Diverticular disease: A therapeutic overview

Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails?

INTRODUCTION

Diverticulitis and appendicitis are common emergency general surgical conditions. Both can be treated with antibiotics alone; however, no antibiotic regimen has been identified as superior to others. In this study, we review different antibiotic regimens and their rates of failure.

METHODS

Retrospective cohort study of patients treated empirically with antibiotics for diverticulitis or appendicitis from January 1, 2018, to December 31, 2020, at an independent academic hospital in the Midwest.

RESULTS

A total of 587 (appendicitis, n = 43; diverticulitis, n = 544) patients were included in the cohort. They were equally male (49%) and female (51%) with a median age of 59 y. Three major antibiotic classes were compared: cephalosporin + metronidazole (C + M), penicillins, and quinolone + metronidazole. Appendicitis patients were more likely to receive C + M for empiric treatment (73%, P < 0.001), while diverticulitis patients were more likely to receive quinolone + metronidazole (45%, P < 0.001). Patients empirically treated with antibiotics for appendicitis were more likely than those treated for diverticulitis to require additional antibiotics or procedure within 90 d (33% versus 13%, respectively; P = 0.005). Empiric treatment with C + M for diverticulitis was more likely to be associated with the need for additional antibiotics or procedures within 90 d than treatment with other regimens (P = 0.003). Choice of antibiotic for empiric treatment did not correlate with death at 90 d for appendicitis or diverticulitis. Diverticulitis patients who were initially treated as inpatients and were prescribed C + M at hospital discharge had a higher rate of death than those who were prescribed the other antibiotics (P = 0.04).

CONCLUSIONS

Empiric antibiotic treatment of appendicitis is more likely to be associated with additional antibiotics or procedure when compared with diverticulitis; however, antibiotic choice did not correlate with any of the other outcomes. Empiric treatment with a C + M for diverticulitis was more likely to be correlated with the need for additional antibiotics or procedure within 90 d.

Effect of mesalazine combined with probiotics on inflammation and immune function of patients with inflammatory bowel disease

OBJECTIVE

To determine the effects of mesalazine combined with probiotics on inflammation and immune function of patients with inflammatory bowel disease (IBD).

METHODS

In this retrospective study, a total of 116 patients with IBD treated in Renmin Hospital of Wuhan University from September 2018 to September 2021 were enrolled and divided into a control group (n=55, treated with mesalazine alone) and a research group (n=61, treated with mesalazine combined with probiotics) according to the treatment regimen. The two groups were compared in the levels of inflammatory factors, immune factors, adverse reactions, clinical efficacy and improvement of patients' disease condition before and after treatment. Logistic regression was used to analyze the independent risk factors of infection in patients with IBD at 6 months after admission.

RESULTS

The research group showed a significantly higher the total effective rate than the control group (P<0.05), and there was no notable difference between the two groups in the incidence of adverse reactions (P>0.05). In addition, compared with the control group, the research group showed significantly lower levels of immunoglobulin A (IgA), immunoglobulin G (IgG), immunoglobulin M (IgM), Tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP), and had significantly lower scores of clinical activity index (CAI) and endoscopic activity index (EAI) after treatment (all P<0.05). Higher IgG, IgM, IL-6, CRP and EAI levels at admission were independent risk factors for infection in patients with IBD.

CONCLUSION

Mesalazine combined with probiotics can substantially improve the disease condition of patients with IBD, improve their immune ability and reduce their inflammation level, with a good safety profile.

Suppurative Thrombosis of the Portal Vein (Pylephlebits): A Systematic Review of Literature

Suppurative portal vein thrombosis (pylephlebitis) is an uncommon condition usually associated with an intra-abdominal infection or inflammatory process. In this study, we aimed to synthesize data on previously published cases according to the PRISMA guidelines. A total of 103 patients were included. Patients were more commonly male (71.8%) and had a mean age of 49 years. The most common infection associated with pylephlebitis was diverticulitis (n = 29, 28.2%), and Escherichia coli was the most isolated pathogen (n = 21, 20.4%). Blood cultures were positive in 64 cases (62.1%). The most common site of thrombosis was the main portal vein (PV) in 59 patients (57.3%), followed by the superior mesenteric vein (SMV) in 40 patients (38.8%) and the right branch of the PV in 30 patients (29.1%). Sepsis developed in 60 patients (58.3%). The mortality rate in our review was 8.7%, and independent risk factors for mortality were the presence of pertinent comorbidities (OR 5.5, p = 0.02), positive blood cultures (OR 2.2, p = 0.02), and sepsis (OR 17.2, p = 0.049).

Symptomatic uncomplicated diverticular disease management: an innovative food-grade formulation of Curcuma longa and Boswellia serrata extracts

Background

The treatment of symptomatic uncomplicated colonic diverticular disease (SUDD) is still under debate, and new data show a pathogenic role of dysbiosis and low-grade inflammation in intestinal mucosa. Recent research has highlighted the anti-inflammatory effects of botanical extracts such as Curcuma longa L. and Boswellia serrata Roxb. ex Colebr. The aim of this work is to investigate the potential role of a new delivery formulation of the association of curcumin and boswellia phytosome extracts (CBP) in SUDD.

Methods

In a 30-day one-group longitudinal explanatory study, patients (men and women) were treated with an innovative association of CBP standardized extracts, 500 mg bid.

Results

Treatment of SUDD with the association of CBP was followed by a significant decrease in abdominal pain (p<0.0001). The study group showed that CBP supplementation was efficacious within 10 days and that efficacy was maintained almost constant until the 30th day of intervention.

Conclusion

A phytosome of curcumin and boswellia extracts may be useful for the relief of SUDD pain. However, controlled studies should be performed for final conclusions to be drawn.

Antibiotics Versus No Antibiotics for Acute Uncomplicated Diverticulitis: A Systematic Review and Meta-analysis

BACKGROUND

Antibiotics are routinely used for diverticulitis irrespective of severity. Current practice guidelines favor against the use of antibiotics for acute uncomplicated diverticulitis.

OBJECTIVE

We performed a systematic review and meta-analysis to examine the role of antibiotic use in an episode of uncomplicated diverticulitis.

DATA SOURCES

PubMed/Medline, Embase, Scopus, and Cochrane were used.

STUDY SELECTION

Eligible studies included those with patients with uncomplicated diverticulitis receiving any antibiotics compared with patients not receiving any antibiotics (or observed alone).

MAIN OUTCOME MEASURES

Pooled odds rate of total complications, treatment failure, recurrent diverticulitis, readmission rate, sigmoid resection, mortality rate, and length of stay were measured.

RESULTS

Of 1050 citations reviewed, 7 studies were eligible for the analysis. There were total of 2241 patients: 895 received antibiotics (mean age = 59.1 y; 38% men) and 1346 did not receive antibiotics (mean age = 59.4 y; 37% men). Antibiotics were later added in 2.7% patients who initially were observed off antibiotics. Length of hospital stay was not significantly different among either group (no antibiotics = 3.1 d vs antibiotics = 4.5 d; p = 0.20). Pooled rate of recurrent diverticulitis was not significantly different among both groups (pooled OR = 1.27 (95%, CI 0.90-1.79); p = 0.18). Rate of total complications (pooled OR = 1.99 (95% CI, 0.66-6.01); p = 0.22), treatment failure (pooled OR = 0.68 (95% CI, 0.42-1.09); p = 0.11), readmissions (pooled OR = 0.75 (95% CI, 0.44-1.30); p = 0.31). and patients who required sigmoid resection (pooled OR = 3.37 (95% CI, 0.65-17.34); p = 0.15) were not significantly different among patients who received antibiotics and those who did not. Mortality rates were 4 of 1310 (no-antibiotic group) versus 4 of 863 (antibiotic group).

LIMITATIONS

Only 2 randomized controlled studies were available and there was high heterogeneity in existing data.

CONCLUSIONS

This meta-analysis of current literature shows that patients with uncomplicated diverticulitis can be monitored off antibiotics.

Role of TNFSF15 in the intestinal inflammatory response

Gastrointestinal diseases, specifically Crohn’s disease, ulcerative colitis, diverticular disease, and primary biliary cirrhosis are all characterized by complicated inflammation of the digestive tract. Their pathology is multifactorial, and risk factors encompass both genetic and environmental factors. Recent advances in the genetic component of inflammatory bowel diseases (IBDs) have revealed that the tumor necrosis factor superfamily member 15 (TNFSF15) contains a number of risk alleles associated not only with IBD but also with other diseases such as diverticular disease and primary biliary cirrhosis. These risk alleles in TNFSF15 and the altered expression of its gene product can serve as the common ground between these disorders by explaining at least some of the underlying processes that lead to a dysregulated immune response and subsequent chronic inflammation. Here, we aim to outline how the TNFSF15 gene is involved in the proliferation and cell fate of different populations of T cells and subsequently in the control of both pro- and anti-inflammatory cytokines. Furthermore, we summarize what is currently known of TNFSF15 control region variants, how they are associated with each mentioned disease, and how these variants can explain the autoimmune pathology of said diseases through altered TNFSF15 expression.

Animal Models of Diverticulosis: Review and Recommendations

Diverticulosis is a structural alteration of the colon tissue characterized by the development of pouch-like structures called diverticula. It afflicts a significant portion of the population in Western countries, with a higher prevalence among the elderly. Diverticulosis is believed to be the result of a synergetic interaction between inherent tissue weakness, diet, colonic microstructure, motility, and genetic factors. A validated etiology has, however, not yet been established. Non-surgical treatment is currently lacking due to this poor understanding, and surgical colon resection is the only long-term solution following recurrent complications. With rising prevalence, the burden of diverticulosis on patients and hospital resources has increased over the past several years. More efficient and less invasive treatment approaches are, thus, urgently needed. Animal models of diverticulosis are crucial to enable a preclinical assessment and evaluation of such novel approaches. This review discusses the animal models of diverticulosis that have been proposed to date. The current models require either a significant amount of time to develop diverticulosis, present a relatively low success rate, or seriously deteriorate the animals' systemic health. Recommendations are thus provided to address these pitfalls through the selection of a suitable animal and the combination of multiple risk factors for diverticulosis.

A national evaluation of the management practices of acute diverticulitis

INTRODUCTION

Diverticulitis is a common surgical admission that presents with a wide range of symptoms and severity. Overall there has been a shift to conservative management practices, including the consideration of non-antibiotic treatment approaches in select cases.

METHODS

A national survey of all consultant surgeons evaluating their practices was performed. Reasons for changes in management, use of radiological imaging, role of non-antibiotic treatment approaches and indications for elective surgical management were evaluated.

RESULTS

Response rate for this survey was 67.7% (n = 67/99). An overwhelming 92.5% stated that computed tomography imaging was routinely used to investigate acute presentations. Interestingly, 22.4% stated they would consider a non-antibiotic treatment approach in uncomplicated diverticulitis. Main reasons for adopting this approach was low inflammatory markers with short duration of symptoms. Co-amoxiclav was the most common antibiotic used for acute diverticulitis, with considerable variability in duration of treatment. Additionally, there was considerable heterogeneity regarding how many recurrences were necessary before surgical management was required.

CONCLUSION

This review highlights substantial variation in the management of diverticulitis across Ireland. Shifts to non-antibiotic treatment approaches for uncomplicated cases are observed, but less so than in Northern Europe. National guidelines are required to establish uniform treatment protocols including indications for surgical resection.

Surgery for diverticulitis: a re-evaluation of the changing trends

The surgical management of diverticulitis continues to evolve but recent literature has not qualified just how different current practice is compared with the previous era. This study aims to update the seminal paper by Rodkey and Welch regarding indications and operation types performed for diverticulitis by comparing their findings with present practice at a community based institution. The charts of 407 patients admitted with "diverticular disease" between 2005 and 2010 were identified. For each admission, patients' demographics, presentations and management were recorded. Direct comparisons were made with results from the study by Rodkey and Welch. Of the 407 admissions studied, the distribution was 335 emergency and 72 elective. Medical management alone treated 90% of emergency admissions, while 4% required additional radiologic intervention. Emergency surgery was necessary in only 6% of cases with Hartmann's procedure being the most common procedure. Recurrent diverticulitis was a prime indication for elective surgery with 96% of cases undergoing a 1-staged procedure. Compared with the previous era, the nonoperative approach to managing acute diverticulitis is now applied for the vast majority of admissions. Improved success in medically temporizing patients in the present era has allowed for a higher percentage of successful single-staged elective surgeries.

Development and validation of algorithms to identify acute diverticulitis

PURPOSE

The objectives of this study were to develop and validate algorithms to accurately identify patients with diverticulitis using electronic medical records (EMRs).

METHODS

Using Kaiser Permanente Southern California's EMRs of adults (≥18 years) with International Classification of Diseases, Clinical Modifications, Ninth Revision diagnosis codes of diverticulitis (562.11, 562.13) between 1 January 2008 and 31 August 2009, we generated random samples for pilot (N = 692) and validation (N = 1502) respectively. Both samples were stratified by inpatient (IP), emergency department (ED), and outpatient (OP) care settings. We developed and validated several algorithms using EMR data on diverticulitis diagnosis code, antibiotics, computed tomography, diverticulosis history, pain medication and/or pain diagnosis, and excluding patients with infections and/or conditions that could mimic diverticulitis. Evidence of diverticulitis was confirmed through manual chart review. Agreement between EMR algorithm and manual chart confirmation was evaluated using sensitivity and positive predictive value (PPV).

RESULTS

Both samples were similar in socio-demographics and clinical symptoms. An algorithm based on diverticulitis diagnosis code with antibiotic prescription dispensed within 7 days of diagnosis date, performed well overall. In the validation sample, sensitivity and PPV were (84.6, 98.2%), (95.8, 98.1%), and (91.8, 82.6%) for OP, ED, and IP, respectively.

CONCLUSION

Using antibiotic prescriptions to supplement diagnostic codes improved the accuracy of case identification for diverticulitis, but results varied by care setting.

Efficacy, safety, and applicability of outpatient treatment for diverticulitis

Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Although current guidelines recommend use of antibiotics for the outpatient treatment of acute uncomplicated diverticulitis, evidence for this is still lacking. Hence, significant effort is now being made to identify the appropriate therapeutic approach to treat and prevent relapses of diverticulitis. Outpatient treatment has been identified as a safe and effective therapeutic approach in up to 90% of patients with uncomplicated diverticulitis. It allows important costs saving to health systems without a negative influence on quality of life for patients with uncomplicated diverticulitis, and reduces health care costs by more than 60%.

New physiopathological and therapeutic approaches to diverticular disease: an update

INTRODUCTION

Diverticular disease (DD) of the colon is a widespread disease, which shows worldwide increasing incidence and represents a significant burden for National Health Systems. The current guidelines claim that symptomatic uncomplicated DD (SUDD) has to be treated with spasmolithics and high-fiber diet, whereas both uncomplicated and complicated acute diverticulitis has to be treated with antibiotics. However, new physiopathological knowledge suggests that further treatment may be promising.

AREAS COVERED

Pathogenetic and treatment studies on SUDD and acute diverticulitis published in PubMed, www.clinicaltrials.gov , and in the main International Congress were reviewed.

EXPERT OPINION

Although absorbable antibiotics and 5-aminosalycilic acid seem to be effective in treating SUDD, their role in preventing diverticulitis recurrence is still under debate. Antibiotic use in managing acute diverticulitis is at least questionable, and use of probiotics seems to be promising but need further robust studies to confirm the preliminary results.

Diarrhea after laparoscopic cholecystectomy: associated factors and predictors

BACKGROUND

Diarrhea is part of the postlaparoscopic cholecystectomy syndrome, but is not well defined. Published reports have ignored possible associated factors such as the preoperative excretion pattern, gastrointestinal disorders, personality disorders, the effect of drugs, unsanitary food, and high-fat diets.

PURPOSE

The aim of this study was to define the associated factors and predictors of postlaparoscopic cholecystectomy diarrhea (PLCD) at different time intervals after the operation and to identify the possible associated factors and predictors of PLCD. We also aimed to determine the effectiveness of a low-fat diet in these patients and to educate the patients about their diet after the operation.

METHODS

Data were obtained from clinical records and preoperative interviews with patients, who were also interviewed or contacted by telephone 1 week after the operation, and then surveyed by telephone 3 months later using standardized questionnaires. A total of 125 consecutive patients who were adequately informed and who had assented to accepting a prescription of a low-fat diet after undergoing laparoscopic cholecystectomy participated in this prospective study.

RESULTS

Thirty-eight patients (25.2%) had diarrhea 1 week after laparoscopic cholecystectomy and seven patients (5.7%) had diarrhea 3 months after laparoscopic cholecystectomy. The important predictors of PLCD at 1 week were a low-fat diet (B = -0.177, p = 0.000) and a high score on a preoperative diarrhea scale (B = 0.311, p = 0.031). There was no predictor for PLCD 3 months after laparoscopic cholecystectomy.

CONCLUSION

We advise patients who have undergone laparoscopic cholecystectomy to follow a low-fat diet for at least 1 week to reduce the possibility of diarrhea, especially when they are ≤45 years of age, of male sex, and had a high preoperative tendency for diarrhea.

Plasma serotonin level in left-sided colonic diverticulosis: A pilot study

Neurotransmitters might participate in the development of diverticular disease. We measured fasting and postprandial serotonin levels in colonic diverticulosis patients and healthy volunteers. We demonstrated significantly lower maximal concentrations of serotonin in patients than the controls (respectively 109.8±61.4 and 251.3±44.1 ng/ml, p<0.001) as well as lower serotonin minimal values (respectively 38.4±21.8 and 124.6±41.4 ng/ml, p<0.001) and areas under time-course curves (respectively 288.8±139.8 and 739±167.4 ng/ml, p<0.001); significant difference between alternating pattern and normal bowel habit concerning fasting serotonin level, the hormone response to test meal (p=0.041) as well as minimal serotonin level (p=0.044). Bowel habit was also related to peak serotonin values following a test meal with 38.5 ng/ml in constipation, 139.5 ng/ml in diarrhea, 122.4 ng/ml in alternating pattern and 249 ng/ml in subjects with normal bowel habit (p=0.040) as well as AUC with 120.8 ng/ml in constipation, 416 ng/ml in diarrhea, 298 ng/ml in alternating pattern and 684 ng/ml in subjects with normal bowel habit (p=0.043). We demonstrated substantial differences in fasting serum serotonin levels as well as the hormone response to a test meal between colonic diverticulosis patients and healthy individuals, which seemed to be associated with abnormal bowel habits rather than presence of diverticula.