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Schena CA, Covino M, Laterza V, Quero G, La Greca A, Cina C, de'Angelis N, Marchegiani F, Sganga G, Gasbarrini A, Franceschi F, Longo F, Alfieri S, Rosa F. The role of procalcitonin as a risk stratification tool of severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis. Surgery 2024; 176:162-171. [PMID: 38594101 DOI: 10.1016/j.surg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Imaging-based classifications do not always reflect the clinical severity and prognosis of acute left-sided colonic diverticulitis. This study aims to investigate the role of an early procalcitonin assessment in the emergency department as a risk stratification tool for severity, prognosis, and need for surgery in patients with acute left-sided colonic diverticulitis. METHODS In this retrospective cohort study, all adult patients consecutively admitted from January 2015 to September 2020 for acute left-sided colonic diverticulitis and having a procalcitonin determination at admission were enrolled. The following data were collected: age, sex, comorbidities, laboratory parameters, level of urgency, clinical presentation, type of treatment, complications, and post-management outcomes. The association between the procalcitonin value at admission and the following endpoints was analyzed: type of treatment, classification of acute left-sided colonic diverticulitis, mortality, and type of surgery. RESULTS A total of 503 consecutive patients were enrolled. Procalcitonin >0.5 ng/mL emerged as an independent risk factor for complicated acute left-sided colonic diverticulitis (P = .007). Procalcitonin >0.5 ng/mL (P = .033), together with a history of complicated acute left-sided colonic diverticulitis (P < .001), abdominal pain (P = .04), bowel perforation (P < .001), and peritonitis (P < .001), was a significant risk factor for surgery. Procalcitonin >0.5 ng/mL (P = .007) and peritonitis (P = .03) emerged as independent risk factors for sigmoidectomy without colorectal anastomosis. Procalcitonin >0.5 ng/mL (P = .004), a higher level of urgency at admission (P = .005), Hartmann's procedure (P = .002), and the necessity of mechanical ventilation (P = .004) emerged as independent risk factors for mortality. CONCLUSION Procalcitonin >0.05 ng/mL at emergency department admission is a useful risk stratification tool for severity, prognosis, and need for surgical treatment in patients with acute left-sided colonic diverticulitis.
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Affiliation(s)
- Carlo Alberto Schena
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marcello Covino
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Vito Laterza
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, France.
| | - Giuseppe Quero
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio La Greca
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Caterina Cina
- Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Gabriele Sganga
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Francesco Franceschi
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Fabio Longo
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Sergio Alfieri
- Department of Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fausto Rosa
- School of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Emergency and Trauma Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
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Carmona Agúndez M, Gallarín Salamanca IM, Salas Martínez J. Free perforation during the first episode of acute diverticulitis: can it be avoided? Updates Surg 2024; 76:521-528. [PMID: 38168842 DOI: 10.1007/s13304-023-01743-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
The aims of the present study are to compare the severity of acute diverticulitis in the first episode and in later bouts, and to determine whether there are risk factors for the presence of free perforation at the onset of diverticulitis. A single-center retrospective study was conducted of patients who developed a first episode of acute diverticulitis between January 2011 and August 2021 diagnosed by computed tomography and followed up for at least 1 year. Free perforation was considered to be present in patients with diverticulitis stage III and IV according to the Hinchey classification (modified by Wasvary). The analysis included 394 patients (224 men and 170 women) with a mean age of 58 years. Forty-eight patients (12.2%) presented free perforation at some point in the course of the disease, 43 during the first episode and 5 during subsequent bouts. The perforation subgroup showed higher rates of stoma creation and mortality (relative risks of 12.3 and 23.5, respectively). In the multivariate analysis, age (OR: 1.041 95% CI 1.016-1.067), lung disease (OR 2.154 95% CI 1.038-4.472) and immunosuppression (OR: 2.812 95% CI 1.315-6.015) were independent factors for free perforation at diverticulitis onset. Free perforation occurs more frequently during the first episode of acute diverticulitis. Older patients, immunosuppressed patients and those with respiratory disease have a greater risk of presenting freely perforated diverticulitis. Therefore, it is essential to maintain a high level of clinical suspicion in these patients to activate early focus control and thus avoid fatal outcomes.
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Affiliation(s)
- María Carmona Agúndez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Badajoz, Badajoz, Spain.
| | | | - Jesús Salas Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Badajoz, Badajoz, Spain
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Chang CY, Hsu TY, He GY, Shih HM, Wu SH, Huang FW, Chen PC, Tsai WC. Utility of monocyte distribution width in the differential diagnosis between simple and complicated diverticulitis: a retrospective cohort study. BMC Gastroenterol 2023; 23:96. [PMID: 36977993 PMCID: PMC10047462 DOI: 10.1186/s12876-023-02736-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis. METHODS This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher's exact test. The Mann-Whitney U test was used for continuous variables. Multivariable regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases. RESULTS Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that the left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784-0.956); CRP, 0.800 (95% CI, 0.707-0.892); NLR, 0.724 (95% CI, 0.616-0.832); PLR, 0.662 (95% CI, 0.525-0.798); and WBC, 0.679 (95% CI, 0.563-0.795). When the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively. CONCLUSIONS A large MDW was a significant and independent predictor of complicated diverticulitis. The optimal cutoff value for MDW is 20.38 as it exhibits maximum sensitivity and specificity for distinguishing between simple and complicated diverticulitis The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.
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Affiliation(s)
- Chang-Yuan Chang
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Tai-Yi Hsu
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Guan-Yi He
- Department of Dermatology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hong-Mo Shih
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Shih-Hao Wu
- College of Medicine, China Medical University, Taichung, Taiwan
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Exercise Health Science, National Taiwan University of Sport, Taichung, Taiwan
| | - Fen-Wei Huang
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Pei-Chun Chen
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, No. 100, Sec. 1, Jingmao Rd., Beitun Dist., Taichung City, 406040, Taiwan.
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Biochemical predictors of complicated diverticulitis: A case-control study evaluating white cell count and C-reactive protein in the assessment of acute diverticulitis. JOURNAL OF SURGERY AND MEDICINE 2023. [DOI: 10.28982/josam.7684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background/Aim: Acute diverticulitis represents a common surgical condition and one of the leading gastrointestinal causes of surgical admissions in Western societies. Complicated diverticulitis increases the length of the hospital stay and the risk of requiring surgical intervention. In areas of limited availability or long waiting times for CT scanning, biochemical predictors of complicated diverticulitis might be valuable. In the available literature, there is no consensus on cut-off values of C-reactive protein or the value of a white cell count in the diagnosis of complicated diverticulitis. Additional studies among different populations are required to add to the existing literature to reach a consensus on diagnostic cut-off levels of inflammatory markers to diagnose complicated diverticulitis. The aim of the present study is to evaluate the predictive value of a white cell count and C-reactive protein, and their sensitivity and specificity in differentiating complicated from uncomplicated diverticulitis.
Methods: This case-control study was performed for patients with acute diverticulitis in Lyell McEwin Hospital in Adelaide, South Australia. Data were collected for consecutive patients admitted from January 2015 to December 2017. Patients with acute diverticulitis confirmed by computed tomography were included in the study. Data of patients with complicated diverticulitis were compared to those of patients with uncomplicated diverticulitis as a control group. Patient characteristics, symptoms, number of attacks of diverticulitis, presence of immunosuppression, past history of complicated diverticulitis, inflammatory markers (white cell count and C-reactive protein), and computed tomography findings were collected and compared.
Results: A total of 106 consecutive cases were recruited for the period from 2015 to 2017. There were 44 cases of complicated diverticulitis and 62 cases with uncomplicated diverticulitis (control group). A white cell count (WCC) and C-reactive protein (CRP) were collected at the time of presentation from the clinical records and pathology reports. A receiver operating characteristic (ROC) analysis was performed and multiple cut-off values for both WCC and CRP were reported. For WCC, the area under curve (AUC) was 0.69 (0.582-0.797) with a P-value of 0.001. At a cut-off of 14, sensitivity was found to be 56.8% and specificity of 80.7%. The sensitivity gradually decreased and specificity gradually increased as the cut-off value increased. At 18 the sensitivity was 25% and specificity was 79%. The positive predictive value for the study sample at WCC of 18 × 109/L or above is 79.5%. For CRP, the AUC was 0.828 (0.729-0.927) with a P-value of <0.001. At a cut-off value of 100 mg/L, the sensitivity was 72.7% and specificity was 80.6%. Sensitivity gradually decreased and specificity increased as the cut-off increased in value. At 160 mg/L, sensitivity was 36.36% and specificity was 97.22% with a positive predictive value of 76%.
Conclusion: Contrary to what has been previously reported in the literature, we found that WCC remains a significant test in diagnosing complicated diverticulitis. A high cut-off value of 18 × 109/L is useful in predicting complicated diverticulitis with high positive predictive value. When compared to WCC, CRP is a more sensitive test in detecting complicated diverticulitis. We recognized a cut-off value of 160 mg/L to be a significant value to rule in complicated diverticulitis with a significant positive predictive value. WCC and CRP are very specific predictors of complicated diverticulitis with high positive predictive value at high cut-off values of 18 × 109/L and 160 mg/L, respectively.
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Zakari FO, Omontese BO. Comparison of axillary and inguinal temperature with rectal temperature in dogs at a veterinary teaching hospital. J Small Anim Pract 2023; 64:330-336. [PMID: 36747342 DOI: 10.1111/jsap.13589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 10/22/2022] [Accepted: 12/15/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The objective of the study was to determine the agreement between rectal, axillary and inguinal temperatures and to estimate the accuracy of these measurements in detecting hyperthermia and hypothermia in dogs presented at a veterinary teaching hospital in the tropical Guinea Savannah zone. MATERIALS AND METHODS Prospectively, body temperature was measured in 610 dogs, using digital thermometry in the axillary, inguinal and rectal regions. RESULTS Overall, axillary and inguinal temperatures significantly underestimated rectal temperature, with a mean difference of -0.39 ± 0.02°C (95% confidence interval: -0.43 to -0.35; limit of agreement: -1.27 to 0.49) and - 0.34 ± 0.02°C (95% confidence interval, -0.37 to -0.30; limit of agreement: -1.15 to 0.47), respectively. The limits of agreement of axillary and inguinal temperatures were wide and above the pre-determined maximal acceptable difference of ±0.50°C recommended for clinical significance of rectal temperature in dogs. Bland-Altman plots showed that the confidence intervals of the mean differences of axillary and inguinal temperatures did not include the value zero, thereby indicating that the tested methods lack agreement with rectal temperature. Sensitivity and specificity for the detection of hyperthermia with axillary temperature were 72.1% and 30.5%, respectively. In contrast, sensitivity and specificity for the detection of hyperthermia with inguinal temperature were 77.9% and 26.2%, respectively. The magnitude of disagreement between axillary, inguinal and rectal temperatures was affected by age, breed and sex being slightly lower in mature, non-native breed and female dogs. CLINICAL SIGNIFICANCE Axillary and inguinal temperature measurements in dogs significantly underestimated rectal temperature measurements by -0.39 ± 0.02°C and -0.34 ± 0.02°C, respectively. The results indicate that axillary and inguinal temperatures should not be used as a replacement for rectal temperature due to the wide limits of agreement. In addition, axillary and inguinal temperatures may not be suitable in detecting hyperthermia because the sensitivity were lower than the required set-point of 90.0% for clinical identification of hyperthermia.
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Affiliation(s)
- F O Zakari
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Jos, Jos, Nigeria.,Winfred Thomas Agricultural Research Station, Alabama A & M University, Normal, AL, 35762, USA
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Muacevic A, Adler JR. Evaluation of Clinical Assessment in Predicting Complicated Acute Diverticulitis. Cureus 2023; 15:e34709. [PMID: 36777973 PMCID: PMC9907385 DOI: 10.7759/cureus.34709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
Background Acute diverticulitis is a common surgical condition and one of the leading gastrointestinal conditions that require hospital admission. The presence of complications increases the hospital stay and risk of requiring surgical intervention. This study aimed to investigate the clinical features that can be identified during clinical assessment and evaluate their predictive value and sensitivity in differentiating between complicated and uncomplicated diverticulitis. Methodology This retrospective case-control study was performed on patients with acute diverticulitis at Lyell McEwin Hospital, Adelaide, South Australia. Data were collected for patients presenting from January 2015 to December 2017. Patients with acute diverticulitis confirmed by computed tomography (CT) were included in the study. Multiple clinical assessment aspects were reported and compared between complicated diverticulitis and uncomplicated diverticulitis groups. Results Data from a total of 116 cases were collected, 10 of which were excluded due to lack of CT diagnosis. Forty-four cases had complicated diverticulitis (case group), and 62 cases had uncomplicated diverticulitis (control group). Twenty-three cases (52.2%) had the first episode of diverticulitis in the complicated group compared to 24 cases (38.7%) in the uncomplicated group, with an odds ratio of 1.73 (0.79-3.789). Eight cases (18.2%) had previously complicated diverticulitis in the complicated group compared to 11 cases (17.7%) in the uncomplicated group, with an odds ratio of 1.03 (0.37-2.82). Six cases (13.6%) had a fever (T > 38) in the complicated group compared to two cases (3.2%) in the uncomplicated group, with an odds ratio of 4.74 (0.9-24.7), a sensitivity of only 13.64%, and a specificity of 96.77%. Twelve cases (27.3%) had tachycardia, two cases (4.5%) had hypotension, and five cases (11.4%) had peritonism in the complicated group compared to two cases (3.2%), one case (1.6%), and one case (1.6%) in the uncomplicated group, with odds ratios of 11.25 (2.37-53.4), 2.9 (0.255-33), and 7.82 (0.88-69.5), respectively; sensitivity was 27.27%, 4.55%, and 11.36% for tachycardia, hypotension, and peritonism, whereas specificity was 96.77%, 98.39%, and 98.39%, respectively. Conclusions The study found no significant correlation between having complicated diverticulitis and previous episodes of complicated diverticulitis, immunosuppression, pain severity, or change in bowel habits. Perrectal bleeding was found to reduce the risk of having complicated diverticulitis. Our results did not demonstrate a statistically significant relationship between the first episode of diverticulitis and having complicated diverticulitis. Physical signs, when abnormal, are highly specific in predicting complicated diverticulitis. Tachycardia was found to have the highest positive predictive value and odds ratio compared to the other observed physical signs.
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Chen Y, Bai Y, Wang X, Zhang H, Zheng H, Gu N. Plasmonic/magnetic nanoarchitectures: From controllable design to biosensing and bioelectronic interfaces. Biosens Bioelectron 2023; 219:114744. [PMID: 36327555 DOI: 10.1016/j.bios.2022.114744] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 02/08/2023]
Abstract
Controllable design of the nanocrystal-assembled plasmonic/magnetic nanoarchitectures (P/MNAs) inspires abundant methodologies to enhance light-matter interactions and control magnetic-induced effects by means of fine-tuning the morphology and ordered packing of noble metallic or magnetic building blocks. The burgeoning development of multifunctional nanoarchitectures has opened up broad range of interdisciplinary applications including biosensing, in vitro diagnostic devices, point-of-care (POC) platforms, and soft bioelectronics. By taking advantage of their customizability and efficient conjugation with capping biomolecules, various nanoarchitectures have been integrated into high-performance biosensors with remarkable sensitivity and versatility, enabling key features that combined multiplexed detection, ease-of-use and miniaturization. In this review, we provide an overview of the representative developments of nanoarchitectures that being built by plasmonic and magnetic nanoparticles over recent decades. The design principles and key mechanisms for signal amplification and quantitative sensitivity have been explored. We highlight the structure-function programmability and prospects of addressing the main limitations for conventional biosensing strategies in terms of accurate selectivity, sensitivity, throughput, and optoelectronic integration. State-of-the-art strategies to achieve affordable and field-deployable POC devices for early multiplexed detection of infectious diseases such as COVID-19 has been covered in this review. Finally, we discuss the urgent yet challenging issues in nanoarchitectures design and related biosensing application, such as large-scale fabrication and integration with portable devices, and provide perspectives and suggestions on developing smart biosensors that connecting the materials science and biomedical engineering for personal health monitoring.
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Affiliation(s)
- Yi Chen
- State Key Laboratory of Bioelectronics, Jiangsu Key Laboratory for Biomaterials and Devices, School of Biological Science and Medical Engineering, Southeast University, Nanjing, 210096, China; Southeast University-Monash University Joint Research Institute, Suzhou, 215123, China.
| | - Yu Bai
- State Key Laboratory of Bioelectronics, Jiangsu Key Laboratory for Biomaterials and Devices, School of Biological Science and Medical Engineering, Southeast University, Nanjing, 210096, China; Southeast University-Monash University Joint Research Institute, Suzhou, 215123, China
| | - Xi Wang
- State Key Laboratory of Bioelectronics, Jiangsu Key Laboratory for Biomaterials and Devices, School of Biological Science and Medical Engineering, Southeast University, Nanjing, 210096, China; Southeast University-Monash University Joint Research Institute, Suzhou, 215123, China
| | - Heng Zhang
- State Key Laboratory of Bioelectronics, Jiangsu Key Laboratory for Biomaterials and Devices, School of Biological Science and Medical Engineering, Southeast University, Nanjing, 210096, China; Southeast University-Monash University Joint Research Institute, Suzhou, 215123, China
| | - Haoran Zheng
- State Key Laboratory of Bioelectronics, Jiangsu Key Laboratory for Biomaterials and Devices, School of Biological Science and Medical Engineering, Southeast University, Nanjing, 210096, China; Southeast University-Monash University Joint Research Institute, Suzhou, 215123, China
| | - Ning Gu
- State Key Laboratory of Bioelectronics, Jiangsu Key Laboratory for Biomaterials and Devices, School of Biological Science and Medical Engineering, Southeast University, Nanjing, 210096, China; Southeast University-Monash University Joint Research Institute, Suzhou, 215123, China.
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Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: Value of current severity classification schemes. RADIOLOGIA 2023; 65:32-42. [PMID: 36842784 DOI: 10.1016/j.rxeng.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/28/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The current management of acute diverticulitis of the left colon (ADLC) requires tests with high prognostic value. This paper analyzes the usefulness of ultrasonography (US) in the initial diagnosis of ADLC and the validity of current classifications schemes for ADLC. PATIENTS This retrospective observational study included patients with ADLC scheduled to undergo US or computed tomography (CT) following a clinical algorithm. According to the imaging findings, ADLC was classified as mild, locally complicated, or complicated. We analyzed the efficacy of US in the initial diagnosis and the reasons why CT was used as the first-line technique. We compared the findings with published classifications schemes for ADLC. RESULTS A total of 311 patients were diagnosed with acute diverticulitis; 183 had ADLC, classified at imaging as mild in 104, locally complicated in 60, and complicated in 19. The diagnosis was reached by US alone in 98 patients, by CT alone in 77, and by combined US and CT in 8. The main reasons for using CT as the first-line technique were the radiologist's lack of experience in abdominal US and the unavailability of a radiologists on call. Six patients diagnosed by US were reexamined by CT, but the classification changed in only three. None of the published classification schemes included all the imaging findings. CONCLUSIONS US should be the first-line imaging technique in patients with suspected ADLC. Various laboratory and imaging findings are useful in establishing the prognosis of ADLC. New schemes to classify the severity of ADLC are necessary to ensure optimal clinical decision making.
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Imam A, Steiner E, Imam R, Omari L, Lin G, Khalayleh H, Pines G. Identifying patients with complicated diverticulitis, is it that complicated? Turk J Surg 2022; 38:169-174. [PMID: 36483174 PMCID: PMC9714650 DOI: 10.47717/turkjsurg.2022.5426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Discriminating simple from complicated diverticulitis solely on clinical bases is challenging. The aim of this study was to identify clinical predictive factor for the need for invasive treatment for patients presenting with acute diverticulitis in the emergency room. MATERIAL AND METHODS The records of all patients, who were discharged from a university hospital between January 2010 and March 2018 with "diverticulitis" diagnosis, were reviewed. Data collected included clinical features, whether this was a first or recurrent episode, WBC, and Hinchey score. Patients were divided into conservative and invasive treatment groups. Groups were compared by age, sex, BMI, fever, WBC and CT findings. Hinchey score groups were also compared by age, sex, BMI, fever, WBC. RESULTS A total of 809 patients were included. Mean age was 60.6 years, with 10% below 40 years. Most patients were treated conservatively (95.9%) while only 4.1% were treated invasively. WBC at presentation was significantly higher in those who required invasive treatment in comparison with the conservative group (13.72 vs. 11.46K/uL, p= 0.024). A statistically significant higher WBC was found among patients with a higher Hinchey score (13.16 vs 11.69, p <0.005). No difference between the groups was found in terms of age, sex, fever or BMI. CONCLUSION This study showed that patients who present with acute diverticulitis and an elevated WBC are prone to a more severe disease and a higher Hinchey score. Prudence should be taken with these patients, and CT scan is warranted as there is a greater chance that invasive treatment will be required.
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Affiliation(s)
- Ashraf Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Israel
| | - Elad Steiner
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Riham Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Israel
| | - Loai Omari
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Lin
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Harbi Khalayleh
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine Hebrew University of Jerusalem, Rehovot, Israel
| | - Guy Pines
- Department of Thoracic Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Rehovot, Israel
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Ojetti V, Saviano A, Brigida M, Petruzziello C, Caronna M, Gayani G, Franceschi F. Randomized control trial on the efficacy of Limosilactobacillus reuteri ATCC PTA 4659 in reducing inflammatory markers in acute uncomplicated diverticulitis. Eur J Gastroenterol Hepatol 2022; 34:496-502. [PMID: 35045564 PMCID: PMC9936969 DOI: 10.1097/meg.0000000000002342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Recent guidelines suggest treating acute uncomplicated diverticulitis (AUD) without antibiotics. We tested the efficacy of Limosilactobacillus reuteri ATCC PTA 4659 in AUD. Primary outcome was the reduction of abdominal pain and inflammatory markers [C-reactive protein (C-RP) and calprotectin]. Secondary outcome was the reduction of hours of hospitalization. PATIENTS AND METHODS A double-blind, randomized controlled trial was conducted in 119 patients with AUD. The probiotic group (61 patients) was treated with fluids, bowel rest and L. reuteri/b.i.d. for 10 days. The placebo group (58 patients) was treated with the same therapy and placebo/b.i.d. for 10 days. All patients completed a daily visual analogue scale (VAS) for abdominal pain. RESULTS Both groups showed a mean VAS score of 7 at enrolment and a reduction of 4 points after 3 days. C-RP value, after 72 h, decreased by 58.8% in the probiotic group and by only 40% in the placebo group (P < 0.05). Calprotectin levels, after 72 h, decreased by 17% in the probiotic group and by only 10.6% in the control group (P < 0.05). In the probiotic group, the hospitalization was done for 75.5 h compared to 83.5 in the placebo group. CONCLUSIONS The supplementation with L. reuteri 4659 together with bowel rest and fluids significantly reduced both blood and faecal inflammatory markers compared to the placebo group.
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Affiliation(s)
- Veronica Ojetti
- Emergency Department – Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma
- Emergency Department – Università Cattolica del Sacro Cuore, Roma
| | - Angela Saviano
- Emergency Department – Università Cattolica del Sacro Cuore, Roma
| | - Mattia Brigida
- Emergency Department – Università Cattolica del Sacro Cuore, Roma
| | | | - Martina Caronna
- Emergency Department – Università Cattolica del Sacro Cuore, Roma
| | | | - Francesco Franceschi
- Emergency Department – Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma
- Emergency Department – Università Cattolica del Sacro Cuore, Roma
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11
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Kobayashi K, Nagata N, Furumoto Y, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Tominaga N, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Kaise M. Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: a large-scale multicenter cohort study. Endoscopy 2022; 54:735-744. [PMID: 34820792 PMCID: PMC9329063 DOI: 10.1055/a-1705-0921] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND : Prior studies have shown the effectiveness of both endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Therefore, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. METHODS : We reviewed data for 1679 patients with CDH who were treated with EBL (n = 638) or clipping (n = 1041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J study). Logistic regression analysis was used to compare outcomes between the two treatments. RESULTS : In multivariate analysis, EBL was independently associated with reduced risk of early rebleeding (adjusted odds ratio [OR] 0.46; P < 0.001) and late rebleeding (adjusted OR 0.62; P < 0.001) compared with clipping. These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant differences were found between the treatments in the rates of initial hemostasis or mortality. Compared with clipping, EBL independently reduced the risk of needing interventional radiology (adjusted OR 0.37; P = 0.006) and prolonged length of hospital stay (adjusted OR 0.35; P < 0.001), but not need for surgery. Diverticulitis developed in one patient (0.16 %) following EBL and two patients (0.19 %) following clipping. Perforation occurred in two patients (0.31 %) following EBL and none following clipping. CONCLUSIONS : Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH, offering the advantages of lower early and late rebleeding rates, reduced need for interventional radiology, and shorter length of hospital stay.
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Affiliation(s)
- Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan,Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yohei Furumoto
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga Medical Center Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan,Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki Japan
| | | | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
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12
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Fugazzola P, Ceresoli M, Coccolini F, Gabrielli F, Puzziello A, Monzani F, Amato B, Sganga G, Sartelli M, Menichetti F, Puglisi GA, Tartaglia D, Carcoforo P, Avenia N, Kluger Y, Paolillo C, Zago M, Leppäniemi A, Tomasoni M, Cobianchi L, Dal Mas F, Improta M, Moore EE, Peitzman AB, Sugrue M, Agnoletti V, Fraga GP, Weber DG, Damaskos D, Abu-Zidan FM, Wani I, Kirkpatrick AW, Pikoulis M, Pararas N, Tan E, Broek RT, Maier RV, Davies RJ, Kashuk J, Shelat VG, Mefire AC, Augustin G, Magnone S, Poiasina E, De Simone B, Chiarugi M, Biffl W, Baiocchi GL, Catena F, Ansaloni L. The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly. World J Emerg Surg 2022; 17:5. [PMID: 35063008 PMCID: PMC8781436 DOI: 10.1186/s13017-022-00408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/27/2021] [Indexed: 02/08/2023] Open
Abstract
Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.
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Affiliation(s)
- Paola Fugazzola
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy.
| | - Marco Ceresoli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Francesco Gabrielli
- General Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alessandro Puzziello
- Department of Surgery and Transplants, AOU San Giovanni di Dio and Ruggi d'Aragona, University of Salerno, Fisciano, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - Francesco Menichetti
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Dario Tartaglia
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Paolo Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Nicola Avenia
- Medical School, General Surgery and Surgical Specialties Unit, S. Maria University Hospital University of Perugia, Terni, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ciro Paolillo
- Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Mauro Zago
- Department of Robotic and Emergency Surgery, Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matteo Tomasoni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Lorenzo Cobianchi
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Lincoln International Business School, University of Lincoln, Lincoln, UK
| | | | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Michael Sugrue
- Donegal Clinical Research Academy, Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | | | - Gustavo P Fraga
- Surgery Department, Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Imtiaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Sringar, Kashmir, India
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attiko Hospital, MSc "Global Health-Disaster Medicine", National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Nikolaos Pararas
- General Surgery, Dr Sulaiman Al Habib/Alfaisal University, Riyadh, Saudi Arabia
| | - Edward Tan
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - R Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Goran Augustin
- Department of Surgery, University Hospital Centre, Zagreb, Croatia
| | - Stefano Magnone
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Elia Poiasina
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Gian Luca Baiocchi
- Department of General Surgery, ASST Cremona, University of Brescia, Cremona, Italy
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luca Ansaloni
- IRCCS Policlinico San Matteo Foundation, General Surgery, Pavia, Italy
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13
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Machine Learning Model for Outcome Prediction of Patients Suffering from Acute Diverticulitis Arriving at the Emergency Department-A Proof of Concept Study. Diagnostics (Basel) 2021; 11:diagnostics11112102. [PMID: 34829448 PMCID: PMC8625306 DOI: 10.3390/diagnostics11112102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 12/23/2022] Open
Abstract
Background & Aims: We aimed at identifying specific emergency department (ED) risk factors for developing complicated acute diverticulitis (AD) and evaluate a machine learning model (ML) for predicting complicated AD. Methods: We analyzed data retrieved from unselected consecutive large bowel AD patients from five hospitals from the Mount Sinai health system, NY. The study time frame was from January 2011 through March 2021. Data were used to train and evaluate a gradient-boosting machine learning model to identify patients with complicated diverticulitis, defined as a need for invasive intervention or in-hospital mortality. The model was trained and evaluated on data from four hospitals and externally validated on held-out data from the fifth hospital. Results: The final cohort included 4997 AD visits. Of them, 129 (2.9%) visits had complicated diverticulitis. Patients with complicated diverticulitis were more likely to be men, black, and arrive by ambulance. Regarding laboratory values, patients with complicated diverticulitis had higher levels of absolute neutrophils (AUC 0.73), higher white blood cells (AUC 0.70), platelet count (AUC 0.68) and lactate (AUC 0.61), and lower levels of albumin (AUC 0.69), chloride (AUC 0.64), and sodium (AUC 0.61). In the external validation cohort, the ML model showed AUC 0.85 (95% CI 0.78–0.91) for predicting complicated diverticulitis. For Youden’s index, the model showed a sensitivity of 88% with a false positive rate of 1:3.6. Conclusions: A ML model trained on clinical measures provides a proof of concept performance in predicting complications in patients presenting to the ED with AD. Clinically, it implies that a ML model may classify low-risk patients to be discharged from the ED for further treatment under an ambulatory setting.
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14
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Lee SGW, Shin SD, Lee HJ, Suh GJ, Park DJ. Development of a prediction model for clinically important outcomes of acute diverticulitis. Am J Emerg Med 2021; 50:27-35. [PMID: 34271232 DOI: 10.1016/j.ajem.2021.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Acute diverticulitis (AD) is a common disease with various outcomes. When AD is diagnosed in the emergency department (ED), the ED clinician must determine the patient's treatment strategy whether the patient can be discharged, needs to be admitted to the general ward, ICU, or needs surgical consultation. This study aimed to identify potential risk factors for clinically important outcomes (CIOs) and to develop a prediction model for CIOs in AD to aid clinical decision making in the ED. METHODS Retrospective data from between 2013 and 2017 in an ED in an urban setting were reviewed for adult AD. Potential risk factors were age, sex, past medical history, symptoms, physical exams, laboratory results, and imaging results. A CIO was defined as a case with one of the following outcomes: hospital death, ICU admission, surgery or invasive intervention, and admission for 7 or more days. The prediction model for CIOs was developed using potential risk factors. Model discrimination and calibration were assessed using the area under the curve (AUC) and 95% confidence intervals (CIs) and the Hosmer-Lemeshow (HL) test, respectively. Model validation was conducted using 500 random bootstrap samples. RESULTS Of the final 337 AD patients, 63 patients had CIOs. Six potential factors (age, abdominal pain (≥ 3 days), anorexia, rebound tenderness, white blood cell count (> 15,000/μl), C-reactive protein (> 10 mg/dL), and CT findings of a complication) were used for the final model. The AUC (95% CI) for CIOs was 0.875 (0.826-0.923), and χ2 was 2.969 (p-value = 0.936) with the HL test. Validation using bootstrap samples resulted in an optimism-corrected AUC of 0.858 (0.856-0.861). CONCLUSION A prediction model for clinically important outcomes of AD visiting a single ED showed good discrimination and calibration power with an acceptable range.
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Affiliation(s)
- Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea.
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| | - Do Joong Park
- Department of Surgery, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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15
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Park YY, Nam S, Han JH, Lee J, Cheong C. Predictive factors for conservative treatment failure of right colonic diverticulitis. Ann Surg Treat Res 2021; 100:347-355. [PMID: 34136431 PMCID: PMC8176199 DOI: 10.4174/astr.2021.100.6.347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/26/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Conservative treatment is the first-line therapy for acute colonic diverticulitis without severe complications, but treatment failure may increase hospitalization duration, medical costs, and morbidities. Usage of the modified Hinchey classification is insufficient to predict the outcome of conservative management. We aimed to investigate the clinical efficacy of the modified Hinchey classification and to evaluate predictive factors such as inflammatory markers for the failure of conservative management. Methods Patients diagnosed with right colonic diverticulitis undergoing conservative treatment at 3 hospitals between 2017 and 2019 were included. Patients were categorized into conservative treatment success (n = 494) or failure (n = 46) groups. Clinical characteristics and blood inflammatory markers were assessed. Results The conservative treatment failure group presented with more elderly patients (>50 years, P = 0.002), more recurrent episodes (P < 0.001), a higher lymphocyte count (P = 0.021), higher C-reactive protein (CRP) levels (P = 0.044), and higher modified Glasgow prognostic scores (P = 0.021). Multivariate analysis revealed that age of >50 years (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.27–5.08; P = 0.008), recurrent episodes (OR, 4.78; 95% CI, 2.38–9.61; P < 0.001), and higher CRP levels (OR, 1.08; 95% CI, 1.03–1.12; P = 0.001) were predictive factors for conservative treatment failure, but not the modified Hinchey grade (P = 0.159). Conclusion Age of >50 years, recurrent episodes, and CRP levels are potential predictors for conservative management failure of patients with right-sided colonic diverticulitis. Further studies are warranted to identify candidates requiring early surgical intervention.
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Affiliation(s)
- Youn Young Park
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soomin Nam
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jeong Hee Han
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Jaeim Lee
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chinock Cheong
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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16
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Abstract
Left sided colonic diverticulitis is a common and costly gastrointestinal disease in Western countries, characterized by acute onset of often severe abdominal pain. Imaging is necessary to make an initial diagnosis and determine disease severity. Colonoscopy should be done six to eight weeks after diagnosis to rule out a missed colon malignancy. Antibiotic treatment is used selectively in immunocompetent patients with mild acute uncomplicated diverticulitis. The clinical course of diverticulitis commonly includes unpredictable recurrences and chronic gastrointestinal symptoms, which are a detriment to quality of life. A better understanding of prognosis has prompted a shift toward non-operative approaches. The decision to undergo prophylactic colon resection should be individualized to consider the severity of diverticulitis, the patient's health and immune status, and the patient's preferences and values, as well as benefits and risks. Because only a section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis with an abscess is treated with antibiotics that cover Gram negative and anaerobic bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent or feculent contamination of the peritoneal cavity is managed with surgery; primary resection and anastomosis is the procedure of choice in stable patients.
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Affiliation(s)
- Anne F Peery
- University of North Carolina School of Medicine, Chapel Hill, NC 27599-7555, USA
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17
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Roson Gradaille N, Narbona Díez A, Garriga Farriol MV, Pruna Comella X, Pedraza Gutiérrez S, López Cano M, Badia JM. Classification of acute diverticulitis in the left colon with ultrasonography and computed tomography: value of current severity classification schemes. RADIOLOGIA 2021:S0033-8338(21)00028-X. [PMID: 33612278 DOI: 10.1016/j.rx.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS The current management of acute diverticulitis of the left colon (ADLC) requires tests with high prognostic value. This paper analyzes the usefulness of ultrasonography (US) in the initial diagnosis of ADLC and the validity of current classifications schemes for ADLC. PATIENTS This retrospective observational study included patients with ADLC scheduled to undergo US or computed tomography (CT) following a clinical algorithm. According to the imaging findings, ADLC was classified as mild, locally complicated, or complicated. We analyzed the efficacy of US in the initial diagnosis and the reasons why CT was used as the first-line technique. We compared the findings with published classifications schemes for ADLC. RESULTS A total of 311 patients were diagnosed with acute diverticulitis; 183 had ADLC, classified at imaging as mild in 104, locally complicated in 60, and complicated in 19. The diagnosis was reached by US alone in 98 patients, by CT alone in 77, and by combined US and CT in 8. The main reasons for using CT as the first-line technique were the radiologist's lack of experience in abdominal US and the unavailability of a radiologists on call. Six patients diagnosed by US were reexamined by CT, but the classification changed in only three. None of the published classification schemes included all the imaging findings. CONCLUSIONS US should be the first-line imaging technique in patients with suspected ADLC. Various laboratory and imaging findings are useful in establishing the prognosis of ADLC. New schemes to classify the severity of ADLC are necessary to ensure optimal clinical decision making.
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Affiliation(s)
- N Roson Gradaille
- Servicio de Diagnóstico por la imagen, Hospital Universitari Vall d'Hebron, Institut de Diagnòstic per la Imatge (IDI), Barcelona, España.
| | - A Narbona Díez
- Servicio de Diagnóstico por la Imagen, Hospital General de Granollers, Granollers, Barcelona, España
| | - M V Garriga Farriol
- Servicio de Diagnóstico por la Imagen, Hospital Universitari Josep Trueta, Institut de Diagnòstic per la Imatge (IDI), Girona, España
| | - X Pruna Comella
- Servicio de Diagnóstico por la Imagen, Hospital General de Granollers, Granollers, Barcelona, España
| | - S Pedraza Gutiérrez
- Servicio de Diagnóstico por la Imagen, Hospital Universitari Josep Trueta, Institut de Diagnòstic per la Imatge (IDI), Girona, España
| | - M López Cano
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - J M Badia
- Servicio de Cirugía General y Aparato Digestivo, Hospital General de Granollers, Granollers, Barcelona, España; Universitat Internacional de Catalunya, Barcelona, España
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Covino M, Papa V, Tursi A, Simeoni B, Lopetuso LR, Vetrone LM, Franceschi F, Rapaccini G, Gasbarrini A, Papa A. Development and Validation of Predictive Assessment of Complicated Diverticulitis Score. J Pers Med 2021; 11:jpm11020080. [PMID: 33572940 PMCID: PMC7911244 DOI: 10.3390/jpm11020080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The prevalence of acute diverticulitis (AD) has progressively increased in recent decades, with correspondingly greater morbidity and mortality. The aim of the study is to develop a predictive score to identify patients with the highest risk of complicated AD. The clinical records of 1089 patients referred to the emergency department (ED) over a five-year period were reviewed. In multivariate analysis, male sex (p < 0.001), constipation (p = 0.002), hemoglobin < 11.9 g/dL (p < 0.001), C reactive protein > 80 mg/L (p < 0.001), severe obesity (p = 0.049), and no proton pump inhibitor treatment (p = 0.003) were independently associated with complicated AD. The predictive assessment of complicated (PACO)-diverticulitis (D) score, including these six variables, was applied to the retrospective cohort and then validated prospectively in a cohort including 282 patients. It categorized patients into three risk classes for complicated AD. The PACO-D score showed fair discrimination for complicated AD with an area under the receiver operating characteristic curve of 0.674 and 0.648, in the retrospective and prospective cohorts, respectively. The PACO-D score could be a practical clinical tool to identify patients at highest risk for complicated AD referred to the ED so that appropriate diagnostic and therapeutic resources could be appropriately allocated. Further external validation is needed to confirm these results.
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Affiliation(s)
- Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Valerio Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, 70031 Andria, Italy;
| | - Benedetta Simeoni
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
| | - Loris Riccardo Lopetuso
- Department of Medicine and Ageing Sciences, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy;
- Center for Advanced Studies and Technology (CAST), G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Lorenzo Maria Vetrone
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (M.C.); (B.S.); (F.F.)
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
| | - Gianludovico Rapaccini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Alfredo Papa
- Facoltà di Medicina e Chirurgia, Università Cattolica del S. Cuore, L.go A. Gemelli 8, 00168 Rome, Italy; (V.P.); (L.M.V.); (G.R.); (A.G.)
- Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-063-0151
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Abstract
Objective
Diverticulosis is extremely common in western society. A recent study has shown that outpatient, nonantibiotic management of acute uncomplicated diverticulitis may be a feasible and safe option. However, the ability to identify these patients is still difficult. This study explores the ability of white cell count, C-reactive protein, and bilirubin in differentiating patients with complicated and uncomplicated diverticulitis, as well as progression to surgical intervention.
Methods
This is a retrospective study of patients admitted with acute diverticulitis over a 5-year period (2009–2014) at a single institution in Australia. Patients were classified into 3 groups; uncomplicated diverticulitis, complicated diverticulitis without surgery, and complicated diverticulitis with surgery. Analysis of variance (ANOVA) and Bonferroni's post hoc analyses were used to compare markers across the groups.
Results
A total of 541 patients met the inclusion criteria for this study. One-way ANOVA showed a significant difference in white cell count (P < 0.0001), C-reactive protein (P < 0.0001), and bilirubin (P = 0.0006) between all 3 groups. Post hoc analyses showed a significant difference in white cell count, C-reactive protein, and bilirubin when comparing uncomplicated diverticulitis against complicated diverticulitis without surgery (P < 0.05) and complicated diverticulitis with surgery (P < 0.05). White cell count also showed a significant difference when comparing complicated diverticulitis without surgery and complicated diverticulitis with surgery (P < 0.05).
Conclusions
White cell count, C-reactive protein, and bilirubin can distinguish between uncomplicated and complicated diverticulitis.
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Ahmadi N, Ravindran P, Kim T, Ayoubi SE, Byrne CM, Young CJ. C-reactive protein trajectory in the first 48 hours predicts the need for intervention in conservative management of acute diverticulitis. ANZ J Surg 2020; 90:2036-2040. [PMID: 32755032 DOI: 10.1111/ans.16176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/27/2020] [Accepted: 07/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND C-reactive protein (CRP) is a useful marker for monitoring response to treatment in sepsis. The aim of this study was to examine the use of CRP trajectory in predicting the need for intervention in conservatively managed patients with acute diverticulitis (AD). METHODS A retrospective review of patients with AD who were managed conservatively was performed. They were divided into four groups based on CRP relative to the median at day 0 and 2: 'Low rise' (levels below median at day 0 and 2), 'High rise' (levels above median at day 0 and 2), 'Rapid rise' (levels below median at day 0 but above median at day 2) and 'Decline' (levels above median at day 0 but below median at day 2). RESULTS Intervention was required in 64 of 456 (14%) with 30 (48%) of these performed after day 2 of admission. There were 150 patients (54%) in the 'Low rise', 76 (27%) in the 'Decline', 26 patients (9%) in the 'Rapid rise' and 25 patients (9%) in the 'High rise' groups. Within these groups 5%, 8%, 19% and 32% of patients required intervention (P = 0.001). On multivariate analysis, patients with a pelvic abscess were more likely to need intervention (odds ratio 19.1 (confidence interval 6.2-59.4), P < 0.0001). CONCLUSION The CRP trajectory during the initial 48 h of admission can predict the need for intervention in AD patients being managed conservatively. Patients with a 'Rapid rise' or 'High rise' in CRP from day 0 to 2 are more likely to need intervention.
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Affiliation(s)
- Nima Ahmadi
- Department of Colorectal Surgery, Discipline of Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Praveen Ravindran
- Department of Colorectal Surgery, Discipline of Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Taejun Kim
- Department of Colorectal Surgery, Discipline of Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Salah E Ayoubi
- Department of Colorectal Surgery, Discipline of Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher M Byrne
- Department of Colorectal Surgery, Discipline of Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Discipline of Surgery, University of Sydney, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Perrone G, Sartelli M, Mario G, Chichom-Mefire A, Labricciosa FM, Abu-Zidan FM, Ansaloni L, Biffl WL, Ceresoli M, Coccolini F, Coimbra R, Demetrashvili Z, Di Saverio S, Fraga GP, Khokha V, Kirkpatrick AW, Kluger Y, Leppaniemi A, Maier RV, Moore EE, Negoi I, Ordonez CA, Sakakushev B, Lohse HAS, Velmahos GC, Wani I, Weber DG, Bonati E, Catena F. Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations. Int J Infect Dis 2020; 99:140-148. [PMID: 32739433 DOI: 10.1016/j.ijid.2020.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.
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Affiliation(s)
- Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | | | - Giuffrida Mario
- Department of General Surgery, Maggiore Hospital, Parma, Italy.
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Francesco Maria Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'i, Honolulu, USA
| | - Marco Ceresoli
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, CA, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Salomone Di Saverio
- Department of General Surgery, University Hospital of Varese, University of Insubria, Varese, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Carlos A Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - George C Velmahos
- Trauma, Emergency Surgery, and Surgical Critical Care Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Elena Bonati
- Department of General Surgery, Maggiore Hospital, Parma, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
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22
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Sartelli M, Weber DG, Kluger Y, Ansaloni L, Coccolini F, Abu-Zidan F, Augustin G, Ben-Ishay O, Biffl WL, Bouliaris K, Catena R, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cortese F, Cui Y, Damaskos D, De' Angelis GL, Delibegovic S, Demetrashvili Z, De Simone B, Di Marzo F, Di Saverio S, Duane TM, Faro MP, Fraga GP, Gkiokas G, Gomes CA, Hardcastle TC, Hecker A, Karamarkovic A, Kashuk J, Khokha V, Kirkpatrick AW, Kok KYY, Inaba K, Isik A, Labricciosa FM, Latifi R, Leppäniemi A, Litvin A, Mazuski JE, Maier RV, Marwah S, McFarlane M, Moore EE, Moore FA, Negoi I, Pagani L, Rasa K, Rubio-Perez I, Sakakushev B, Sato N, Sganga G, Siquini W, Tarasconi A, Tolonen M, Ulrych J, Zachariah SK, Catena F. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020; 15:32. [PMID: 32381121 PMCID: PMC7206757 DOI: 10.1186/s13017-020-00313-4] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023] Open
Abstract
Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.
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Affiliation(s)
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- General Surgery Department, Bufalini Hospital Hospital, Cesena, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Offir Ben-Ishay
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Walter L Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA, USA
| | | | - Rodolfo Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Marco Ceresoli
- Department of General and Emergency Surgery, ASST, San Gerardo Hospital, Monza, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, University of Milano, ASST Niguarda Milano, Milan, Italy
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, CA, USA
| | | | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | | | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Belinda De Simone
- Department of Digestive Surgery, Guastalla Hospital, Reggio Emilia, Italy
| | | | - Salomone Di Saverio
- Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Mario Paulo Faro
- Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP, Brazil
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - George Gkiokas
- Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Timothy C Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenneth Y Y Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Kenji Inaba
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Arda Isik
- Department of General Surgery, Faculty of Medicine, Erzincan University, Erzincan, Turkey
| | | | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Ari Leppäniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Andrey Litvin
- Surgical Disciplines, Immanuel Kant Baltic Federal University/Regional Clinical Hospital, Kaliningrad, Russian Federation
| | - John E Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, USA
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Michael McFarlane
- Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO, USA
| | - Frederick A Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Ines Rubio-Perez
- General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Norio Sato
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Gabriele Sganga
- Emergency Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Walter Siquini
- Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Matti Tolonen
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Jan Ulrych
- First Department of Surgery, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | | | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Abstract
BACKGROUND Diverticulitis is separated into complicated and uncomplicated, based on the patient's presentation at the time of his or her initial attack of acute diverticulitis. OBJECTIVE The aim of this study was to identify risk factors for persistent complex diverticulitis, defined as an abscess, fistula, or stricture, at the time of elective surgery, and to characterize outcomes in this patient population. DESIGN This was a retrospective review of 2010 to 2016 in the American College of Surgeons National Surgical Quality Improvement Project database. SETTINGS Individuals diagnosed with diverticulitis who underwent elective surgery were included. PATIENTS A total of 1502 patients underwent elective surgery for diverticulitis, of which 559 (37%) patients had a surgical indication of persistent complex diverticulitis. INTERVENTIONS We performed logistic regression analysis to identify risk factors for complex diverticulitis and evaluated a new prediction model. MAIN OUTCOME MEASURES The predictive factors of persistent complex diverticulitis for elective colon resection were measured. RESULTS The patients with complex diverticulitis were older (p < 0.001), had worse functional status (p < 0.001), more comorbidities (diabetes mellitus and hypertension), and a higher Charlson Comorbidity Index (2.7 vs 1.6, p < 0.001). They were more likely to have a history of tobacco or alcohol use (p < 0.001) and to be malnourished. Interestingly, patients found to have persistent complex diverticulitis did not have more episodes than patients with uncomplicated cases did (p = 0.67). Surgical time was longer in complex diverticulitis, and the patients were more likely to require diverting stomas and concurrent resections of adjacent structures. The area under the curve from the test set was (0.75; 95% CI, 0.72-0.78), sensitivity and specificity were 0.890 (95% CI, 0.870-0.891) and 0.450 (95% CI, 0.410-0.490). LIMITATIONS The study was limited by its retrospective review and observational bias. CONCLUSIONS Patients undergoing elective surgery for complex diverticulitis did not have more episodes. Instead, complex diverticulitis may be a reflection of a complicated patient, suggesting that complicated patients should have a different algorithm of care at the time of their initial presentation with diverticulitis to prevent the development of complex disease. See Video Abstract at http://links.lww.com/DCR/B183. ¿PODEMOS PREDECIR DIVERTICULITIS QUIRÚRGICAMENTE COMPLEJA EN CASOS ELECTIVOS?: La diverticulitis se divide en complicada y sin complicaciones, según la presentación del paciente en el momento de su ataque inicial de diverticulitis aguda.El objetivo de este estudio fue identificar los factores de riesgo para la diverticulitis compleja persistente, definida como un absceso, fístula o estenosis, en el momento de la cirugía electiva, y caracterizar los resultados en esta población de pacientes.Esta fue una revisión retrospectiva del 2010-2016 en la base de datos del Proyecto de Mejora de la Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Se incluyeron individuos diagnosticados con diverticulitis que se sometieron a cirugía electiva.1502 pacientes fueron sometidos a cirugía electiva por diverticulitis, de los cuales 559 (37%) pacientes tenían una indicación quirúrgica de diverticulitis compleja persistente.Realizamos un análisis de regresión logística para identificar los factores de riesgo de diverticulitis compleja y evaluamos un nuevo modelo de predicción.Se midieron los factores predictivos de diverticulitis compleja persistente para la resección de colon electiva.Los pacientes con diverticulitis compleja eran mayores (p <0,001), tenían un peor estado funcional (p <0,001), más comorbilidades (diabetes e hipertensión) y un índice de comorbilidad de Charlson más alto (2,7 frente a 1,6, p <0,001). Tenían más probabilidades de tener antecedentes de consumo de tabaco o alcohol (p <0.001) y estar desnutridos. Curiosamente, los pacientes con diverticulitis compleja persistente no tuvieron más episodios que los pacientes sin complicaciones (p = 0,67). El tiempo quirúrgico fue más largo en la diverticulitis compleja y era más probable que requirieran estomas para desvio y resecciones concurrentes de estructuras adyacentes. El área bajo la curva de prueba fue (0.75, intervalo de confianza del 95% 0.72-0.78), la sensibilidad y la especificidad fueron 0.890 (intervalo de confianza del 95%; 0.870-0.891) y 0.450 (intervalo de confianza del 95%; 0.410-0.490), respectivamente.El estudio estuvo limitado por su revisión retrospectiva y sesgo observacional.Los pacientes sometidos a cirugía electiva por diverticulitis compleja no tuvieron más episodios. En cambio, la diverticulitis compleja puede ser un reflejo de un paciente complicado, lo que sugiere que los pacientes complicados deben tener un algoritmo de atención diferente al momento de su presentación inicial con diverticulitis para prevenir el desarrollo de una enfermedad compleja. Consulte Video Resumen en http://links.lww.com/DCR/B183. (Traducción-Dr. Yesenia Rojas-Kahlil).
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Diagnostic effectiveness of preoperative water-soluble contrast enema in colorectal perforation. Asian J Surg 2019; 42:696-701. [PMID: 31104697 DOI: 10.1016/j.asjsur.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation. METHODS We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I-II versus those with Hinchey III-IV. RESULTS WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I-II and Hinchey III-IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III-IV, with an odds ratio of greater than 24 (P = 0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III-IV from those with Hinchey I-II were 76.5% and 97.1%, respectively. CONCLUSIONS This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III-IV in patients with colorectal perforation.
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Kechagias A, Sofianidis A, Zografos G, Leandros E, Alexakis N, Dervenis C. Index C-reactive protein predicts increased severity in acute sigmoid diverticulitis. Ther Clin Risk Manag 2018; 14:1847-1853. [PMID: 30323607 PMCID: PMC6174315 DOI: 10.2147/tcrm.s160113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose Conservative management is successful in unperforated (Hinchey Ia) acute diverticulitis (AD) and also generally in local perforation or small abscesses (Hinchey Ib). A higher degree of radiological severity (Hinchey >Ib), ie, a larger abscess (>3-4 cm) or peritonitis, commonly requires percutaneous drainage or surgery. Retrospective studies show that high levels of C-reactive protein (CRP) distinguish Hinchey Ia from all cases of minor and major perforations (Hinchey >Ia). The current study aims to evaluate the usefulness of CRP in distinguishing AD with a higher degree of severity (Hinchey >Ib) from cases that can be treated noninvasively (Hinchey Ia/Ib). Methods Data from consecutive patients with AD were collected prospectively. All underwent computed tomography (CT). Index parameters obtained at the initial evaluation at the emergency unit were analyzed to assess the association with the outcome. The exclusion criteria comprised concomitant conditions that affected CRP baseline levels. Results Ninety-nine patients were analyzed. Eighty-eight had mild radiological grading (Hinchey Ia/Ib), and 11 had severe radiological grading (Hinchey >Ib) (median index CRP 80 mg/L vs 236 mg/L [P<0.001]). White blood cells, neutrophils/lymphocytes, serum creatinine, serum glucose, generalized peritonitis, generalized abdominal tenderness, urinary symptoms, and index CRP were related to severe disease. Index CRP was the only independent predictor for Hinchey >Ib (P=0.038). The optimal cutoff value calculated by receiver operating characteristic curve analysis was found to be 173 mg/L (sensitivity 90.9%, specificity 90.9%, P<0.001). All patients who underwent radiological drainage or surgery had an index CRP >173 mg/L and Hinchey >Ib. Conclusion CRP levels >173 mg/L obtained at the initial evaluation at the emergency unit predict major acute complications in AD. These patients commonly require urgent percutaneous drainage or surgical management.
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Affiliation(s)
- Aristotelis Kechagias
- Department of Surgery, Konstantopouleion Hospital, Athens, Greece, .,Department of Gastrointestinal Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland,
| | | | - Georgios Zografos
- First Department of Propaedeutic Surgery, Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouel Leandros
- First Department of Propaedeutic Surgery, Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicholas Alexakis
- First Department of Propaedeutic Surgery, Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Mora López L, Flores Clotet R, Serra Aracil X, Montes Ortega N, Navarro Soto S. The use of the modified Neff classification in the management of acute diverticulitis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:328-334. [PMID: 28376628 DOI: 10.17235/reed.2017.4738/2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Acute diverticulitis (AD) is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management. OBJECTIVE To determine whether the combined use of the modified Neff radiological classification (mNeff) and clinical criteria (systemic inflammatory response syndrome [SIRS] and comorbidity) can ensure safe management of AD. MATERIAL AND METHODS Prospective descriptive study in a population of patients diagnosed with AD by computerized tomography (CT). The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. RESULTS The study was carried out from February 2010 to February 2016. A total of 590 episodes of AD were considered: 271 women and 319 men, with a median age of 60 years (range: 25-92 years). mNeff grades were as follows: grade 0 (408 patients 70.6%); 376/408 (92%) were considered for home treatment; of these 376 patients, 254 (67.5%) were discharged and controlled by the Home Hospitalization Unit; 33 returned to the Emergency Room for consultation and 22 were re-admitted; the success rate was 91%. Grade Ia (52, 8.9%): 31/52 (59.6%) were considered for outpatient treatment; of these 31 patients, 11 (35.5%) were discharged; eight patients returned to the Emergency Room for consultation and five were re-admitted. Grade Ib (49, 8.5%): five surgery and two drainage. Grade II (30, 5.2%): ten surgery and four drainage. Grade III (5, 0.9%): one surgery and one drainage. Grade IV (34, 5.9%): ten patients showed good evolution with conservative treatment. Of the 34 grade IV patients, 24 (70.6%) underwent surgery, and three (8.8%) received percutaneous drainage. CONCLUSIONS The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD.
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Affiliation(s)
- Laura Mora López
- Servicio de Cirugía General, Hospital Universitari Parc Taulí, ESPAÑA
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Kang HS, Cha YS, Park KH, Hwang SO. Delta neutrophil index as a promising prognostic marker of emergent surgical intervention for acute diverticulitis in the emergency department. PLoS One 2017; 12:e0187629. [PMID: 29091955 PMCID: PMC5665552 DOI: 10.1371/journal.pone.0187629] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/03/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early identification of patients with acute diverticulitis who require emergent surgical intervention in the emergency department (ED) is important to the physician. Although computed tomography (CT) has an important role in evaluating the severity of diverticulitis, its findings alone may not predict the need for emergent surgical intervention in all patients with acute diverticulitis in the ED. Serum inflammation markers may help to differentiate severity of acute diverticulitis and predict the need for surgical intervention in clinical practice. No information is currently available on the clinical usefulness of the delta neutrophil index (DNI), with respect to the prediction of emergent surgical intervention in patients with acute diverticulitis at the ED. METHODS This was a retrospective observational study of consecutive adult patients with acute diverticulitis confirmed by CT in the ED, between January 2014 and December 2016. Recruited patients were divided into two groups: emergent surgical intervention and no surgical intervention. The following laboratory serum parameters were examined in the ED: DNI value, C-reactive protein (CRP) levels, white blood cell count, neutrophil count, and neutrophil-to-lymphocyte ratio (NLR). The patients were also examined for the presence or absence of complications by CT. RESULTS A total of 132 patients were finally included in the study, with the emergent surgical intervention group constituting 52 patients. The median DNI value, CRP levels, neutrophil count, and NLR were significantly higher in the emergent surgical intervention group than in the no surgical intervention group. The area under the curve for predicting emergent surgical intervention, using the DNI was significantly higher than that of CRP levels, neutrophil count, or NLR. Moreover, the combination of initial DNI and CT was most powerful diagnostic modality. CONCLUSIONS DNI values measured at the ED combined with CT were good predictors for emergent surgical intervention in acute diverticulitis. If the DNI value is greater than 0.7% and complications in CT are suspected in patients suspected to have acute diverticulitis, the need for emergent surgical intervention should be considered carefully in the ED.
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Affiliation(s)
- Hee Seung Kang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- * E-mail:
| | - Kyung Hye Park
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Department of Medical Education, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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Bolkenstein HE, van de Wall BJM, Consten ECJ, Broeders IAMJ, Draaisma WA. Risk factors for complicated diverticulitis: systematic review and meta-analysis. Int J Colorectal Dis 2017; 32:1375-1383. [PMID: 28799055 PMCID: PMC5596043 DOI: 10.1007/s00384-017-2872-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this systematic review is to identify risk factors that can predict complicated diverticulitis. Uncomplicated diverticulitis is a self-limiting and mild disease, but 10% of patients with diverticulitis develop complications requiring further treatment. It is important to estimate the risk of developing complicated diverticulitis at an early stage to set the right treatment at initial presentation. METHODS Embase, MEDLINE, and Cochrane databases were searched for studies reporting on risk factors for complicated diverticulitis. Complicated diverticulitis was defined as Hinchey ≥Ib or severe diverticulitis according to the Ambrosetti criteria. Meta-analyses were performed when at least four studies reported on the outcome of interest. This study was conducted according to the PRISMA guidelines. RESULTS A total of 12 studies were included with a total of 4619 patients. Most were of reasonable quality. Only the risk factors "age" and "sex" were eligible for meta-analysis, but none showed a significant effect on the risk for complicated diverticulitis. There was reasonable quality of evidence suggesting that high C-reactive protein; white blood cell count; clinical signs including generalized abdominal pain, constipation and vomiting; steroid usage; a primary episode; and comorbidity are risk factors for complicated diverticulitis. CONCLUSION Although high-level evidence is lacking, this study identified several risk factors associated with complicated diverticulitis. Individually, these risk factors have little value in predicting the course of diverticulitis. The authors propose a prognostic model combining these risk factors which might be the next step to aid the physician in predicting the course of diverticulitis and setting the right treatment at initial presentation.
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Affiliation(s)
- H E Bolkenstein
- Department of Surgery, Meander Medisch Centrum, 3813 TZ, Amersfoort, Netherlands.
| | - B J M van de Wall
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, Netherlands
| | - E C J Consten
- Department of Surgery, Meander Medisch Centrum, 3813 TZ, Amersfoort, Netherlands
| | - I A M J Broeders
- Department of Surgery, Meander Medisch Centrum, 3813 TZ, Amersfoort, Netherlands
| | - W A Draaisma
- Department of Surgery, Meander Medisch Centrum, 3813 TZ, Amersfoort, Netherlands
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Jamal Talabani A, Endreseth BH, Lydersen S, Edna TH. Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis. Int J Colorectal Dis 2017; 32:41-47. [PMID: 27613727 PMCID: PMC5219887 DOI: 10.1007/s00384-016-2644-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The study investigated the capability of clinical findings, temperature, C-reactive protein (CRP), and white blood cell (WBC) count to discern patients with acute colonic diverticulitis from all other patients admitted with acute abdominal pain. METHODS The probability of acute diverticulitis was assessed by the examining doctor, using a scale from 0 (zero probability) to 10 (100 % probability). Receiver operating characteristic (ROC) curves were used to assess the clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain. RESULTS Of 833 patients admitted with acute abdominal pain, 95 had acute colonic diverticulitis. ROC curve analysis gave an area under the ROC curve (AUC) of 0.95 (CI 0.92 to 0.97) for ages <65 years, AUC = 0.86 (CI 0.78 to 0.93) in older patients. Separate analysis showed an AUC = 0.83 (CI 0.80 to 0.86) of CRP alone. White blood cell count and temperature were almost useless to discriminate acute colonic diverticulitis from other types of acute abdominal pain, AUC = 0.59 (CI 0.53 to 0.65) for white blood cell count and AUC = 0.57 (0.50 to 0.63) for temperature, respectively. CONCLUSION This prospective study demonstrates that standard clinical evaluation by non-specialist doctors based on history, physical examination, and initial blood tests on admission provides a high degree of diagnostic precision in patients with acute colonic diverticulitis.
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Affiliation(s)
- A Jamal Talabani
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7602, Levanger, Norway
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - B H Endreseth
- Clinic of Surgery, St Olavs Hospital, University of Trondheim, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - S Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare - Central Norway, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - T-H Edna
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, N-7602, Levanger, Norway.
- Unit for Applied Clinical Research, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
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Kechagias A. Letter to the Editor on the article "Predictors of acute diverticulitis severity: A systematic review". Int J Surg 2016; 28:69-70. [PMID: 26915290 DOI: 10.1016/j.ijsu.2016.02.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Aristotelis Kechagias
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.
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Tan JPL, Barazanchi AWH, Singh PP, Hill AG, Maccormick AD. Predictors of acute diverticulitis severity: A systematic review. Int J Surg 2016; 26:43-52. [PMID: 26777741 DOI: 10.1016/j.ijsu.2016.01.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 12/14/2015] [Accepted: 01/06/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring systems exist for predicting prognosis associated with severe complications of diverticulitis such as peritonitis. However, predicting disease severity has not received as much attention. Therefore, the aim of this review was to identify the factors that are predictive of severe acute diverticulitis. METHODS A systematic literature search was performed using Medline, PubMed, EMBASE, and the Cochrane Library to identify papers that evaluated factors predictive of severe diverticulitis. Severe diverticulitis was defined as complicated diverticulitis (associated with haemorrhage, abscess, phlegmon, perforation, purulent/faecal peritonitis, stricture, fistula, or small-bowel obstruction) or diverticulitis that resulted in prolonged hospital admission, surgical intervention or death. RESULTS Twenty one articles were included. Studies were categorised into those that identified patient characteristics (n = 12), medications (n = 5), biochemical markers (n = 8) or imaging (n = 3) as predictors. Predictors for severe diverticulitis included first episode of diverticulitis, co-morbidities (Charlson score ≥ 3), non-steroidal anti-inflammatory drug use, steroid use, a high CRP on admission and severe disease on radiological imaging. Age and gender were not associated with disease severity. CONCLUSION A number of predictors exist for identifying severe diverticulitis, and CT remains the gold standard for diagnosing complicated disease. Patients who present with identified risk factors for severe disease warrant early imaging, closer in-patient observation and a lower threshold for early surgical intervention. Patients without these factors may be suitable for outpatient-based treatment.
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Affiliation(s)
- James P L Tan
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Ahmed W H Barazanchi
- Department of Surgery, Lower Hutt Hospital, Hutt Valley District Health Board, Lower Hutt, New Zealand.
| | - Primal P Singh
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrew G Hill
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Andrew D Maccormick
- Department of Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
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Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM, Di Saverio S, Ulrych J, Kluger Y, Ben-Ishay O, Moore FA, Ivatury RR, Coimbra R, Peitzman AB, Leppaniemi A, Fraga GP, Maier RV, Chiara O, Kashuk J, Sakakushev B, Weber DG, Latifi R, Biffl W, Bala M, Karamarkovic A, Inaba K, Ordonez CA, Hecker A, Augustin G, Demetrashvili Z, Melo RB, Marwah S, Zachariah SK, Shelat VG, McFarlane M, Rems M, Gomes CA, Faro MP, Júnior GAP, Negoi I, Cui Y, Sato N, Vereczkei A, Bellanova G, Birindelli A, Di Carlo I, Kok KY, Gachabayov M, Gkiokas G, Bouliaris K, Çolak E, Isik A, Rios-Cruz D, Soto R, Moore EE. WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg 2016; 11:37. [PMID: 27478494 PMCID: PMC4966807 DOI: 10.1186/s13017-016-0095-0] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/26/2016] [Indexed: 02/06/2023] Open
Abstract
Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62019 Macerata, Italy
| | - Fausto Catena
- Department of Surgery, Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Ewen A. Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ofir Ben-Ishay
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | - Andrew B. Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca’Granda Hospital, Milan, Italy
| | - Jeffry Kashuk
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | - Dieter G. Weber
- Department of Traumatology, John Hunter Hospital, Newcastle, NSW Australia
| | - Rifat Latifi
- Department of Surgery, Trauma Research Institute, University of Arizona, Tucson, AZ USA
| | - Walter Biffl
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Kenji Inaba
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA USA
| | - Carlos A. Ordonez
- Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Goran Augustin
- Department of Surgery, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Renato Bessa Melo
- Department of General Surgery, Centro Hospitalar São João, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | | | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore, Singapore
| | - Michael McFarlane
- Department of Surgery, Radiology, Anaesthetics and Intensive Care, University Hospital of the West Indies, Kingston, Jamaica
| | - Miran Rems
- Surgical Department, General Hospital Jesenice, Jesenice, Slovenia
| | - Carlos Augusto Gomes
- Federal University of Juiz de Fora (UFJF) AND Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora, MG Brazil
| | - Mario Paulo Faro
- Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Gerson Alves Pereira Júnior
- Emergency Surgery and Trauma Unit, Department of Surgery, University of Ribeirão Preto, Ribeirão Preto, Brazil
| | - Ionut Negoi
- Emergency Hospital of Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Norio Sato
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | | | | | - Isidoro Di Carlo
- Department of Surgical Sciences, Organs Transplantation and Advanced Technologies, “G.F. Ingrassia” University of Catania, Cannizzaro Hospital, Catania, Italy
| | - Kenneth Y Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Mahir Gachabayov
- Department of Surgery, Clinical Hospital of Emergency Medicine, Vladimir City, Russian Federation
| | - Georgios Gkiokas
- 2nd Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Elif Çolak
- Department of Surgery, Samsun Education and Research Hospital, Samsun, Turkey
| | - Arda Isik
- Department of Surgery, Mengucek Gazi Training Research Hospital, Erzincan, Turkey
| | - Daniel Rios-Cruz
- Department of Surgery, Hospital de Alta Especialidad de Veracruz, Veracruz, Mexico
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
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Ambrosetti P. Acute left-sided colonic diverticulitis: clinical expressions, therapeutic insights, and role of computed tomography. Clin Exp Gastroenterol 2016; 9:249-57. [PMID: 27574459 PMCID: PMC4993273 DOI: 10.2147/ceg.s110428] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The diagnostic approach of patients with suspected acute diverticulitis remains debated. On the one hand, a scoring system with the best predictive value in diagnosing acute diverticulitis has been developed in order to reduce the use of computed tomography (CT) scan, while, on the other hand, patients with a high probability of acute diverticulitis should benefit from CT scan from a clinical viewpoint, ensuring that they will receive the most appropriate treatment. The place and classification of CT scan for acute diverticulitis need to be reassessed. If the management of uncomplicated acute diverticulitis, abscess, and fecal peritonitis is now well codified, urgent surgical or medical treatment of hemodynamically stable patients presenting with intraperitoneal air or fluid without uncontrolled sepsis is still under discussion. Furthermore, the indications for laparoscopic lavage are not yet well established. It is known for years that episode(s) of acute uncomplicated diverticulitis may induce painful recurrent bowel symptoms, known as symptomatic uncomplicated diverticular disease and irritable bowel syndrome-like diverticular disease. These two clinical expressions of diverticular disease, that may darken quality of life, are treated medically aimed at symptom relief. The possible place of surgery should be discussed. Clinical and CT scan classifications should be separated entities.
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Affiliation(s)
- Patrick Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Geneva, Switzerland
- Correspondence: Patrick Ambrosetti, Department of Surgery, Clinique Générale Beaulieu, Ch Beau-Soleil, 1205 Geneva, Switzerland, Tel +41 22 830 0520, Fax +41 22 830 2343, Email
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The role of low CRP values in the prediction of the development of acute diverticulitis. Int J Colorectal Dis 2016; 31:23-7. [PMID: 26519151 DOI: 10.1007/s00384-015-2410-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Computed tomography (CT) is the most appropriate imaging modality for the assessment of acute diverticulitis at the emergency unit. The aim of this study was to determine the clinical outcome of the patients presented first time with symptoms of acute diverticulitis and low CRP values. METHODS Two-hundred patients, who presented with the symptoms of acute diverticulitis and had CRP values under 150 mg/L, underwent abdominal CT examination on admission to Oulu University Hospital. The clinical parameters and radiological findings were compared in relation to clinical outcome both by means of univariate and multivariate analyses. RESULTS Seventy-one (35.5 %) of the 200 patients presented on admission with complicated diverticulitis. CRP values between 100 and 150 mg/L predicted complicated disease, but the mean values of CRP between uncomplicated disease, 89 mg/L ± 39, and complicated disease, 101 mg/L ± 39, did not differ significantly. Free intra-abdominal fluid in CT was the only independent risk factor of the need for interventional therapy and treatment in the intensive care unit. Longevity of the patients and free fluid in CT predicted significantly prolonged hospitalization. Mortality was 1 % and older patients were significantly affected. The recurrence rate of acute diverticulitis was 24 % (43/177) in the whole group and 18 % (23/129) after uncomplicated diverticulitis. CONCLUSIONS Low CRP values do not reliably predict uncomplicated disease in patients presented first time at the emergency unit with acute diverticulitis. We recommend that the need for abdominal CT is carefully evaluated according to the patient's clinical status, always even when the CRP value is under 150 mg/L.
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Mäkelä JT, Klintrup K, Takala H, Rautio T. The role of C-reactive protein in prediction of the severity of acute diverticulitis in an emergency unit. Scand J Gastroenterol 2015; 50:536-41. [PMID: 25665622 DOI: 10.3109/00365521.2014.999350] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Computed tomography (CT) is the most appropriate initial imaging modality for the assessment of acute diverticulitis. The aim here was to determine the usefulness of C-reactive protein (CRP) in predicting the severity of the diverticulitis process and the need for a CT examination. METHODS The CRP values of 350 patients who presented first time with symptoms of acute diverticulitis and underwent CT imaging on admission to Oulu University Hospital were compared with the CT findings and clinical parameters by means of both univariate and multivariate analyses. RESULTS The receiver operating characteristic curve showed that a CRP cut-off value of 149.5 mg/l significantly discriminated acute uncomplicated diverticulitis from complicated diverticulitis (specificity 65%, sensitivity 85%, area under the curve 0.811, p = 0.0001). In multivariate analysis, a CRP value over 150 mg/l and old age were independent risk factors for acute complicated diverticulitis. The mean CRP value was significantly higher in the patients who died, 207 (84 SD), than in those who survived, 139 (SD 83). In addition, a CRP value over 150 mg/l and free abdominal fluid in CT were independent variables predicting postoperative mortality. CONCLUSIONS CRP is useful for the predicting the severity of acute diverticulitis on admission. Patients with a CRP value higher than 150 mg/l have an in increased risk of complicated diverticulitis and a CT examination should always be carried out.
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Affiliation(s)
- Jyrki T Mäkelä
- Department of Surgery, Oulu University Hospital, Division of Gastroenterology , Kajaanintie 50, 90220 Oulu , Finland
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Kechagias A, Rautio T, Kechagias G, Mäkelä J. The Role of C-reactive Protein in the Prediction of the Clinical Severity of Acute Diverticulitis. Am Surg 2014. [DOI: 10.1177/000313481408000423] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study is to investigate the value of C-reactive protein (CRP) and of other laboratory parameters obtained during the initial evaluation of the patient in the prediction of the clinical severity of acute diverticulitis. The records of patients treated for acute diverticulitis at the Oulu University Hospital from December 2006 to December 2008 were retrospectively reviewed. Mild disease was defined when conservative treatment was successful. Severe acute diverticulitis was considered when percutaneous drainage of an abscess and/or surgery was necessary. From the 182 patients considered for analysis, 158 (87%) had mild disease, whereas 24 (13%) had severe. CRP ( P = 0.034) and the Hinchey classification ( P = 0.006) were shown to be independent risk factors for severe acute diverticulitis in the logistic regression analysis. The receiver operating characteristic curve showed that a CRP cutoff value of 170 mg/L significantly discriminated severe from mild diverticulitis (87.5% sensitivity, 91.1% specificity, area under the curve 0.942, P < 0.00001). CRP is a useful tool in the prediction of the clinical severity of acute diverticulitis. A mild episode is very likely in patients with CRP less than 170 mg/L. Those with higher CRP values have a greater probability to undergo surgical treatment or at least a percutaneous intervention.
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Affiliation(s)
- Aristotelis Kechagias
- Department of Surgery, Division of Gastroenterology, Oulu University Hospital, Oulu, Finland
| | - Tero Rautio
- Department of Surgery, Division of Gastroenterology, Oulu University Hospital, Oulu, Finland
| | - Georgios Kechagias
- Second Department of Gastroenterology, Evaggelismos Hospital, Athens, Greece
| | - Jyrki Mäkelä
- Department of Surgery, Division of Gastroenterology, Oulu University Hospital, Oulu, Finland
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McDermott FD, Collins D, Heeney A, Winter DC. Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis. Br J Surg 2013; 101:e90-9. [PMID: 24258427 DOI: 10.1002/bjs.9359] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The severity of acute diverticulitis ranges from mild, simple inflammation to pericolic abscesses, or perforation with faeculent peritonitis. Treatment of diverticulitis has evolved towards more conservative and minimally invasive strategies. The aim of this review is to highlight recent concepts and advances in management. METHODS A literature review was performed on the electronic databases MEDLINE from PubMed, Embase and the Cochrane Library for publications in English. The keywords 'diverticulitis', 'diverticular' were searched for the past decade (to September 2013). RESULTS Diverticulitis occurs frequently in the Western world, but only one in five patients develops complications (such as abscess and perforation) during the first acute presentation. The reported perforation rate is 3.5 per 100,000 population. Based on recent data, including the AVOD and DIVER trials, antibiotic therapy for mild episodes may be unnecessary and outpatient management reasonable in most patients. Antibiotics and admission to hospital is required for complicated diverticulitis confirmed on imaging and for patients with sepsis. Diverticular abscesses (about 5 per cent of patients) may require percutaneous drainage if antibiotics alone fail. Laparoscopic management of non-faecal perforated diverticulitis is feasible in selected patients, and peritoneal lavage in combination with antibiotic therapy may avoid colonic resection and a stoma. However, the collective, published worldwide experience is limited to fewer than 800 patients, and results from ongoing randomized trials (LapLAND, SCANDIV, DILALA and LADIES trials) are needed to inform better decision-making. CONCLUSION The treatment of diverticulitis continues to evolve with a trend towards a more conservative and minimally invasive management approach. Judicious use of antibiotics in uncomplicated cases, greater application of laparoscopic techniques, and primary resection and anastomosis are of benefit in selected patients.
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Affiliation(s)
- F D McDermott
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park Dublin 4, Ireland
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Mora Lopez L, Serra Pla S, Serra-Aracil X, Ballesteros E, Navarro S. Application of a modified Neff classification to patients with uncomplicated diverticulitis. Colorectal Dis 2013; 15:1442-7. [PMID: 24192258 DOI: 10.1111/codi.12449] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 04/07/2013] [Indexed: 02/06/2023]
Abstract
AIM Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management. METHOD All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients. Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded. RESULTS Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25-90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixty-four (94%) successfully completed the outpatient treatment protocol; four patients were readmitted. CONCLUSION Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme.
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Affiliation(s)
- L Mora Lopez
- Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), Sabadell, Spain
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C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications. Tech Coloproctol 2013; 18:145-9. [PMID: 23807310 DOI: 10.1007/s10151-013-1044-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 06/16/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids. METHODS We analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT. RESULTS A total of 295 patients were included in the study. Two hundred and forty-three (82 %) were classified with uncomplicated (Hinchey 1a) and 52 (18 %) with complicated disease (Hinchey > 1a). Mean CRP levels were 133.5 and 63.5 mg/ml for those with complicated and uncomplicated disease, respectively (p < 0.001), and 139 and 60 mg/ml, respectively (p < 0.001) in the subgroup of patients taking aspirin (n = 61). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRP > 90 mg/ml had 88 % sensitivity and 75 % specificity for complicated disease. CONCLUSIONS The CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.
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