 0.001). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale overpredicted mortality in patients with generalized peritonitis (Hinchey III and IV). There was no significant difference between the observed and colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity predicted mortality across patient subgroups and when the overall sample was considered. CONCLUSIONS The study suggested a lack of calibration of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale at the extreme of age and for patients with severe peritoneal contamination. Colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity was found to accurately evaluate mortality arising from complicated diverticular disease.
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Affiliation(s)
- Vasilis A Constantinides
- Department of Surgical Oncology and Technology, Imperial College London, St. Mary's Hospital, Praed Street, London W2 1NY, U.K
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Munikrishnan V, Helmy A, Elkhider H, Omer AA. Management of acute diverticulitis in the East Anglian region: results of a United Kingdom regional survey. Dis Colon Rectum 2006; 49:1332-40. [PMID: 16897334 DOI: 10.1007/s10350-006-0594-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Acute diverticulitis is the most common presentation of diverticular disease; however, no published guidelines for management are available in the United Kingdom. This survey was designed to assess the current United Kingdom regional practice compared with the guidelines published by The American Society of Colon and Rectal Surgeons. METHODS A questionnaire survey focused on the management of acute diverticulitis was sent to all consultants, specialist registrars, and staff-grade surgeons in general surgery in one United Kingdom region. RESULTS Eighty-two questionnaires were returned (80 percent). A majority (80 percent) would request routine blood tests, abdominal, and erect chest x-rays on arrival. Pethidine (56 percent) was the preferred analgesic, followed by morphine (40 percent). Ninety-four percent used an antibiotic combination of second/third-generation cephalosporin and metronidazole. Computerized tomography was the most commonly used initial investigation (42 percent). Forty percent use barium enema and 31 percent use a combination of barium enema and sigmoidoscopy as follow-up investigations. In patients older than aged 50 years, elective resection would be considered by a majority (51 percent) only when complications arose. In those aged 50 years or younger, 35 percent would resect only if complications arose with only 6 percent after a single episode of acute diverticulitis. CONCLUSIONS There are major differences in the management of patients with acute diverticulitis in our current practice in one United Kingdom region compared with the guidelines published by The American Society of Colon and Rectal Surgeons, which are based on published literature. There is an urgent need to establish similar guidelines in the United Kingdom to improve the clinical outcome of patients with such a common condition.
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Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, Kreis ME. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol 2005; 17:649-54. [PMID: 15879727 DOI: 10.1097/00042737-200506000-00009] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION The indication for surgery after conservative treatment of acute diverticulitis is still under debate. This is partly as a result of limited data on the outcome of conservative management in the long run. We therefore aimed to determine the long-term results of conservative treatment for acute diverticulitis. METHODS The records of all patients treated at our institution for diverticulitis between 1985 and 1991 were reviewed (n=363, median age 64 years, range 29-93). Patients who received conservative treatment were interviewed in 1996 and 2002 [follow-up time 7 years 2 months (range 58-127 months) and 13 years 4 months (range 130-196 months). RESULTS A total of 252 patients (69%) were treated conservatively, whereas 111 (31%) were operated on. At the first follow-up, 85 patients treated conservatively had died, one of them from bleeding diverticula. A recurrence of symptoms was reported by 78 of the remaining 167 patients, and 13 underwent surgery. At the second follow-up, one patient had died from sepsis after perforation during another episode of diverticulitis. Thirty-one of the 85 patients interviewed reported symptoms and 12 had been operated on. In summary, at the second follow-up interview, 34% of patients treated initially had had a recurrence and 10% had undergone surgery. No predictive factors for the recurrence of symptoms or later surgery could be determined. CONCLUSION Despite a high rate of recurrences after conservative treatment of acute diverticulitis, lethal complications are rare. Surgery should thus mainly be undertaken to achieve relief of symptoms rather than to prevent death from complications.
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Affiliation(s)
- M H Mueller
- Department of Surgery, Ludwig-Maximilian University, Munich-Grosshadern, Germany
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Greenberg AS, Gal R, Coben RM, Cohen S, Dimarino AJ. A retrospective analysis of medical or surgical therapy in young patients with diverticulitis. Aliment Pharmacol Ther 2005; 21:1225-9. [PMID: 15882243 DOI: 10.1111/j.1365-2036.2005.02450.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute diverticulitis is increasingly being recognized in younger patients, but its management remains controversial. AIM To compare long-term outcomes of young patients treated with surgery vs. medical therapy for their first episode of diverticulitis. METHODS A retrospective chart analysis at a university and an affiliated community hospital between 1991 and 2002 revealed 149 patients < or = 40 years of age with confirmed diverticulitis. Forty-nine patients (38 males, 11 females) were contacted at least 1 year after their first episode of diverticulitis. Outcomes were compared based on initial therapy--antibiotics or surgical resection. The groups were compared by outcomes, gender, age, white blood cell count, temperature and diet. RESULTS Three (15%) of 20 surgical patients (mean follow-up 6.89 years), and 16 (55%) of 29 medical patients had a recurrence of diverticulitis (mean follow-up 5.72 years; P = 0.01). The treatment groups did not differ in age, white blood cell count, or temperature. CONCLUSIONS (i) Surgical treatment is effective initial therapy but disease may recur in a minority of patients; (ii) medical treatment is less effective initial therapy, with recurrence in half of the patients; (iii) initial presentation is not a strong predictor of disease recurrence.
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Affiliation(s)
- A S Greenberg
- Division of Gastroenterology and Hepatology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Tursi A, Brandimarte G, Giorgetti GM, Elisei W. Assessment of small intestinal bacterial overgrowth in uncomplicated acute diverticulitis of the colon. World J Gastroenterol 2005; 11:2773-6. [PMID: 15884120 PMCID: PMC4305914 DOI: 10.3748/wjg.v11.i18.2773] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Small intestinal bacterial overgrowth (SIBO) may contribute to the appearance of several gastrointestinal nonspecific symptoms. Acute diverticulitis is affected by some similar symptoms and bacterial colonic overgrowth. We assessed the prevalence of SIBO in acute uncomplicated diverticulitis and evaluated its influence on the clinical course of the disease.
METHODS: We studied 90 consecutive patients (39 males, 51 females, mean age 67.2 years, range 32-91 years). Sixty-one patients (67.78%) and 29 patients (32.22%) were affected by constipation-or diarrhea-prevalent diverticulitis respectively. All subjects were investigated by lactulose H2-breath test at the entry and at the end of treatment. We also studied a control group of 20 healthy subjects (13 males, 7 females, mean age 53 years, range 22-71 years).
RESULTS: Oro-cecal transit time (OCTT) was delayed in 67/90 patients (74.44%) (range 115-210 min, mean 120 min). Fifty-three of ninety patients (58.88%) showed SIBO, while OCTT was normal in 23/90 patients (25, 56%). In the control group, the mean OCTT was 88.2 min (range 75-135 min). The difference between diverticulitic patients and healthy subjects was statistically significant (P<0.01). OCTT was longer in constipation-prevalent disease than in diarrhea-prevalent disease [180.7 min (range 150-210 min) vs 121 min (range 75-180 min) (P<0.001)], but no difference in bacterial overgrowth was found between the two forms of diverticulitis.After treatment with rifaximin plus mesalazine for 10 d, followed by mesalazine alone for 8 wk, 70 patients (81.49%) were completely asymptomatic, while 16 patients (18.60%) showed only slight symptoms. Two patients (2.22%) had recurrence of diverticulitis, and two other patients (2.22%) were withdrawn from the study due to side-effects. Seventy-nine of eighty-six patients (91.86%) showed normal OCTT (range 75-105 min, mean 83 min), while OCTT was longer, but it was shorter in the remaining seven (8.14%) patients (range 105-115 min, mean of 110 min). SIBO was eradicated in all patients, while it persisted in one patient with recurrence of diverticulitis.
CONCLUSION: SIBO affects most of the patients with acute diverticulitis. SIBO may worsen the symptoms of patients and prolong the clinical course of the disease, as confirmed in the case of persistence of SIBO and diverticulitis recurrence. In this case, we can hypothesize that bacteria from small bowel may re-colonize in the colon and provoke recurrence of symptoms.
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Affiliation(s)
- Antonio Tursi
- Digestive Endoscopy Unit, Lorenzo Bonomo Hospital, Galleria Pisani 4, 70031 Andria, Italy.
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Abstract
BACKGROUND Diverticulitis is a common condition. Practice guidelines from many organizations recommend bowel resection after two attacks. The evidence for such a recommendation is reviewed. METHODS A Medline literature search was performed to locate English language articles on surgery for diverticular disease. Further articles were obtained from the references cited in the literature initially reviewed. RESULTS Most people with diverticulosis are asymptomatic. Diverticular disease occurs in over 25 per cent of the population, increasing with age. After one episode of diverticulitis one-third of patients have recurrent symptoms; after a second episode a further third have a subsequent episode. Perforation is commonest during the first episode of acute diverticulitis. After recovering from an episode of diverticulitis the risk of an individual requiring an urgent Hartmann's procedure is one in 2000 patient-years of follow-up. Surgery for diverticular disease has a high complication rate and 25 per cent of patients have ongoing symptoms after bowel resection. CONCLUSION There is no evidence to support the idea that elective surgery should follow two attacks of diverticulitis. Further prospective trials are required.
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Affiliation(s)
- S Janes
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elective colectomy in diverticulitis: a decision analysis. J Am Coll Surg 2005; 199:904-12. [PMID: 15555974 DOI: 10.1016/j.jamcollsurg.2004.07.029] [Citation(s) in RCA: 170] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Revised: 07/23/2004] [Accepted: 07/28/2004] [Indexed: 12/19/2022]
Abstract
BACKGROUND Determining the optimal strategy for elective colectomy in patients with diverticular disease involves a balance of the morbidity, mortality, costs, and quality of life associated with both elective and expectant management. We used decision and cost analysis to simulate the clinical and economic outcomes after recovery from an episode of nonsurgically treated diverticulitis to determine the preferable management strategy. STUDY DESIGN A Markov model was constructed to evaluate lifetime risks of death and colostomy, care costs, and quality of life associated with elective colectomy after subsequent episodes of diverticulitis. The analysis was from the payer's perspective, using hypothetical cohorts of 35- and 50-year-old patients who recovered from a nonsurgically treated diverticulitis episode. Probabilities of clinical events and costs for the base-case analysis were derived from a large cohort using a statewide administrative database and published estimates. RESULTS Performing colectomy after the fourth rather than the second episode in patients older than 50 years resulted in 0.5% fewer deaths, 0.7% fewer colostomies, and saved US 1,035 dollars per patient. In younger patients, performing colectomy after the fourth episode compared with the first episode resulted in 0.1% fewer deaths, 2% fewer colostomies, and saved US 5,429 dollars per patient. Expectant management through three recurrent episodes with elective colectomy after the fourth episode was the dominant strategy across the full range of the variables tested in the sensitivity analysis compared with earlier intervention. CONCLUSIONS This study suggests that expectant management is associated with lower rates of death and colostomy and is cost-saving for both younger and older patients.
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Affiliation(s)
- Leon Salem
- Department of Surgery, University of Washington, Seattle, WA 98195-6410, USA
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Abstract
BACKGROUND The purpose of this study was to examine the presentation of diverticulitis at an urban county hospital serving predominantly indigent patients and to analyze the differences, if any, in presentation and treatment in younger patients. METHODS A retrospective review of medical records from 1995 to 2001 was performed at a single institution to identify patients admitted to the surgical service with the diagnosis of diverticular disease. Inclusion criteria were either diverticulitis confirmed at operation or radiographic findings consistent with the disease. Patient demographics, history, pertinent physical findings, and treatment were recorded. The data were analyzed after dividing the patients into two populations: a younger population 50 years of age or less, and a second population of patients older than 50. RESULTS During the interval, a total of 64 patients were admitted to the surgical service with the diagnosis of diverticulitis. The mean age of this population was 45.5 years (range 21 to 86). Forty-six patients were under 50 years of age (72%). Analysis of sex differences, type and timing of surgical procedure, and complication rate with respect to age showed no significant difference between the two age groups. CONCLUSIONS We are clearly treating a younger patient population than previous reports on patients with diverticulitis. Although there was a trend toward increased surgical intervention in the younger population, this number did not reach statistical significance. Diverticulitis in young patients at our institution does not appear to take a more aggressive course than the same disease in older patients.
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Affiliation(s)
- Sonlee D West
- Department of Surgery, University of Texas Medical School, Houston 77026, USA
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Schweitzer J, Casillas RA, Collins JC. Acute Diverticulitis in the Young Adult is Not “Virulent”. Am Surg 2002. [DOI: 10.1177/000313480206801203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Acute diverticulitis historically has been considered rare before the age of 40 but “virulent” when it does occur and frequently requiring emergency operation. Recent experience suggests that the demographics and management of this disease are changing. Outcomes at Kaiser Permanente Los Angeles Medical Center were reviewed. Between January 1997 and July 2001 261 patients were discharged with the diagnosis of acute diverticulitis; 46 or 18 per cent of these were aged ≤40. Patients' mean age was 35, 76 per cent were men, 65 per cent were Latino, and 72 per cent were obese (body mass index ≥30 kg/m2). An operation at initial presentation was performed on 35 per cent (16/46) patients. Only 19 per cent of these (3/16) had a correct preoperative diagnosis. The 30 patients who were treated nonoperatively all were managed successfully; one required a percutaneous drain. Given the apparent increasing frequency of acute diverticulitis in young adults and the high success rate of initial nonoperative management surgeons should consider this diagnosis in selected patients who present with abdominal symptoms. Knowledge of typical clinical features and judicious use of computed tomography may decrease the number of unnecessary emergency operations in young adults with acute diverticulitis. Our data do not support a “virulent” label for this disease in the young.
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Affiliation(s)
- Jeremy Schweitzer
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Robert A. Casillas
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - J. Craig Collins
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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Biondo S, Parés D, Martí Ragué J, Kreisler E, Fraccalvieri D, Jaurrieta E. Acute colonic diverticulitis in patients under 50 years of age. Br J Surg 2002; 89:1137-41. [PMID: 12190679 DOI: 10.1046/j.1365-2168.2002.02195.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is ongoing controversy concerning the virulence and management of diverticulitis in young patients. This study reports on the management of acute diverticulitis with reference to the virulence and outcome of the disease with respect to age. METHODS Between January 1994 and June 1999, 327 patients were treated for acute left colonic diverticulitis. Patients were divided in two groups: those aged 50 years or less (group 1, 72 patients) and those older than 50 years (group 2, 255 patients). The diagnosis was confirmed histologically or radiologically in all patients. RESULTS There were differences in gender distribution related to age (P < 0.001). During the first hospital stay, 226 patients (69.1 per cent) had successful conservative treatment, 78 (23.9 per cent) needed emergency surgery and 23 (7.0 per cent) had a semielective operation (P = 0.47). The recurrence rate was 25.5 per cent in group 1 and 22.3 per cent in group 2 (P = 0.93). The type of surgical procedure and grade of peritonitis in emergency patients were similar in the two groups. Overall the mortality rate in patients who underwent an operation was 16.3 per cent. The mortality rate was zero in group 1 and 2.2 per cent in group 2 after elective or semielective operation (P = 1.0), and zero in group 1 and 34.9 per cent in group 2 after emergency operation (P < 0.001). CONCLUSION Diverticulitis in young patients does not have a particularly aggressive course and the risk of recurrence is similar to that of older patients.
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Affiliation(s)
- S Biondo
- Department of Surgery, Ciudad Sanitaria y Universitaria de Bellvitge, University of Barcelona, Barcelona, Spain
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Abstract
Diverticular disease is rare in the adolescent. Acute diverticulitis is almost never considered as a diagnosis for a young patient presenting with abdominal pain. Unfortunately, unrecognized it may be associated with significant morbidity and mortality. Also, when present, diverticulitis in the young adult is considered to be more aggressive compared to diverticulitis in older adults. Therefore, it is important to recognize, diagnose and manage diverticular disease appropriately in this age group. In tis chapter we will review the available literature on diverticula disease in the adolescent and young adult, discuss epidemiology, aetiology and pathogenesis and suggest guidelines for diagnosis and management.
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Affiliation(s)
- Nadeem Ahmad Afzal
- Centre for Paediatric Gastroenterology, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK
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38
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Abstract
Diverticulosis, which is an acquired condition marked by mucosal herniation through defects in the colonic wall, has been termed both a "disease of the 20th century" and a "disease of Western civilization" due to its increasing prevalence in modern times and its striking geographical variability. Both of these epidemiological observations may provide interesting insights into the pathophysiology of diverticulosis. This chapter will review the known epidemiology of diverticulosis coli and its main complications: diverticulitis and diverticular haemorrhage. Where possible, attempts will be made to place these observational reports in the context of both the cause and clinical behaviour of this disorder.
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Affiliation(s)
- Stephanie Jun
- Department of Internal Medicine, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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Minardi AJ, Johnson L, Sehon JK, Zibari GB, Mcdonald JC. Diverticulitis in the Young Patient. Am Surg 2001. [DOI: 10.1177/000313480106700516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center—Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16–40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3–14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.
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Affiliation(s)
- Andrew J. Minardi
- Department of Surgery, Louisiana State University Health Sciences Center and Affiliated Hospitals, Shreveport, Louisiana
| | - L.W. Johnson
- Department of Surgery, Louisiana State University Health Sciences Center and Affiliated Hospitals, Shreveport, Louisiana
| | - J. Kenneth Sehon
- Department of Surgery, Louisiana State University Health Sciences Center and Affiliated Hospitals, Shreveport, Louisiana
| | - Gazi B. Zibari
- Department of Surgery, Louisiana State University Health Sciences Center and Affiliated Hospitals, Shreveport, Louisiana
| | - John C. Mcdonald
- Department of Surgery, Louisiana State University Health Sciences Center and Affiliated Hospitals, Shreveport, Louisiana
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Wong WD, Wexner SD, Lowry A, Vernava A, Burnstein M, Denstman F, Fazio V, Kerner B, Moore R, Oliver G, Peters W, Ross T, Senatore P, Simmang C. Practice parameters for the treatment of sigmoid diverticulitis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000; 43:290-7. [PMID: 10733108 DOI: 10.1007/bf02258291] [Citation(s) in RCA: 286] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
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Wolff BG, Devine RM. Surgical Management of Diverticulitis. Am Surg 2000. [DOI: 10.1177/000313480006600210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diverticular disease, and particularly diverticulitis, has an increasing incidence in Westernized countries because of low-fiber diet. Diverticular disease may be classified as asymptomatic, atypical, acute or uncomplicated, and complicated. Conservative or medical management is usually indicated for acute or uncomplicated diverticulitis, with elective surgical resection generally being recommended after two documented episodes. Complicated diverticulitis, because of the high rate of recurrent problems, is generally managed promptly with sigmoid resection. Sigmoid resection for diverticulitis, under appropriate circumstances, has one of the highest success rates of any of the common gastrointestinal procedures.
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Mäkelä J, Vuolio S, Kiviniemi H, Laitinen S. Natural history of diverticular disease: when to operate? Dis Colon Rectum 1998; 41:1523-8. [PMID: 9860333 DOI: 10.1007/bf02237300] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The natural history of patients admitted because of acute diverticulitis is largely unknown, and the selection of patients for surgical treatment varies notably. This study presents our experience concerning the outcome for 366 patients admitted during a 10-year period. METHODS Three hundred sixty-six patients admitted to our hospital with acute diverticulitis from 1981 to 1990 were identified from a computer database, and their clinical data up to the end of 1996 were reviewed from the database and patient records. RESULTS There were significantly more males than females in the age group less than 50 years old, and young males underwent surgical treatment during the first treatment period more frequently than the others. Young patients were operated on without mortality, and all their temporary colostomies were closed. Older patients died more often of diseases unrelated to the diverticular disease during the years after the first episode of acute diverticulitis. Recurrences of diverticular disease developed in 22 percent of patients, and they were significantly more common in patients less than 50 years old than in the older age groups. Males less than 50 years old more often developed complications of diverticular disease after two hospital admissions. CONCLUSIONS Males first admitted when less than 50 years of age undergo more primary operations and develop more recurrences of diverticular disease than do older people. Based on our data, however, we recommend surgery for all patients after two episodes of acute diverticulitis that resolves after conservative treatment with antibiotics.
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Affiliation(s)
- J Mäkelä
- Department of Surgery, Oulu University Hospital, Finland
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45
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Affiliation(s)
- R Bergamaschi
- National Centre for Advanced Laparoscopic Surgery, Trondheim University Hospital, Norway
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46
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Cunningham MA, Davis JW, Kaups KL. Medical versus surgical management of diverticulitis in patients under age 40. Am J Surg 1997; 174:733-5; discussion 735-6. [PMID: 9409607 DOI: 10.1016/s0002-9610(97)00187-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Diverticulitis in patients under age 40 is a distinct entity. We compared the medical versus surgical management of diverticulitis for complications and outcomes in these patients. METHODS A retrospective review was performed for treatment, hospitalizations, complications, and outpatient visits. Complications included readmission, recurrent symptoms after antibiotic therapy, and postoperative problems. RESULTS Twenty-nine patients had a radiographic or surgical diagnosis of diverticulitis (18 surgical, 11 medical). Medically managed patients had significantly more emergency department visits (4.7 +/- 6.6 versus 0.3 +/- 0.6, P < or =0.01), and readmissions (7 versus 4, P < or =0.02). Three surgical patients (17%) had a total of 6 complications as compared with 6 medical patients (55%) with 25 complications (chi square, P < or =0.05). All medically treated patients had recurrent symptoms, and 6 required surgery. CONCLUSION Medically managed patients had significantly more emergency department visits and complications than those managed surgically. Surgery is the indicated treatment for the first episode of diverticulitis in patients under age 40.
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Affiliation(s)
- M A Cunningham
- Department of Surgery, University of California, San Francisco, USA
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Spivak H, Weinrauch S, Harvey JC, Surick B, Ferstenberg H, Friedman I. Acute colonic diverticulitis in the young. Dis Colon Rectum 1997; 40:570-4. [PMID: 9152186 DOI: 10.1007/bf02055381] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Colonic diverticulitis in the young has been considered to have a virulent course, high morbidity, and high operative rate. As a result, elective resection of the involved colonic segment after the first clinical episode has been the usual practice. PURPOSE This study presents our experience with acute diverticulitis in the young. METHODS In the last nine years, 63 patients younger than 45 years were treated for acute diverticulitis at our institution. A retrospective review was performed to determine the clinical course and outcome of these patients. RESULTS Clinical presentations, radiographic tests, operative findings, and pathology results revealed that 57 patients had a pericolonic contained disease (Hinchey State I). Two patients had a large pelvic abscess (Hinchey Stage II), and four patients had a diffuse peritonitis (Hinchey Stage III). Forty-one patients (65 percent) were successfully treated medically with antibiotics and bowel rest. Of 22 patients (35 percent) who underwent emergent operations, 12 patients' diseases had been erroneously diagnosed preoperatively (9 "appendicitis"). CONCLUSION Diverticulitis at a young age does not have a specific aggressive nature. Although, it is associated with a high rate of emergency operations, many of these are performed for a mistaken diagnosis. The recommendation for routine elective resection following the first episode of diverticulitis should be reassessed.
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Affiliation(s)
- H Spivak
- Department of Surgery, Beth Israel Medical Center, New York, New York, USA
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Abstract
PURPOSE This study was designed to determine the natural history of documented diverticulitis that resolves after treatment with intravenous antibiotics and bowel rest in patients under the age of 50. METHODS Records of 40 patients aged 50 or under who were hospitalized with the diagnosis of acute diverticulitis between 1980 and 1984 were reviewed to obtain data regarding how the diagnosis was made. Patients successfully treated with antibiotics were contacted five to nine years after their attack and surveyed via telephone questionnaire about symptoms, recurrent attacks, and surgical interventions. RESULTS A total of 40 patients were included in the study. Ten patients (25 percent) required surgery during initial admission, and 30 patients were discharged with resolution of their symptoms after treatment with intravenous antibiotics and bowel rest. A five-year to nine-year follow-up was obtained on patients treated medically, one-third of whom underwent operation for diverticulitis during this period, and two-thirds of whom did not require surgery during the follow-up period. All operations were elective with single-stage resections. CONCLUSION Based on our data, we do not recommend surgery in this population after a single episode of diverticulitis that resolves after treatment with antibiotics.
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Affiliation(s)
- P V Vignati
- Department of Surgery, Hartford Hospital, Connecticut, USA
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50
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