United States Guidelines for Diverticulitis Treatment

Recurrence of Uncomplicated Diverticulitis: A Meta-Analysis

Background and objective: This study aimed to investigate the estimated rate and risk of recurrence of uncomplicated diverticulitis (UCD) after the first episode through a meta-analysis. Methods: Eligible studies were searched and reviewed; 27 studies were included in this study. Subgroup analyses were performed, based on lesion location, medical treatment, follow-up period, and study location. Results: The estimated recurrence rate of UCD was 0.129 (95% confidence interval [CI] 0.102–0.162). The recurrence rates of the right-and left-sided colon were 0.092 (95% CI 27.063–0.133) and 0.153 (95% CI 0.104–0.218), respectively. The recurrence rate according to follow-up period was highest in the subgroup 1–2 years, compared with that of other subgroups. The recurrence rate of the Asian subgroup was significantly lower than that of the non-Asian subgroup (0.092, 95% CI 0.064–0.132 vs. 0.147, 95% CI 0.110–0.192; p = 0.043 in the meta-regression test). There were significant correlations between UCD recurrence and older age and higher body temperature. However, UCD recurrence was not significantly correlated with medications, such as antibiotics or anti-inflammatory drugs. Conclusions: In this study, detailed information on estimated recurrence rates of UCD was obtained. In addition, older age and higher body temperature may be risk factors for UCD recurrence after the first episode.

Predictive model estimating the decrease of postoperative gastrointestinal quality of life index (GIQLI) in patients after elective laparoscopic sigmoid resection for diverticular disease

Background

Growing consideration in quality of life (QoL) has changed the therapeutic strategy in patients suffering from diverticular disease. Patients’ well-being plays a crucial role in the decision-making process. However, there is a paucity of studies investigating patients’ or surgery-related factors influencing the postoperative gastrointestinal function. The aim of this study was to investigate in a predictive model patients or surgical variables that allow better estimation of the postoperative gastrointestinal QoL.

Methods

This observational study retrospectively analyzed patients undergoing elective laparoscopic sigmoidectomy for diverticulitis between 2004 and 2017. The one-time postoperative QoL was assessed with the gastrointestinal quality of life index (GIQLI) in 2019. A linear regression model with stepwise selection has been applied to all patients and surgery-related variables.

Results

Two hundred seventy-two patients with a mean age of 62.30 ± 9.74 years showed a mean GIQLI of 116.39±18.25 at a mean follow-up time of 90.4±33.65 months. Women (n=168) reported a lower GIQLI compared to male (n=104; 112.85±18.79 vs 122.11±15.81, p<0.001). Patients with pre-operative cardiovascular disease (n=17) had a worse GIQLI (106.65 ±22.58 vs 117.08±17.66, p=0.010). Finally, patients operated less than 5 years ago (n=63) showed a worse GIQLI compared to patients operated more than 5 years ago (n=209; 111.98±19.65 vs 117.71±17.63, p=0.014).

Conclusions

Female gender and the presence of pre-operative cardiovascular disease are predictive for a decreased postoperative gastrointestinal QoL. Furthermore, patients’ estimation of gastrointestinal functioning seems to improve up to 5 years after surgery.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02186-w.

Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis

BACKGROUND

The aim of this study was to assess the long-term results in patients with uncomplicated diverticulitis who had participated in the Antibiotics in Acute Uncomplicated Diverticulitis (AVOD) RCT, which randomized patients with CT-verified left-sided acute uncomplicated diverticulitis to management without or with antibiotics.

METHODS

The medical records of patients who had participated in the AVOD trial were reviewed for long-term results such as recurrences, complications and surgery. Quality-of-life questionnaires (EQ-5D™) were sent to patients, who were also contacted by telephone. Descriptive statistics were used for the analysis of clinical outcomes.

RESULTS

A total of 556 of the 623 patients (89·2 per cent) were followed up for a median of 11 years. There were no differences between the no-antibiotic and antibiotic group in recurrences (both 31·3 per cent; P = 0·986), complications (4·4 versus 5·0 per cent; P = 0·737), surgery for diverticulitis (6·2 versus 7·1 per cent; P = 0·719) or colorectal cancer (0·4 versus 2·1 per cent; P = 0·061). The response rate for the EQ-5D™ was 52·8 versus 45·2 per cent respectively (P = 0·030), and no differences were found between the two groups in any of the measured dimensions.

CONCLUSION

Antibiotic avoidance for uncomplicated diverticulitis is safe in the long term.

The management of diverticulitis: a review of the guidelines

Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis. CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred. Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management. Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis. For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively. For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; larger abscesses of 3-5 cm should be drained percutaneously. Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery. Surgical intervention with either Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy, is indicated for peritonitis or in failure of non-operative management. Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria.

Non-operative management of perforated diverticulitis with extraluminal or free air - a retrospective single center cohort study

OBJECTIVES

The aim of this study was to describe patient characteristics and results of non-operative management for patients presenting with computed tomography (CT) verified perforated diverticulitis with extraluminal or free air.

METHODS

All patients treated for diverticulitis (ICD-10: K-57) during 2010-2014 were identified and medical records were reviewed. Re-evaluations of CT examinations for all patients with complicated disease according to medical records were performed. All patients diagnosed with perforated diverticulitis and extraluminal or free air on re-evaluation were included and characteristics of patients having immediate surgery and those whom non-operative management was attempted are described.

RESULTS

Of 141 patients with perforated diverticulitis according to medical records, 136 were confirmed on CT re-evaluation. Emergency surgical intervention within 24 h of admission was performed in 29 (21%) patients. Non-operative management with iv antibiotics was attempted for 107 patients and was successful in 101 (94%). The 30-day mortality rate was 2%. The presence of a simultaneous abscess was higher for patients with failure of non-operative management compared with those that were successfully managed non-operatively (67% compared to 17%, p = .013). Eleven out of thirty-two patients (34%) with free air were successfully managed conservatively. Patients that were operated within 24 h from admission were more commonly on immunosuppressive therapy, had more commonly free intraperitoneal air and free fluid in the peritoneal cavity.

CONCLUSIONS

Non-operative management is successful in the majority of patients with CT-verified perforated diverticulitis with extraluminal air, and also in one-third of those with free air in the peritoneal cavity.

Outpatient management of acute uncomplicated diverticulitis results in health-care cost savings

PURPOSE

Outpatient management without antibiotics has been shown to be safe for selected patients diagnosed with acute uncomplicated diverticulitis (AUD). The aim of this study was to evaluate the impact on admissions, complication rates and health-care costs of the policy of outpatient treatment without using antibiotics.

METHODS

The medical records of all patients diagnosed with AUD in the year before (2011) and after (2014) the implementation of outpatient management without antibiotics in Västmanland County were reviewed. Health-care cost analysis was performed using the Swedish cost-per-patient model.

RESULTS

In total, 494 episodes of AUD were identified, 254 in 2011 and 240 in 2014. The proportion of patients managed as outpatients was 20% in 2011 compared with 60% in 2014 (p < .001). There were 203 hospital admissions and a total length of stay of 677 days in 2011 compared with 95 admissions and 344 days in 2014 (both p < .001). The total health-care cost was €558,679 in 2011 compared with €370,370 in 2014 (p < .001). Three patients developed complications in 2011 and four in 2014 (p = .469).

CONCLUSIONS

The new policy of outpatient management without antibiotics in routine health care almost halved the total health-care cost without an increase in the complication rate.

Antibiotics versus no antibiotics in the treatment of acute uncomplicated diverticulitis - a systematic review and meta-analysis

BACKGROUND

Acute uncomplicated diverticulitis (AUD) is common and antibiotics are the cornerstone of traditional conservative management. This approach lacks clear evidence base and studies have recently suggested that avoidance of antibiotics is a safe and efficacious way to manage AUD. The aim of this systematic review is to determine the safety and efficacy of treating AUD without antibiotics.

METHODS

A systematic search of Embase, Cochrane library, MEDLINE, Science Citation Index Expanded, and ClinicalTrials. gov was performed. Studies comparing antibiotics versus no antibiotics in the treatment of AUD were included. Meta-analysis was performed using the random effects model with the primary outcome measure being diverticulitis-associated complications. Secondary outcomes were readmission rate, diverticulitis recurrence, mean hospital stay, requirement for surgery and requirement for percutaneous drainage.

RESULTS

Eight studies were included involving 2469 patients; 1626 in the non-antibiotic group (NAb) and 843 in the antibiotic group (Ab). There was a higher complication rate in the Ab group however this was not significant (1.9% versus 2.6%) with a combined risk ratio (RR) of 0.63 (95% CI, 0.25 to 1.57, p=0.32). There was a shorter mean length of hospital stay in the Nab group (standard mean difference of -1.18 (95% CI, -2.34 to -0.03 p= 0.04). There was no significant difference in readmission, recurrence and surgical intervention rate or requirement for percutaneous drainage.

CONCLUSION

Treatment of AUD without antibiotics may be feasible with outcomes that are comparable to antibiotic treatment and with potential benefits for patients and the NHS. Large scale randomised multicentre studies are needed. This article is protected by copyright. All rights reserved.

A systematic review and meta-analysis of outpatient treatment for acute diverticulitis

BACKGROUND

The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.

PURPOSE

Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.

METHODS

PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.

RESULTS

A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I² 48%). Only 0.2% (2/1288) of patients underwent emergency surgery, and 0.2% (2/1082) of patients underwent percutaneous abscess drainage. Only two studies compared readmission rates outpatients that had similar characteristics as a control group of inpatients; 4.5% (3/66) and 6.3% (2/32) readmissions in outpatient groups versus 6.1% (4/66) and 0.0% (0/44) readmissions in inpatient groups (p = 0.619 and p = 0.174, respectively). Average healthcare cost savings for outpatient compared with inpatient treatment ranged between 42 and 82%.

CONCLUSION

Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.