Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its ...Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations.Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis.Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended.Rather,a more individualized approach,taking into account frequency,severity of the attacks and their impact on quality of life,should guide the indication for surgery.On the other hand,complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation.Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis.There is not sufficient evidence supporting any changes in the approach to management in younger patients.Conversely,the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.展开更多
BACKGROUND Abnormal colonic pressure profiles have been associated with an increased risk of colonic diverticulosis.A surgical history is a known risk factor for abdominal adhesions and these may lead to increased int...BACKGROUND Abnormal colonic pressure profiles have been associated with an increased risk of colonic diverticulosis.A surgical history is a known risk factor for abdominal adhesions and these may lead to increased intraluminal colonic pressure.AIM To assess whether previous abdominal surgery is associated with colonic divertic-ulosis or diverticulitis.METHODS We analyzed data from a study of patients undergoing colonoscopy for different indications from 2020 through 2021.Patients completed a structured question-naire concerning previous abdominal surgeries,dietary and lifestyle exposures including smoking,alcohol use and co-morbidities.RESULTS Three hundred and fifty-nine patients were included in the study.The mean age was 67.6 and 46%were females.Diabetes mellitus,hypertension,ischemic heart disease,chronic obstructive pulmonary disease,chronic renal failure,and body mass index were similar in the diverticulosis and control groups.The overall prevalence of colonic diverticulosis was 25%(91/359)and 48%of the patients had previous abdominal surgery.As expected,the prevalence of diverticulosis increased with age.There was no difference in the rate of previous abdominal surgery between patients with or without diverticulosis(49%vs 47%,P=0.78).In regards to specific surgeries,inguinal hernia repair was significantly associated with diverticulosis(52%vs 20%,P=0.001),but not diverticulitis.In contrast,appendectomy was not associated with diverticulosis(6%vs 14%,P=0.048).CONCLUSION These findings suggest that post-operative abdominal adhesions inducing high colonic intraluminal pressures do not appear to be the mechanism for diverticula formation.Rather,inguinal hernia and diverticulosis may share similar connective tissue pathologies with no causative relationship between them.展开更多
BACKGROUND Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses ...BACKGROUND Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound(EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization.CASE SUMMARY A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography(CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey Ⅱ diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient’s general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection.CONCLUSION We report the first successful management of a pelvic abscess in patient with Hinchey Ⅱ acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.展开更多
The disease burden of diverticulitis is high across inpatient and outpatient settings,and the prevalence of diverticulitis has increased.Historically,patients with acute diverticulitis were admitted routinely for intr...The disease burden of diverticulitis is high across inpatient and outpatient settings,and the prevalence of diverticulitis has increased.Historically,patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes.Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed,and many clinical practice guidelines(CPGs)have pivoted to recommend outpatient management and individualized decisions about surgery.Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States,suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease.In this review,we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.展开更多
BACKGROUND Although the treatment guidelines for left sided diverticulitis are clear,the management of right colonic diverticulitis is not well established.This disease can no longer be ignored due to significant spre...BACKGROUND Although the treatment guidelines for left sided diverticulitis are clear,the management of right colonic diverticulitis is not well established.This disease can no longer be ignored due to significant spread throughout Asia.AIM To analyse epidemiology,diagnosis and treatment of right-sided diverticulitis in western countries.METHODS MEDLINE and PubMed searches were performed using the key words "rightsided diverticulitis","right colon diverticulitis","caecal diverticulitis","ascending colon diverticulitis" and "caecum diverticula" in order to find relevant articles published until 2021.RESULTS A total of 18 studies with 422 patients were found.Correct diagnosis was made only in 32.2%,mostly intraoperatively or via CT scan.The main reason for misdiagnosis was a suspected acute appendicitis(56.8%).The treatment was a nonoperative management(NOM)in 184 patients(43.6%)and surgical in 238 patients(56.4%),seven of which after NOM failure.Recurrence rate was low(5.45%),similar to eastern studies and inferior to left-sided diverticulitis.Recurrent patients were successfully conservatively retreated in most cases.CONCLUSION The management of right-sided diverticulitis is not well clarified in the western world and no selective guidelines have been considered even if principles are similar to those with left-sided diverticulitis.Wrong diagnosis is one of the most important problems and CT scan seems to be the best imaging modality.NOM offers a safe and effective treatment;surgery should be considered only in cases of complicated diverticulitis or if malignancy cannot be excluded.Further studies are needed to clarify the correct treatment.展开更多
AIM:To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis.METHODS:We retrospectively reviewed the clinical records and radiolog...AIM:To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis.METHODS:We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography(CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis(PEA) or left acute colonic diverticulitis(ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics,laboratory findings,treatments,and clinical results of left PEA with those of left ACD.RESULTS:Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD,respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant(82.1%). On CT examination,most(89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD,the patients presented with a more diffuse abdominal tenderness throughout the left side(52.0%vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA(40.0% vs 7.1%,P = 0.004; 52.0% vs14.3%,P = 0.003,respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD(52.0% vs 15.4%,P = 0.006).CONCLUSION:If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities,clinicians should suspect the diagnosis of PEA and consider a CT scan.展开更多
AIM:To compare the recurrence rate following initial antibiotic management to that following laparoscopic treatment for suspected uncomplicated cecal diverticulitis. METHODS: We examined the records of 132 patients wh...AIM:To compare the recurrence rate following initial antibiotic management to that following laparoscopic treatment for suspected uncomplicated cecal diverticulitis. METHODS: We examined the records of 132 patients who were diagnosed with uncomplicated cecal diverticulitis and a first attack during an 8-year period. The diagnosis of uncomplicated diverticulitis was made based on imaging findings, such as inflamed diverticulum or a phlegmon with cecal wall thickening. Concurrent appendiceal dilatation from 8 to 12 mm was observed in 36 patients (27%). One hundred and two patients were treated initially with antibiotics only, whereas 30 underwent laparoscopic treatment, including partial cecectomy (n=8) or appendectomy with diverticulectomy (n=9) or appendectomy alone (n =13). We compared clinical outcomes in both groups over a median follow-up period of 46 mo. RESULTS: All patients were successfully treated with initial therapy. Of the 102 patients who initially received only antibiotic treatment, 6 (6%) had a recurrence (3 in the cecum and 3 in the ascending colon or transverse colon) during the follow-up period. Five of these pa-tients were managed with repeated antibiotic treatmentand 1 underwent ileocolic resection for perforation. Of the 30 patients treated by the laparoscopic approach, 2 (7%) had a recurrence (ascending colon) which was treated with antibiotics. CONCLUSION: Initial antibiotic management for suspected uncomplicated cecal diverticulitis showed comparable effi cacy to laparoscopic treatment in the prevention of recurrence.展开更多
AIM: To study the clinical features and computed tomography(CT) findings of appendiceal diverticulitis vs acute appendicitis.METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendect...AIM: To study the clinical features and computed tomography(CT) findings of appendiceal diverticulitis vs acute appendicitis.METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendectomy inour in stitution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis.RESULTS: Among 451 patients, 44(9.7%) were diagnosed to have appendiceal diverticulitis and 398(86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older(59 vs 37 years, P < 0.001) and had a longer duration of the illness(4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher(68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients(52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix(84% vs 12%, P < 0.001), absence of appendicolith(92% vs 52%, P = 0.005), and formation of abscess(68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients(24%).CONCLUSION: Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis.展开更多
The current case report is related to a male patient with diabetes, obesity [body mass index(BMI) 33], hypertension and recurrence of anemia associated to melena and deep asthenia. M.P., a 60-year-old obese individual...The current case report is related to a male patient with diabetes, obesity [body mass index(BMI) 33], hypertension and recurrence of anemia associated to melena and deep asthenia. M.P., a 60-year-old obese individual, was referred to our department by the primary care unit(PCU) of our hospital for severe anemia(Hemoglobin 6.5 g/d L) associated to episodes of melena and abdominal pain. In the past 5 mo the patient referred to the local hospital 3 times for episodes of melena(hemoglobin levels showed anemia 9.8 g/d L) but the main gastroenterological exams were completely negative(colonoscopy and gastroscopy). The PCU of our Hospital, after stabilization of the main parameters and blood transfusion for the low levels of hemoglobin, referred the patient to gastroenterologists: the patient was subjected to both colonoscopy and gastroscopy that were negative. Due to the condition of acute severe hemorrhage the patient, during the first 3 h from the access to the PCU, was subjected to arteriography that did not reveal any hemorrhagic foci or vascular alterations. The video capsule for the study of the small bowel showed the presence of blood beginning from the third portion of duodenum but deep gastroscopy did not reveal it. The patient was then subjected to double balloon endoscopy that revealed a severe diverticulosis of the small bowel with blood from the diverticula. The entero-tomografia computerizzata confirmed the diagnosis and revealed an extension of the diverticula for almost the entire small bowel(no diverticula in the colon). The patient was subjected to wide spectrum antibiotic therapy with resolution of the symptoms and stabilization of hemoglobin levels. The surgeon suggests no indication to surgery for the wide area involved from the disease and potential high risk of complication due to the high BMI. At home, the patient started a monthly therapy with rifaximin and probiotics associated to mesalazine. At present, after 12 mo from the last episode of hemorrhage, the patient is in good clinical condition, reduced his body weight of about 7 kg and the hemoglobin levels appear in slow progressive increase(last measurement 13.2 g/d L).展开更多
BACKGROUND The current guidelines suggest that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The us...BACKGROUND The current guidelines suggest that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The usefulness of routine endoscopic evaluation of CT proven diverticulitis remains unknown. AIM To establish whether routine colonoscopy should be offered to patients after an episode of diverticulitis. METHODS We performed a retrospective study, comparing two groups: a diverticulitis group and a control group. The diverticulitis group consisted of patients undergoing a colonoscopy after an episode of diverticulitis. The control group consisted of asymptomatic patients undergoing a screening sigmoidoscopy. We also performed a systematic review and meta-analysis. We searched electronic data resources to identify all relevant studies. The primary outcome was the number of adenomas found, while the secondary outcomes were the number of cancers and polyps identified, and the adenoma risk. RESULTS 68 and 1309 patients were included in the diverticulitis and control groups respectively. There was no difference in the risk of adenomas (5.9% vs 7.6%, P =0.59), non-advanced adenomas (5.9% vs 6.9%, P = 0.75), advanced adenomas (0% vs 0.8%, P = 1), cancer (0% vs 0.15%, P = 1.00), and polyps (16.2% vs 14.2%, P = 0.65) between both groups. Meta-analysis of data from 4 retrospective observational studies, enrolling 4459 patients, showed no difference between the groups in terms of risk of adenomas (RD =-0.05, 95%CI:-0.11, 0.01, P = 0.10), non-advanced adenomas (RD =-0.02, 95%CI:-0.08, 0.04, P = 0.44), advanced adenomas (RD =-0.01, 95%CI:-0.04, 0.02, P = 0.36), cancer (RD = 0.01, 95%CI:- 0.01, 0.03, P = 0.32), and polyps (RD =-0.05, 95%CI:-0.12, 0.02, P = 0.18). CONCLUSION Routine colonoscopy may not be appropriate in patients with acute diverticulitis. High quality prospective studies are required for more robust conclusions.展开更多
AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surg...AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography-confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20(study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30(control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline(ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements(passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay.RESULTS: Patients characteristics and inflammatoryparameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2(mean CRP 6.0 +/- 4.2 mg/d L and 10.0 +/- 6.7 mg/d L respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1(P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3(P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake(median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay(median 5 d and 5.5 d, study group vs controls respectively, P = 0.03).CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.展开更多
AIM To assess risk factors of hospital admission for acute colonic diverticulitis.METHODS The study was conducted as part of the second wave of the population-based North Trondelag Health Study(HUNT2), performed in No...AIM To assess risk factors of hospital admission for acute colonic diverticulitis.METHODS The study was conducted as part of the second wave of the population-based North Trondelag Health Study(HUNT2), performed in North Trondelag County, Norway, 1995 to 1997. The study consisted of 42570 participants(65.1% from HUNT2) who were followed up from 1998 to 2012. Of these, 22436(52.7%) were females. The cases were defined as those 358 participants admitted with acute colonic diverticulitis during follow-up. The remaining participants were used as controls. Univariable and multivariable Cox regression analyses was used for each sex separately after multiple imputation to calculate HR.RESULTS Multivariable Cox regression analyses showed that increasing age increased the risk of admission for acute colonic diverticulitis: Comparing with ages < 50 years, females with age 50-70 years had HR = 3.42, P < 0.001 and age > 70 years, HR = 6.19, P < 0.001. In males the corresponding values were HR = 1.85, P = 0.004 and 2.56, P < 0.001. In patients with obesity(body mass index ≥ 30) the HR = 2.06, P < 0.001 in females and HR = 2.58, P < 0.001 in males. In females, present(HR = 2.11, P < 0.001) or previous(HR = 1.65, P = 0.007) cigarette smoking increased the risk of admission. In males, breathlessness(HR = 2.57, P < 0.001) and living in rural areas(HR = 1.74, P = 0.007) increased the risk. Level of education, physical activity, constipation and type of bread eaten showed no association with admission for acute colonic diverticulitis.CONCLUSION The risk of hospital admission for acute colonic diverticulitis increased with increasing age, in obese individuals, in ever cigarette smoking females and in males living in rural areas.展开更多
Diverticular disease incidence is increasing up to 65% by age 85 in industrialized nations,low fiber diets,and in younger and obese patients.Twenty-five percent of patients with diverticulosis will develop acute diver...Diverticular disease incidence is increasing up to 65% by age 85 in industrialized nations,low fiber diets,and in younger and obese patients.Twenty-five percent of patients with diverticulosis will develop acute diverticulitis.This imposes a significant burden on healthcare systems,resulting in greater than 300000 admissions per year with an estimated annual cost of $3 billion USD.Abdominal computed tomography(CT) is the diagnostic study of choice,with a sensitivity and specificity greater than 95%.Unfortunately,similar CT findings can be present in colonic neoplasia,especially when perforated or inflamed.This prompted professional societies such as the American Society of Colon Rectal Surgeons to recommend patients undergo routine colonoscopy after an episode of acute diverticulitis to rule out malignancy.Yet,the data supporting routine colonoscopy after acute diverticulitis is sparse and based small cohort studies utilizing outdated technology.While any patient with an indication for a colonoscopy should undergo appropriate endoscopic evaluation,in the era of widespread use of high-resolution computed tomography,routine colonic endoscopic evaluation following resolution of acute uncomplicated diverticulitis poses additional costs,comes with inherent risks,and may require further study.In this manuscript,we review the current data related to this recommendation.展开更多
AIM:To investigate the comorbid disease could be the predictors for the elective colectomy in colonic diverticulitis.METHODS:A retrospective chart review of 246 patients with colonic diverticulitis admitted between 20...AIM:To investigate the comorbid disease could be the predictors for the elective colectomy in colonic diverticulitis.METHODS:A retrospective chart review of 246 patients with colonic diverticulitis admitted between 2000and 2008 was conducted,and 19 patients received emergent operation were identified and analyzed.Data were collected with regard to age,sex,albumin level on admission,left or right inflammation site,the history of recurrent diverticulitis,preoperative comorbidity,smoking habits,medication,treatment policy,morbidity,and mortality.Preoperative comorbid diseases included cardiovascular disease,diabetes,pulmonary disease,peptic ulcer disease,gouty arthritis,and uremia.Medications in use included non-steroidal anti-inflammatory drugs,acetylsalicylic acid(Aspirin),and corticosteroids.Univariate and multivariate logistic regression analyses were performed to identify the relevant risk factors correlating to colectomy.RESULTS:The mean age of the 246 patients was 69.5years(range,24-94 years).Most diverticulitis could be managed with conservative treatment(n=227,92.3%),and urgent colectomy was performed in 19patients(7.7%).There were three deaths in the surgical group and four deaths in the nonsurgical group.The overall mortality rate in the study was 1.7%among patients with conservative treatment and 15.7%among patients undergoing urgent colectomy.Multiple logistic regression analysis indicated that comorbidities were risk factors for urgent colectomy for diverticulitis.CONCLUSION:To avoid high mortality and morbidity related to urgent colectomy,we suggest that patients with colonic diverticulitis and comorbid diseases may require elective colectomy.展开更多
Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potent...Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potential emergency. However, most emergency surgery happens during the initial presentation. After recovery from an episode, much of the subsequent management of diverticulitis occurs in the outpatient setting, rendering inpatient "episode counting" a poor measure of the severity or burden of disease. Evidence also suggests that the risk of recurrence of diverticulitis is small and similar with or without an operation. Accordingly, contemporary evaluations of the epidemiologic patterns of treatments for diverticulitis have failed to demonstrate that the substantial rise in elective surgery over the last few decades has been successful at preventing emergency surgery at a population level. Multiple professional societies are calling to "individualize" decisions for elective colectomy and there is an international focus on "appropriate" indications for surgery. The rethinking of elective colectomy should come from a patient-centered approach that considers the risks of recurrence, quality of life, patient wishes and experiences about surgical and medical treatment options as well as operative morbidity and risks.展开更多
Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon.It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits.There has ...Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon.It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits.There has been a growing evolution in our understanding and the treatment guidelines for this disease.To provide an updated review of the epidemiology,pathogenesis,classification and highlight changes in the medical and surgical management of diverticulitis.Diverticulitis is increasingly being seen in young patients(<50 years).Genetic contributions to diverticulitis may be larger than previously thought.Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist.Computed tomography imaging represents the standard to classify the severity of diverticulitis.Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis.Non-operative management is primarily based on antibiotics and supportive measures,but antibiotics may be omitted in mild cases.Interval colonoscopy remains advisable after an acute attack,particularly after a complicated form.Acute surgery is needed for the most severe as well as refractory cases,whereas elective resections are individualized and should be considered for chronic,smoldering,or recurrent forms and respective complications(stricture,fistula,etc.)and for patients with factors highly predictive of recurrent attacks.Diverticulitis is no longer a disease of the elderly.Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease.Non-surgical management remains the appropriate treatment for greater than 70%of patients.In individuals with non-relenting,persistent,or recurrent symptoms and those with complicated disease and sequelae,a segmental colectomy remains the most effective surgical treatment in the acute,chronic,or elective-prophylactic setting.展开更多
BACKGROUND Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to q...BACKGROUND Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited. AIM To determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model. METHODS We performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.RESULTS In the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011);median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001);median leukocyte counts were 12600 and 11500/mm3, respectively (P = 0.002);and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) were significantly high in nausea/vomiting (OR: 3.89, 95%CI: 2.04-7.42) and anorexia (OR: 2.13, 95%CI: 1.06-4.28). ORs were significantly lower with a longer onset-to-visit interval (OR: 0.84, 95%CI: 0.72- 0.97), RLQ pain (OR: 0.28, 95%CI: 0.11-0.71), history of diverticulitis (OR: 0.034, 95%CI: 0.005-0.20), and CRP level > 3.0 mg/dL (OR: 0.25, 95%CI: 0.14-0.43). The regression model showed good calibration, discrimination, and optimism. CONCLUSION Clinical findings can differentiate AA and ARCD before imaging studies;nausea/vomiting and anorexia suggest AA, and longer onset-to-visit interval, RLQ pain, previous diverticulitis, and CRP level > 3.0 mg/dL suggest ARCD.展开更多
Although well recognized for tubo-ovarian abscesses, we report, in our best knowledge, the first case of a vaginal drain of a pelvic abscess due to colonic diverticulitis. A 78-year-old patient presented with abdomina...Although well recognized for tubo-ovarian abscesses, we report, in our best knowledge, the first case of a vaginal drain of a pelvic abscess due to colonic diverticulitis. A 78-year-old patient presented with abdominal and pelvic pain, fever(39.3 ℃) and an elevated white blood cell count(18500/mL). After abdominopelvic computed tomography the patient was presumed to have a pelvic abscess, which developed as a complication of the sigmoid diverticulitis. Due to the numerous intervening structures that create obstacles to safe percutaneous access, we planned a trans-vaginal drain. A rapid recovery was obtained within 2 d from the procedure and, at present, the follow-up was uneventful after 18 mo. We believe that transvaginal drain of pelvic abscess could be a useful alternative, when percutaneous approach is not feasible.展开更多
Laparoscopic lavage and drainage is a novel approach for managing patients with Hinchey Ⅲ diverticulitis. However, this less invasive technique has important limitations, which are highlighted in this systematic revi...Laparoscopic lavage and drainage is a novel approach for managing patients with Hinchey Ⅲ diverticulitis. However, this less invasive technique has important limitations, which are highlighted in this systematic review. We performed a Pub Med search and identified 6 individual series reporting the results of this procedure. An analysis was performed regarding treatment-related morbidity, success rates, and subsequent elective sigmoid resection. Data was available for 287 patients only, of which 213(74%) were actually presenting with Hinchey Ⅲ diverticulitis. Reported success rate in this group was 94%, with 3% mortality. Causes of failure were:(1) ongoing sepsis;(2) fecal fistula formation; and(3) perforated sigmoid cancer. Although few patients developed recurrent diverticulitis in follow-up, 106 patients(37%) eventually underwent elective sigmoid resection. Our data indicate that laparoscopic lavage and drainage may benefit a highly selected group of Hinchey Ⅲ patients. It is unclear whether laparoscopic lavage and drainage should be considered a curative procedure or just a damage control operation. Failure to identify patients with either:(1) feculent peritonitis(Hinchey Ⅳ);(2) persistent perforation; or(3) perforated sigmoid cancer, are causes of concern, and will limit the application of this technique.展开更多
Rationale: Necrotizing fasciitis is an aggressive infection of subcutaneous tissues, which tends to spread rapidly through the fascial planes. Colonic diverticulosis is a common disease in advanced age, although it ra...Rationale: Necrotizing fasciitis is an aggressive infection of subcutaneous tissues, which tends to spread rapidly through the fascial planes. Colonic diverticulosis is a common disease in advanced age, although it rarely causes a lethal necrotizing soft-tissue infection. Patient concerns: A 58-year-old woman complained of left leg pain for 15 d without abdominal pain. Diagnosis: Diverticulitis perforation presented as necrotizing fasciitis of the left thigh. Interventions: Extensive debridement. Outcomes: The patient died due to sepsis-induced multiple organ failure and severe metabolic acidosis. Lessons: Clinicians should be aware of presentations of diverticulitis in patients who have a soft-tissue infection in lower extremity even though patients may not have had a history of diverticulosis or abdominal pain.展开更多
文摘Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations.Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis.Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended.Rather,a more individualized approach,taking into account frequency,severity of the attacks and their impact on quality of life,should guide the indication for surgery.On the other hand,complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation.Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis.There is not sufficient evidence supporting any changes in the approach to management in younger patients.Conversely,the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.
基金The study was reviewed and approved by the Helsinki Committee of Shamir Medical Center(0107-20-ASF).
文摘BACKGROUND Abnormal colonic pressure profiles have been associated with an increased risk of colonic diverticulosis.A surgical history is a known risk factor for abdominal adhesions and these may lead to increased intraluminal colonic pressure.AIM To assess whether previous abdominal surgery is associated with colonic divertic-ulosis or diverticulitis.METHODS We analyzed data from a study of patients undergoing colonoscopy for different indications from 2020 through 2021.Patients completed a structured question-naire concerning previous abdominal surgeries,dietary and lifestyle exposures including smoking,alcohol use and co-morbidities.RESULTS Three hundred and fifty-nine patients were included in the study.The mean age was 67.6 and 46%were females.Diabetes mellitus,hypertension,ischemic heart disease,chronic obstructive pulmonary disease,chronic renal failure,and body mass index were similar in the diverticulosis and control groups.The overall prevalence of colonic diverticulosis was 25%(91/359)and 48%of the patients had previous abdominal surgery.As expected,the prevalence of diverticulosis increased with age.There was no difference in the rate of previous abdominal surgery between patients with or without diverticulosis(49%vs 47%,P=0.78).In regards to specific surgeries,inguinal hernia repair was significantly associated with diverticulosis(52%vs 20%,P=0.001),but not diverticulitis.In contrast,appendectomy was not associated with diverticulosis(6%vs 14%,P=0.048).CONCLUSION These findings suggest that post-operative abdominal adhesions inducing high colonic intraluminal pressures do not appear to be the mechanism for diverticula formation.Rather,inguinal hernia and diverticulosis may share similar connective tissue pathologies with no causative relationship between them.
文摘BACKGROUND Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound(EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization.CASE SUMMARY A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography(CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey Ⅱ diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient’s general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection.CONCLUSION We report the first successful management of a pelvic abscess in patient with Hinchey Ⅱ acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.
文摘The disease burden of diverticulitis is high across inpatient and outpatient settings,and the prevalence of diverticulitis has increased.Historically,patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes.Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed,and many clinical practice guidelines(CPGs)have pivoted to recommend outpatient management and individualized decisions about surgery.Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States,suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease.In this review,we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.
文摘BACKGROUND Although the treatment guidelines for left sided diverticulitis are clear,the management of right colonic diverticulitis is not well established.This disease can no longer be ignored due to significant spread throughout Asia.AIM To analyse epidemiology,diagnosis and treatment of right-sided diverticulitis in western countries.METHODS MEDLINE and PubMed searches were performed using the key words "rightsided diverticulitis","right colon diverticulitis","caecal diverticulitis","ascending colon diverticulitis" and "caecum diverticula" in order to find relevant articles published until 2021.RESULTS A total of 18 studies with 422 patients were found.Correct diagnosis was made only in 32.2%,mostly intraoperatively or via CT scan.The main reason for misdiagnosis was a suspected acute appendicitis(56.8%).The treatment was a nonoperative management(NOM)in 184 patients(43.6%)and surgical in 238 patients(56.4%),seven of which after NOM failure.Recurrence rate was low(5.45%),similar to eastern studies and inferior to left-sided diverticulitis.Recurrent patients were successfully conservatively retreated in most cases.CONCLUSION The management of right-sided diverticulitis is not well clarified in the western world and no selective guidelines have been considered even if principles are similar to those with left-sided diverticulitis.Wrong diagnosis is one of the most important problems and CT scan seems to be the best imaging modality.NOM offers a safe and effective treatment;surgery should be considered only in cases of complicated diverticulitis or if malignancy cannot be excluded.Further studies are needed to clarify the correct treatment.
文摘AIM:To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis.METHODS:We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography(CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis(PEA) or left acute colonic diverticulitis(ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics,laboratory findings,treatments,and clinical results of left PEA with those of left ACD.RESULTS:Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD,respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant(82.1%). On CT examination,most(89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD,the patients presented with a more diffuse abdominal tenderness throughout the left side(52.0%vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA(40.0% vs 7.1%,P = 0.004; 52.0% vs14.3%,P = 0.003,respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD(52.0% vs 15.4%,P = 0.006).CONCLUSION:If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities,clinicians should suspect the diagnosis of PEA and consider a CT scan.
文摘AIM:To compare the recurrence rate following initial antibiotic management to that following laparoscopic treatment for suspected uncomplicated cecal diverticulitis. METHODS: We examined the records of 132 patients who were diagnosed with uncomplicated cecal diverticulitis and a first attack during an 8-year period. The diagnosis of uncomplicated diverticulitis was made based on imaging findings, such as inflamed diverticulum or a phlegmon with cecal wall thickening. Concurrent appendiceal dilatation from 8 to 12 mm was observed in 36 patients (27%). One hundred and two patients were treated initially with antibiotics only, whereas 30 underwent laparoscopic treatment, including partial cecectomy (n=8) or appendectomy with diverticulectomy (n=9) or appendectomy alone (n =13). We compared clinical outcomes in both groups over a median follow-up period of 46 mo. RESULTS: All patients were successfully treated with initial therapy. Of the 102 patients who initially received only antibiotic treatment, 6 (6%) had a recurrence (3 in the cecum and 3 in the ascending colon or transverse colon) during the follow-up period. Five of these pa-tients were managed with repeated antibiotic treatmentand 1 underwent ileocolic resection for perforation. Of the 30 patients treated by the laparoscopic approach, 2 (7%) had a recurrence (ascending colon) which was treated with antibiotics. CONCLUSION: Initial antibiotic management for suspected uncomplicated cecal diverticulitis showed comparable effi cacy to laparoscopic treatment in the prevention of recurrence.
文摘AIM: To study the clinical features and computed tomography(CT) findings of appendiceal diverticulitis vs acute appendicitis.METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendectomy inour in stitution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis.RESULTS: Among 451 patients, 44(9.7%) were diagnosed to have appendiceal diverticulitis and 398(86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older(59 vs 37 years, P < 0.001) and had a longer duration of the illness(4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher(68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients(52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix(84% vs 12%, P < 0.001), absence of appendicolith(92% vs 52%, P = 0.005), and formation of abscess(68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients(24%).CONCLUSION: Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis.
文摘The current case report is related to a male patient with diabetes, obesity [body mass index(BMI) 33], hypertension and recurrence of anemia associated to melena and deep asthenia. M.P., a 60-year-old obese individual, was referred to our department by the primary care unit(PCU) of our hospital for severe anemia(Hemoglobin 6.5 g/d L) associated to episodes of melena and abdominal pain. In the past 5 mo the patient referred to the local hospital 3 times for episodes of melena(hemoglobin levels showed anemia 9.8 g/d L) but the main gastroenterological exams were completely negative(colonoscopy and gastroscopy). The PCU of our Hospital, after stabilization of the main parameters and blood transfusion for the low levels of hemoglobin, referred the patient to gastroenterologists: the patient was subjected to both colonoscopy and gastroscopy that were negative. Due to the condition of acute severe hemorrhage the patient, during the first 3 h from the access to the PCU, was subjected to arteriography that did not reveal any hemorrhagic foci or vascular alterations. The video capsule for the study of the small bowel showed the presence of blood beginning from the third portion of duodenum but deep gastroscopy did not reveal it. The patient was then subjected to double balloon endoscopy that revealed a severe diverticulosis of the small bowel with blood from the diverticula. The entero-tomografia computerizzata confirmed the diagnosis and revealed an extension of the diverticula for almost the entire small bowel(no diverticula in the colon). The patient was subjected to wide spectrum antibiotic therapy with resolution of the symptoms and stabilization of hemoglobin levels. The surgeon suggests no indication to surgery for the wide area involved from the disease and potential high risk of complication due to the high BMI. At home, the patient started a monthly therapy with rifaximin and probiotics associated to mesalazine. At present, after 12 mo from the last episode of hemorrhage, the patient is in good clinical condition, reduced his body weight of about 7 kg and the hemoglobin levels appear in slow progressive increase(last measurement 13.2 g/d L).
文摘BACKGROUND The current guidelines suggest that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The usefulness of routine endoscopic evaluation of CT proven diverticulitis remains unknown. AIM To establish whether routine colonoscopy should be offered to patients after an episode of diverticulitis. METHODS We performed a retrospective study, comparing two groups: a diverticulitis group and a control group. The diverticulitis group consisted of patients undergoing a colonoscopy after an episode of diverticulitis. The control group consisted of asymptomatic patients undergoing a screening sigmoidoscopy. We also performed a systematic review and meta-analysis. We searched electronic data resources to identify all relevant studies. The primary outcome was the number of adenomas found, while the secondary outcomes were the number of cancers and polyps identified, and the adenoma risk. RESULTS 68 and 1309 patients were included in the diverticulitis and control groups respectively. There was no difference in the risk of adenomas (5.9% vs 7.6%, P =0.59), non-advanced adenomas (5.9% vs 6.9%, P = 0.75), advanced adenomas (0% vs 0.8%, P = 1), cancer (0% vs 0.15%, P = 1.00), and polyps (16.2% vs 14.2%, P = 0.65) between both groups. Meta-analysis of data from 4 retrospective observational studies, enrolling 4459 patients, showed no difference between the groups in terms of risk of adenomas (RD =-0.05, 95%CI:-0.11, 0.01, P = 0.10), non-advanced adenomas (RD =-0.02, 95%CI:-0.08, 0.04, P = 0.44), advanced adenomas (RD =-0.01, 95%CI:-0.04, 0.02, P = 0.36), cancer (RD = 0.01, 95%CI:- 0.01, 0.03, P = 0.32), and polyps (RD =-0.05, 95%CI:-0.12, 0.02, P = 0.18). CONCLUSION Routine colonoscopy may not be appropriate in patients with acute diverticulitis. High quality prospective studies are required for more robust conclusions.
文摘AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography-confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20(study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30(control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline(ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements(passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay.RESULTS: Patients characteristics and inflammatoryparameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2(mean CRP 6.0 +/- 4.2 mg/d L and 10.0 +/- 6.7 mg/d L respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1(P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3(P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake(median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay(median 5 d and 5.5 d, study group vs controls respectively, P = 0.03).CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.
基金Supported by Institute of Cancer Research and Molecular Medicine,The Medical Faculty,Norwegian University of Science and Technology,Trondheim,Norwaythe Department of Research,Levanger Hospital,Levanger
文摘AIM To assess risk factors of hospital admission for acute colonic diverticulitis.METHODS The study was conducted as part of the second wave of the population-based North Trondelag Health Study(HUNT2), performed in North Trondelag County, Norway, 1995 to 1997. The study consisted of 42570 participants(65.1% from HUNT2) who were followed up from 1998 to 2012. Of these, 22436(52.7%) were females. The cases were defined as those 358 participants admitted with acute colonic diverticulitis during follow-up. The remaining participants were used as controls. Univariable and multivariable Cox regression analyses was used for each sex separately after multiple imputation to calculate HR.RESULTS Multivariable Cox regression analyses showed that increasing age increased the risk of admission for acute colonic diverticulitis: Comparing with ages < 50 years, females with age 50-70 years had HR = 3.42, P < 0.001 and age > 70 years, HR = 6.19, P < 0.001. In males the corresponding values were HR = 1.85, P = 0.004 and 2.56, P < 0.001. In patients with obesity(body mass index ≥ 30) the HR = 2.06, P < 0.001 in females and HR = 2.58, P < 0.001 in males. In females, present(HR = 2.11, P < 0.001) or previous(HR = 1.65, P = 0.007) cigarette smoking increased the risk of admission. In males, breathlessness(HR = 2.57, P < 0.001) and living in rural areas(HR = 1.74, P = 0.007) increased the risk. Level of education, physical activity, constipation and type of bread eaten showed no association with admission for acute colonic diverticulitis.CONCLUSION The risk of hospital admission for acute colonic diverticulitis increased with increasing age, in obese individuals, in ever cigarette smoking females and in males living in rural areas.
文摘Diverticular disease incidence is increasing up to 65% by age 85 in industrialized nations,low fiber diets,and in younger and obese patients.Twenty-five percent of patients with diverticulosis will develop acute diverticulitis.This imposes a significant burden on healthcare systems,resulting in greater than 300000 admissions per year with an estimated annual cost of $3 billion USD.Abdominal computed tomography(CT) is the diagnostic study of choice,with a sensitivity and specificity greater than 95%.Unfortunately,similar CT findings can be present in colonic neoplasia,especially when perforated or inflamed.This prompted professional societies such as the American Society of Colon Rectal Surgeons to recommend patients undergo routine colonoscopy after an episode of acute diverticulitis to rule out malignancy.Yet,the data supporting routine colonoscopy after acute diverticulitis is sparse and based small cohort studies utilizing outdated technology.While any patient with an indication for a colonoscopy should undergo appropriate endoscopic evaluation,in the era of widespread use of high-resolution computed tomography,routine colonic endoscopic evaluation following resolution of acute uncomplicated diverticulitis poses additional costs,comes with inherent risks,and may require further study.In this manuscript,we review the current data related to this recommendation.
文摘AIM:To investigate the comorbid disease could be the predictors for the elective colectomy in colonic diverticulitis.METHODS:A retrospective chart review of 246 patients with colonic diverticulitis admitted between 2000and 2008 was conducted,and 19 patients received emergent operation were identified and analyzed.Data were collected with regard to age,sex,albumin level on admission,left or right inflammation site,the history of recurrent diverticulitis,preoperative comorbidity,smoking habits,medication,treatment policy,morbidity,and mortality.Preoperative comorbid diseases included cardiovascular disease,diabetes,pulmonary disease,peptic ulcer disease,gouty arthritis,and uremia.Medications in use included non-steroidal anti-inflammatory drugs,acetylsalicylic acid(Aspirin),and corticosteroids.Univariate and multivariate logistic regression analyses were performed to identify the relevant risk factors correlating to colectomy.RESULTS:The mean age of the 246 patients was 69.5years(range,24-94 years).Most diverticulitis could be managed with conservative treatment(n=227,92.3%),and urgent colectomy was performed in 19patients(7.7%).There were three deaths in the surgical group and four deaths in the nonsurgical group.The overall mortality rate in the study was 1.7%among patients with conservative treatment and 15.7%among patients undergoing urgent colectomy.Multiple logistic regression analysis indicated that comorbidities were risk factors for urgent colectomy for diverticulitis.CONCLUSION:To avoid high mortality and morbidity related to urgent colectomy,we suggest that patients with colonic diverticulitis and comorbid diseases may require elective colectomy.
基金Supported by Grants from Agency for Healthcare Research and Quality under award No. HS20025a training grant funded by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award No. T32DK070555
文摘Diverticulitis is one of the leading indications for elective colon resection. Surgeons are trained to offer elective operations after a few episodes of diverticulitis in order to prevent future recurrences and potential emergency. However, most emergency surgery happens during the initial presentation. After recovery from an episode, much of the subsequent management of diverticulitis occurs in the outpatient setting, rendering inpatient "episode counting" a poor measure of the severity or burden of disease. Evidence also suggests that the risk of recurrence of diverticulitis is small and similar with or without an operation. Accordingly, contemporary evaluations of the epidemiologic patterns of treatments for diverticulitis have failed to demonstrate that the substantial rise in elective surgery over the last few decades has been successful at preventing emergency surgery at a population level. Multiple professional societies are calling to "individualize" decisions for elective colectomy and there is an international focus on "appropriate" indications for surgery. The rethinking of elective colectomy should come from a patient-centered approach that considers the risks of recurrence, quality of life, patient wishes and experiences about surgical and medical treatment options as well as operative morbidity and risks.
文摘Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon.It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits.There has been a growing evolution in our understanding and the treatment guidelines for this disease.To provide an updated review of the epidemiology,pathogenesis,classification and highlight changes in the medical and surgical management of diverticulitis.Diverticulitis is increasingly being seen in young patients(<50 years).Genetic contributions to diverticulitis may be larger than previously thought.Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist.Computed tomography imaging represents the standard to classify the severity of diverticulitis.Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis.Non-operative management is primarily based on antibiotics and supportive measures,but antibiotics may be omitted in mild cases.Interval colonoscopy remains advisable after an acute attack,particularly after a complicated form.Acute surgery is needed for the most severe as well as refractory cases,whereas elective resections are individualized and should be considered for chronic,smoldering,or recurrent forms and respective complications(stricture,fistula,etc.)and for patients with factors highly predictive of recurrent attacks.Diverticulitis is no longer a disease of the elderly.Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease.Non-surgical management remains the appropriate treatment for greater than 70%of patients.In individuals with non-relenting,persistent,or recurrent symptoms and those with complicated disease and sequelae,a segmental colectomy remains the most effective surgical treatment in the acute,chronic,or elective-prophylactic setting.
文摘BACKGROUND Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited. AIM To determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model. METHODS We performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.RESULTS In the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011);median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001);median leukocyte counts were 12600 and 11500/mm3, respectively (P = 0.002);and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) were significantly high in nausea/vomiting (OR: 3.89, 95%CI: 2.04-7.42) and anorexia (OR: 2.13, 95%CI: 1.06-4.28). ORs were significantly lower with a longer onset-to-visit interval (OR: 0.84, 95%CI: 0.72- 0.97), RLQ pain (OR: 0.28, 95%CI: 0.11-0.71), history of diverticulitis (OR: 0.034, 95%CI: 0.005-0.20), and CRP level > 3.0 mg/dL (OR: 0.25, 95%CI: 0.14-0.43). The regression model showed good calibration, discrimination, and optimism. CONCLUSION Clinical findings can differentiate AA and ARCD before imaging studies;nausea/vomiting and anorexia suggest AA, and longer onset-to-visit interval, RLQ pain, previous diverticulitis, and CRP level > 3.0 mg/dL suggest ARCD.
文摘Although well recognized for tubo-ovarian abscesses, we report, in our best knowledge, the first case of a vaginal drain of a pelvic abscess due to colonic diverticulitis. A 78-year-old patient presented with abdominal and pelvic pain, fever(39.3 ℃) and an elevated white blood cell count(18500/mL). After abdominopelvic computed tomography the patient was presumed to have a pelvic abscess, which developed as a complication of the sigmoid diverticulitis. Due to the numerous intervening structures that create obstacles to safe percutaneous access, we planned a trans-vaginal drain. A rapid recovery was obtained within 2 d from the procedure and, at present, the follow-up was uneventful after 18 mo. We believe that transvaginal drain of pelvic abscess could be a useful alternative, when percutaneous approach is not feasible.
文摘Laparoscopic lavage and drainage is a novel approach for managing patients with Hinchey Ⅲ diverticulitis. However, this less invasive technique has important limitations, which are highlighted in this systematic review. We performed a Pub Med search and identified 6 individual series reporting the results of this procedure. An analysis was performed regarding treatment-related morbidity, success rates, and subsequent elective sigmoid resection. Data was available for 287 patients only, of which 213(74%) were actually presenting with Hinchey Ⅲ diverticulitis. Reported success rate in this group was 94%, with 3% mortality. Causes of failure were:(1) ongoing sepsis;(2) fecal fistula formation; and(3) perforated sigmoid cancer. Although few patients developed recurrent diverticulitis in follow-up, 106 patients(37%) eventually underwent elective sigmoid resection. Our data indicate that laparoscopic lavage and drainage may benefit a highly selected group of Hinchey Ⅲ patients. It is unclear whether laparoscopic lavage and drainage should be considered a curative procedure or just a damage control operation. Failure to identify patients with either:(1) feculent peritonitis(Hinchey Ⅳ);(2) persistent perforation; or(3) perforated sigmoid cancer, are causes of concern, and will limit the application of this technique.
文摘Rationale: Necrotizing fasciitis is an aggressive infection of subcutaneous tissues, which tends to spread rapidly through the fascial planes. Colonic diverticulosis is a common disease in advanced age, although it rarely causes a lethal necrotizing soft-tissue infection. Patient concerns: A 58-year-old woman complained of left leg pain for 15 d without abdominal pain. Diagnosis: Diverticulitis perforation presented as necrotizing fasciitis of the left thigh. Interventions: Extensive debridement. Outcomes: The patient died due to sepsis-induced multiple organ failure and severe metabolic acidosis. Lessons: Clinicians should be aware of presentations of diverticulitis in patients who have a soft-tissue infection in lower extremity even though patients may not have had a history of diverticulosis or abdominal pain.
