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Sokhal BS, Mostafa OES, Ramasamy S, Spyridon R, Zaman S, Hajibandeh S, Hajibandeh S. Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis. Am Surg 2024; 90:1167-1175. [PMID: 38205505 DOI: 10.1177/00031348241227183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Acute uncomplicated diverticulitis (AUD) is a common cause of acute abdominal pain. Recent guidelines advise selective use of antibiotics in AUD patients. This meta-analysis aimed to compare the effectiveness of no antibiotics vs antibiotics in AUD patients. METHODS This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify randomized controlled trials (RCTs) involving AUD patients which compared the use of antibiotics with no antibiotics. Pooled outcome data was calculated using random effects modeling with 95% confidence intervals (CIs). RESULTS 5 RCTs with 1934 AUD patients were included. 979 patients were managed without antibiotics (50.6%). Patients in the no antibiotic and antibiotic groups had comparable demographics (age, sex, and body mass index) and presenting features (temperature, pain score, and C-reactive protein levels). There was no significant difference in rates of complicated diverticulitis (OR: .61, 95% CI: 0.27-1.36, P = .23), abscess (OR: .51, 95% CI: .08-3.25, P = .47) or fistula (OR: .33, 95% CI: .03-3.15, P = .33) formation, perforation (OR: .98, 95% CI: .32-3.07, P = .98), recurrence (OR: .96, 95% CI: .66-1.41, P = .85), need for surgery (OR: 1.36, 95% CI: .47-3.95, P = .37), mortality (OR: 1.27, 95% CI: .14-11.76, P = .82), or length of stay (MD: .215, 95% CI: -.43-.73, P = .61) between the 2 groups. However, the likelihood of readmission was higher in the antibiotics group (OR: 2.13, 95% CI: 1.43-3.18, P = .0002). CONCLUSION There is no significant difference in baseline characteristics, clinical presentation, and adverse health outcomes between AUD patients treated without antibiotics compared to with antibiotics.
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Affiliation(s)
| | | | - Sadhasivam Ramasamy
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Roditis Spyridon
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Shafquat Zaman
- Department of General Surgery, Russells Hall Hospital, Dudley Group NHS Trust, Dudley, UK
| | - Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
- Department of General Surgery, University Hospitals Coventry & Warwickshire, Coventry, UK
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Klinker S, Fitzsimmons A, Borgert A, Fisher M. Nonoperative Treatment of Diverticulitis and Appendicitis: Which Antibiotic Regimen Fails? J Surg Res 2024; 296:78-87. [PMID: 38232581 DOI: 10.1016/j.jss.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 01/19/2024]
Abstract
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.
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Affiliation(s)
- Samuel Klinker
- Department of Medical Education, General Surgery Residency, Gundersen Health System, La Crosse, Wisconsin.
| | - Alec Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin
| | - Andrew Borgert
- Department of Medical Research, Gundersen Health System, La Crosse, Wisconsin
| | - Mason Fisher
- Department of General Surgery, Gundersen Health System, La Crosse, Wisconsin
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Serrano González J, Román García de León L, Galindo Jara P, Lucena de la Poza JL, Sánchez Movilla A, Colao García L, García Schiever JG, Varillas Delgado D. Non-antibiotic treatment of uncomplicated acute diverticulitis is applicable and safe in our environment. A prospective multicenter study. Rev Esp Enferm Dig 2024; 116:140-147. [PMID: 37929981 DOI: 10.17235/reed.2023.9737/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
INTRODUCTION acute diverticulitis is one of the most frequent underlying causes behind individuals attending the Emergency Room with abdominal pain. The most widespread therapy for acute uncomplicated diverticulitis includes outpatient treatment with antibiotics; however, several publications indicate that patients can also be successfully treated without antibiotics. The results of the implementation of this more recent protocol in two hospitals in Madrid are presented. METHODS an observational prospective study was performed. Participants were patients diagnosed with uncomplicated acute diverticulitis at two hospitals in Madrid, Hospital Universitario de Torrejón and Hospital Universitario Puerta de Hierro Majadahonda, between December 2018 and August 2021, treated on an outpatient basis without antibiotic therapy. The study group was compared with a control group, composed of patients diagnosed with uncomplicated acute diverticulitis and treated with outpatient antibiotic therapy at Hospital Universitario Puerta de Hierro between March 2015 and March 2018. RESULTS three hundred and sixty-one patients were included, 182 in the study group and 179 in the control group. Diverticulitis was persistent in 19 patients (10.4 %) in the study group, who were not treated with antibiotics, and in five patients (2.8 %) in the control group, treated with outpatient antibiotic therapy (p = 0.004). Recurrences occurred in 23 patients (12.6 %) in the study group, and in 53 patients (29.6 %) in the control group (p < 0.0001). The analysis of the complications found no significant differences between both groups (p = 0.109). No urgent surgical intervention or mortality was recorded in the study group. CONCLUSIONS in our environment, symptomatic non-antibiotic treatment of uncomplicated acute diverticulitis cases is safe, without showing a higher rate of complications. Although, there seems to be a worse initial symptom control.
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Brière R, Benhamed A, Émond M, Blanchard PG, Drolet S. Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey. CAN J EMERG MED 2023; 25:968-975. [PMID: 37861926 DOI: 10.1007/s43678-023-00606-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change. METHODS A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change. RESULTS The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%). CONCLUSION Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.
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Affiliation(s)
- Raphaëlle Brière
- Département de Chirurgie, CHU de Québec, Université Laval, Quebec, QC, Canada.
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marcel Émond
- Département de Médecine Familiale et de Médecine d'urgence, Centre de Recherche du CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Pierre-Gilles Blanchard
- Département de Médecine Familiale et de Médecine d'urgence, Centre de Recherche du CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Sébastien Drolet
- Département de Chirurgie, CHU de Québec, Université Laval, Quebec, QC, Canada
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Moroi R, Tarasawa K, Nagai H, Shimoyama Y, Naito T, Shiga H, Hamada S, Kakuta Y, Fushimi K, Fujimori K, Kinouchi Y, Masamune A. Effectiveness of Antibiotics for Uncomplicated Diverticulitis: A Retrospective Investigation Using a Nationwide Database in Japan. Digestion 2023; 105:81-89. [PMID: 37857266 PMCID: PMC10994568 DOI: 10.1159/000534167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION The efficacy of antibiotics for diverticulitis without abscess or peritonitis (uncomplicated diverticulitis) is controversial. We aimed to investigate the effectiveness of antibiotics for uncomplicated diverticulitis. METHODS We collected admission data for patients with acute uncomplicated diverticulitis using a nationwide database. We divided eligible admissions into two groups according to antibiotic initiation within 2 days after admission (antibiotic group vs. nonantibiotic group). We conducted propensity score matching and compared the rates of surgery (intestinal resection and stoma creation), in-hospital death, and medical costs between the groups. We also performed multivariate analysis to identify the clinical factors that affect surgery. RESULTS We enrolled 131,936 admissions; among these, we obtained 6,061 pairs after propensity score matching. Rates of both intestinal resection and stoma creation in the antibiotic group were lower than those in the nonantibiotic group (0.61 vs. 3.09%, p < 0.0001, and 0.08 vs. 0.26%, p = 0.027, respectively). Median costs in the antibiotic group were higher than those in the nonantibiotic group (315,820 JPY vs. 300,175 JPY, p < 0.0001, respectively). Multivariate analysis showed that non-initiation of antibiotics within 2 days after admission was a clinical factor that increased the risk of intestinal resection (odds ratio [OR] = 5.19, 95% confidence interval [CI]: 4.38-6.16, p < 0.0001) and stoma creation (OR = 2.68, 95% CI: 1.53-4.70, p = 0.0006). CONCLUSION Our results indicated that antibiotics for uncomplicated diverticulitis expected to have moderate to severe disease activity may reduce the risk of intestinal resection and stoma creation. Further investigations are warranted.
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Affiliation(s)
- Rintaro Moroi
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Nagai
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Yusuke Shimoyama
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Takeo Naito
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Hisashi Shiga
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Shin Hamada
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Yoichi Kakuta
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Bunkyo, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Hospital, Sendai, Japan
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Baca-Atlas M, Mounsey A. Antibiotics for Acute Uncomplicated Diverticulitis. Am Fam Physician 2023; 108:237-238. [PMID: 37725454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Affiliation(s)
- Michael Baca-Atlas
- University of North Carolina Family Medicine Residency Program, Chapel Hill, North Carolina
| | - Anne Mounsey
- University of North Carolina Family Medicine Residency Program, Chapel Hill, North Carolina
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Correa Bonito A, Cerdán Santacruz C, Di Martino M, Blanco Terés L, Gancedo Quintana Á, Martín-Pérez E, Biondo S, García Septiem J. Treatment for acute uncomplicated diverticulitis without antibiotherapy: systematic review and meta-analysis of randomized clinical trials. Int J Surg 2023; 109:1412-1419. [PMID: 37026842 PMCID: PMC10389615 DOI: 10.1097/js9.0000000000000307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/15/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Use of antibiotics in selected cases of acute uncomplicated diverticulitis (AUD) has recently been questioned. OBJECTIVE The aim of this study is to examine the safety and efficacy of treatment regimens without antibiotics compared with that of traditional treatments with antibiotics in selected patients with AUD. DATA SOURCES PubMed, Medline, Embase, Web of Science, and the Cochrane Library. METHODS A systematic review was performed according to PRISMA and AMSTAR guidelines by searching through Medline, Embase, Web of Science, and the Cochrane Library for randomized clinical trials (RCTs) published before December 2022. The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. STUDY SELECTION RCTs on treating AUD without antibiotics published in English before December 2022 were included. INTERVENTION Treatments without antibiotics were compared with treatments with antibiotics. MAIN OUTCOME MEASURES The outcomes assessed were the rates of readmission, change in strategy, emergency surgery, worsening, and persistent diverticulitis. RESULTS The search yielded 1163 studies. Four RCTs with 1809 patients were included in the review. Among these patients, 50.1% were treated conservatively without antibiotics. The meta-analysis showed no significant differences between nonantibiotic and antibiotic treatment groups with respect to rates of readmission [odds ratio (OR)=1.39; 95% CI: 0.93-2.06; P =0.11; I2 =0%], change in strategy (OR=1.03; 95% CI: 0.52-2,02; P =0.94; I2 =44%), emergency surgery (OR=0.43; 95% CI: 0.12-1.53; P =0.19; I2 =0%), worsening (OR=0.91; 95% CI: 0.48-1.73; P =0.78; I2 =0%), and persistent diverticulitis (OR=1.54; 95% CI: 0.63-3.26; P =0.26; I2 =0%). LIMITATIONS Heterogeneity and a limited number of RCTs. CONCLUSIONS Treatment for AUD without antibiotic therapy is safe and effective in selected patients. Further RTCs should confirm the present findings.
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Affiliation(s)
| | | | | | - Lara Blanco Terés
- General and Digestive Surgery Service, Hospital Universitario de La Princesa, Madrid
| | | | - Elena Martín-Pérez
- General and Digestive Surgery Service, Hospital Universitario de La Princesa, Madrid
| | - Sebastiano Biondo
- General and Digestive Surgery – Colorectal Unit, Bellvitge University Hospital, Barcelona, Spain
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Abet E, Bawjeski S, Planche L, Weyd B, de Kerviler B. Evaluation of a treatment pathway for the management of uncomplicated diverticulitis. J Visc Surg 2023; 160:27-32. [PMID: 35459631 DOI: 10.1016/j.jviscsurg.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Recent clinical practice recommendations have radically modified the management of colonic diverticulitis. The goal of our study was to evaluate a treatment pathway for uncomplicated diverticulitis and to analyze the outcome (patient compliance, treatment failure and complications). PATIENTS AND METHODS All patients who presented to the emergency department with the diagnosis of uncomplicated diverticulitis were prospectively included in this study. The treatment pathway included an outpatient clinical re-assessment by a gastrointestinal surgeon. In case of symptomatic treatment failure, oral antibiotics were prescribed. If developed clinical signs of severity developed, the patient was referred to the emergency department for new laboratory and imaging workup. RESULTS Eighty-seven patients were included. The mean interval before re-assessment was 2.8 days. Fifty-nine patients (67.8%) had symptomatic treatment upon discharge from the emergency department and were reassessed as outpatients by the surgical team. Patient evolution was satisfactory for 45 (76.3%); 10 (16.9%) required oral antibiotics. One (1.7%) patient developed complicated diverticulitis. Thirty-four (39.1%) patients did not comply with the current recommendations. CONCLUSION In our experience, uncomplicated diverticulitis can be treated effectively in an ambulatory setting followed by early re-assessment by a surgeon.
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Affiliation(s)
- E Abet
- Department of digestive surgery, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France.
| | - S Bawjeski
- Emergency department, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| | - L Planche
- Clinical research unit, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| | - B Weyd
- Emergency department, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
| | - B de Kerviler
- Department of digestive surgery, centre hospitalier départemental de Vendée, 85000 La-Roche-sur-Yon, France
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Soma K, Nakamatsu D, Nishida T, Minoura Y, Park M, Sugio R, Okamoto A, Sakamoto T, Tsujii Y, Yamaoka S, Osugi N, Sugimoto A, Mukai K, Matsumoto K, Yamamoto M, Hayashi S, Nakajima S, Fukui K, Inada M. Efficacy and Safety of a Strategy for Reviewing Intravenous Antibiotics for Hospitalized Japanese Patients with Uncomplicated Diverticulitis: A Single-center Observational Study. Intern Med 2022; 61:3475-3482. [PMID: 35527022 PMCID: PMC9790783 DOI: 10.2169/internalmedicine.9361-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objective Treatment for uncomplicated diverticulitis (UD) is not well established. We evaluated the strategy of reviewing intravenous antibiotics for hospitalized Japanese patients with UD. Methods Treatment was based on the physician's choice until August 2018; the indications for hospitalization and treatment have been standardized since September 2018. In this study, we monitored the use of intravenous antibiotics administered to patients hospitalized for UD and then reviewed the need for them on hospital day 3. We compared patients' length of antibiotic use, hospital stay, health care cost, and complications via the review strategy from September 2018 to December 2020 and via the previous physicians' choice strategy from January 2016 to August 2018. Results Two hundred and forty-seven patients were admitted to our hospital because of acute colonic diverticulitis from January 2016 to December 2020. After excluding complicated cases, 106 individuals were enrolled during the period of physician's choice; 87 were enrolled when treatment review was employed. There were no significant differences in age, sex, inflammation site, or severity during the first hospital visit. The median duration of antibiotic use was significantly reduced from 5 to 4 days (p=0.0075), with no marked increase in rates of transfer to surgery, mortality, or readmission due to recurrence. A more significant proportion of patients completed 3-day antibiotic treatment with the review strategy than with the physician's choice strategy (6.6% vs. 25.3%, p=0.0004). However, the length of hospital stay and total medical costs did not decrease. Conclusion The strategy of reviewing treatment on day 3 after hospitalization for UD safety reduced the duration of antibiotic use, but the hospital stay and health care costs did not decrease.
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Affiliation(s)
- Kazumasa Soma
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Yutaro Minoura
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Miyoung Park
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Ryo Sugio
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Akino Okamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Tatsuya Sakamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Yuri Tsujii
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Sho Yamaoka
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Naoto Osugi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Aya Sugimoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Kaori Mukai
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
- Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Japan
| | - Sachiko Nakajima
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Koji Fukui
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
| | - Masami Inada
- Department of Gastroenterology, Toyonaka Municipal Hospital, Japan
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10
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Abstract
BACKGROUND Diverticulitis is a complication of the common condition, diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics, as diverticulitis has been regarded as an infectious disease. Risk factors for diverticulitis, however, may suggest that the condition is inflammatory rather than infectious which makes the use of antibiotics questionable. OBJECTIVES The objectives of this systematic review were to determine if antibiotic treatment of uncomplicated acute diverticulitis affects the risk of complications (immediate or late) or the need for emergency surgery. SEARCH METHODS For this update, a comprehensive systematic literature search was conducted in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform on February 2021. SELECTION CRITERIA Randomised controlled trials (RCTs), including all types of patients with a radiologically confirmed diagnosis of left-sided uncomplicated acute diverticulitis. Comparator and interventions included antibiotics compared to no antibiotics, placebo, or to any other antibiotic treatment (different regimens, routes of administration, dosage or duration of treatment). Primary outcome measures were complications and emergency surgery. Secondary outcomes were recurrence, late complications, elective colonic resections, length of hospital stay, length to recovery of symptoms, adverse events and mortality. DATA COLLECTION AND ANALYSIS Two authors performed the searches, identification and assessment of RCTs and data extraction. Disagreements were resolved by discussion or involvement of the third author. Authors of trials were contacted to obtain additional data if needed or for preliminary results of ongoing trials. The Cochrane Collaboration's tool for assessing risk of bias was used to assess the methodological quality of the identified trials. The overall quality of evidence for outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Effect estimates were extracted as risk ratios (RRs) with 95% confidence intervals. Random-effects meta-analyses were performed with the Mantel-Haenzel method. MAIN RESULTS The authors included five studies. Three studies compared no antibiotics to antibiotics; all three were original RCTs of which two also published long-term follow-up information. For the outcome of short-term complications there may be little or no difference between antibiotics and no antibiotics (RR 0.89; 95% CI 0.30 to 2.62; 3 studies, 1329 participants; low-certainty evidence). The rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics (RR 0.47; 95% CI 0.13, 1.71; 1329 participants; 3 studies; low-certainty evidence). However, there is considerable imprecision due to wide confidence intervals for this effect estimate causing uncertainty which means that there may also be a benefit with antibiotics. One of the two remaining trials compared single to double compound antibiotic therapy and, due to wide confidence intervals, the estimate was imprecise and indicated an uncertain clinical effect between these two antibiotic regimens (RR 0.70; 95% CI 0.11 to 4.58; 51 participants; 1 study; low-certainty evidence). The last trial compared short to long intravenous administration of antibiotics and did not report any events for our primary outcomes. Both trials included few participants and one had overall high risk of bias. Since the first publication of this systematic review, an increasing amount of evidence supporting the treatment of uncomplicated acute diverticulitis without antibiotics has been published, but the total body of evidence is still limited. AUTHORS' CONCLUSIONS The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications. The quality of the evidence is low. Only three RCTs on the need for antibiotics are currently available. More trials are needed to obtain more precise effect estimates.
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Affiliation(s)
- Marie-Louise Dichman
- Department of Surgical Gastroenterology , Hvidovre University Hospital, Copenhagen, Denmark
| | - Steffen Jais Rosenstock
- Department of Surgical Gastroenterology , Hvidovre University Hospital , Copenhagen, Denmark
| | - Daniel M Shabanzadeh
- Department of Surgical Gastroenterology , Hvidovre University Hosipital , Copenhagen, Denmark
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Affiliation(s)
- Charles E Gaber
- Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, and School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alan C Kinlaw
- University of North Carolina School of Pharmacy and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne F Peery
- Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Hawkins AT. Fighting Inertia: Why are we Continuing to Treat Acute Uncomplicated Diverticulitis With Antibiotics? Ann Surg 2021; 274:e443-e444. [PMID: 34353993 PMCID: PMC8497435 DOI: 10.1097/sla.0000000000005138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
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13
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Toresen A, Johanssen A, Ansari OBA, Holmedal SH, Schultz JK. Conservative treatment of perforated diverticulitis: following the latest guidelines pays dividends. Lancet 2021; 398:1517. [PMID: 34688370 DOI: 10.1016/s0140-6736(21)02003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/12/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Aasmund Toresen
- Department of Gastrointestinal Surgery, Akershus University Hospital, L⊘renskog, Norway
| | - Anette Johanssen
- Department of Urology, Akershus University Hospital, L⊘renskog, Norway
| | | | | | - Johannes Kurt Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, L⊘renskog, Norway.
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14
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Aouad S, Ricou C, Mouraux S, Bochatay L. [Management of simple acute diverticulitis : Towards a "less is more" approach]. Rev Med Suisse 2021; 17:1740-1744. [PMID: 34644017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Acute diverticulitis is the most common complication of diverticular disease, increasing in industrialized countries and in young people under 45 years of age. The modified Hinchey classification remains the most widely used and includes simple diverticulitis, i.e. localized inflammation without sepsis, and complicated diverticulitis from pericolic abscess to stercoral peritonitis. Recent studies recommend conservative management of uncomplicated forms. This article summarizes the management of simple acute left-sided diverticulitis based on the new recommendations and focusing on antibiotic treatment, outpatient or inpatient management and indications for colonoscopy.
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Affiliation(s)
- Soumaya Aouad
- Service de médecine interne, Groupement hospitalier de l'Ouest lémanique, Hôpital de Nyon, 1260 Nyon
| | - Camille Ricou
- Service de médecine interne, Groupement hospitalier de l'Ouest lémanique, Hôpital de Nyon, 1260 Nyon
| | - Stéphane Mouraux
- Service de médecine interne, Groupement hospitalier de l'Ouest lémanique, Hôpital de Nyon, 1260 Nyon
| | - Laurent Bochatay
- Service de gastroentérologie, Groupement hospitalier de l'Ouest lémanique, Hôpital de Nyon, 1260 Nyon
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15
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Dichman ML, Shabanzadeh DM. [Acute diverticulitis can be treated without antibiotics]. Ugeskr Laeger 2021; 183:V01210081. [PMID: 34356008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Diverticulitis is a complication to the common condition diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics. Risk factors for diverticulitis, however, may suggest, that the condition is inflammatory rather than infectious. The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests, that antibiotics have no effect on complications, emergency surgery, recurrence, elective colonic resections and long-term complications. The evidence is based on three randomised clinical trials on the need for antibiotics, which is summarised in this review.
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16
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Chabok A, Thorisson A, Nikberg M, Schultz JK, Sallinen V. Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis. Scand J Surg 2021; 110:180-186. [PMID: 33934672 PMCID: PMC8258726 DOI: 10.1177/14574969211011032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022]
Abstract
Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.
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Affiliation(s)
- A. Chabok
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - A Thorisson
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
- Department of Radiology, Region Västmanland Hospital, Västerås, Sweden
| | - M. Nikberg
- Department of Surgery, Region Västmanland Hospital, Västerås, Sweden
- Centre for Clinical Research Uppsala University, Region Västmanland Hospital, Västerås, Sweden
| | - J. K. Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - V Sallinen
- Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
- Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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17
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Sartelli M, Ansaloni L, Bartoletti M, Catena F, Cardi M, Cortese F, Di Marzo F, Pea F, Plebani M, Rossolini GM, Sganga G, Viaggi B, Viale P. The role of procalcitonin in reducing antibiotics across the surgical pathway. World J Emerg Surg 2021; 16:15. [PMID: 33761972 PMCID: PMC7988639 DOI: 10.1186/s13017-021-00357-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/26/2021] [Indexed: 12/29/2022] Open
Abstract
Procalcitonin (PCT) is widely considered as a highly sensitive biomarker of bacterial infection, offering general and emergency surgeons a key tool in the management of surgical infections. A multidisciplinary task force of experts met in Bologna, Italy, on April 4, 2019, to clarify the key issues in the use of PCT across the surgical pathway. The panelists presented the statements developed for each of the main questions regarding the use of PCT across the surgical pathway. An agreement on the statements was reached by the Delphi method, and this document reports the executive summary of the final recommendations approved by the expert panel.
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Affiliation(s)
| | | | - Michele Bartoletti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Maurizio Cardi
- Department of Surgery, “P. Valdoni” Sapienza University, Rome, Italy
| | - Francesco Cortese
- Department of Emergency Surgery, San Filippo Neri Hospital, Roma, Italy
| | | | - Federico Pea
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine, University of Padova, Padova, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
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18
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Poola S, Ritchie M. Antibiotics for Uncomplicated Diverticulitis. Am Fam Physician 2020; 102:Online. [PMID: 33252904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Learn more about the benefits and harms of antibiotics for uncomplicated diverticulitis.
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González Plo D, Plá Sánchez P, León Gámez CL, Remirez Arriaga X, Rial Justo X, Artés Caselles M, Lucena de la Poza JL, Sánchez Turrión V. Update on the management of uncomplicated acute diverticulitis at our centre. Equally effective, more efficient. Gastroenterol Hepatol 2020; 43:426-430. [PMID: 32434733 DOI: 10.1016/j.gastrohep.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 10/17/2019] [Accepted: 01/20/2020] [Indexed: 06/11/2023]
Abstract
GOALS The current trend in the treatment of non-complicated diverticulitis is the outpatient management with antibiotic or even anti-inflammatory regimens in selected cases. We present a comparison of the results in our hospital with different protocols applied in 2016 and 2017. MATERIAL AND METHODS All patients selected for this study were diagnosed with diverticulitis grade Ia of Hinchey's classification according to radiological findings on abdominal CT. We have analyzed two retrospective cohorts: 100 patients treated in 2016 according to the old protocol and 104 patients treated in 2017 with a new protocol. In 2016, the candidates for ambulatory treatment remained under observation for 24 hours before being discharged. The treatment consisted of 14 days of ciprofloxacin and metronidazole. In 2017, only patients with more acute symptoms were observed 24 hours and amoxicillin-clavulanic acid was prescribed for only 5 days. RESULTS The persistence of the disease in 2016 was 6% and in 2017 was only 5.77% (p = 0.944). Recurrence during the first year was 13% in the first group, while in the second it was 5.7%, although this difference was not statistically significant. Likewise, a significant reduction in health costs was achieved. CONCLUSIONS Outpatient treatment of acute uncomplicated diverticulitis with oral treatment seems to be a safe and effective therapeutic strategy in selected patients with low comorbidity.
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Affiliation(s)
- Daniel González Plo
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España.
| | - Pau Plá Sánchez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Carmen Lucero León Gámez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Xabier Remirez Arriaga
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Xiana Rial Justo
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Mariano Artés Caselles
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - José Luis Lucena de la Poza
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Víctor Sánchez Turrión
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
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20
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Juszczyk K, Ireland K, Thomas B, Kroon HM, Hollington P. Safety and efficacy of outpatient management for elderly patients with uncomplicated acute diverticulitis. Eur J Intern Med 2020; 76:123-124. [PMID: 32199730 DOI: 10.1016/j.ejim.2020.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 02/29/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Karolina Juszczyk
- Colorectal Unit, Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia.
| | - Kelsey Ireland
- Flinders University, College of Medicine & Public Health, Bedford Park, SA 5042, Australia
| | - Bev Thomas
- Colorectal Unit, Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia
| | - Hidde M Kroon
- Colorectal Unit, Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia
| | - Paul Hollington
- Colorectal Unit, Division of Surgery & Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA 5042, Australia; Flinders University, College of Medicine & Public Health, Bedford Park, SA 5042, Australia
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21
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Tse W, Johns W, Acosta GA, Rivers J, Amendola M, Miller T. Jejunal/Ileal Diverticulitis: A Rare Condition with Potentially Serious Complications. Am Surg 2020; 86:e108-e110. [PMID: 32223811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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22
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Carabotti M, Annibale B. Mesalamine (5-ASA) for the prevention of recurrent diverticulitis (Review). Tech Coloproctol 2019; 23:597-599. [PMID: 31346815 DOI: 10.1007/s10151-019-02037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/08/2019] [Indexed: 02/08/2023]
Affiliation(s)
- M Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy
| | - B Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy.
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23
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Fornaro R, Caristo G, De Rosa R, Ammirati CA, Oliva A, Batistotti P, Mascherini M, Frascio M. Surgical management of acute diverticulitis. An update based on our experience and literature data. Ann Ital Chir 2019; 90:432-441. [PMID: 31814600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The treatment of acute diverticulitis is a matter of debate and has undergone significant changes. Currently the main focus of surgical treatment is a more conservative and less invasive management. AIMS AND METHODS To focus the role of surgery in the treatment of acute diverticulitis, the Authors have conducted a review of the literature of the last two decades and have revised critically their own experience. RESULTS The indications for elective surgery based on the number of episodes, the young age at diagnosis and the presence of risk factors such as immunosuppression, have to be overcome in favour of a more individual approach based on the severity of the disease. Similarly the presence of pneumoperitoneum is no longer a compelling indication for urgent surgery just as it was in the past. In the treatment of complicated diverticulitis with abscess (Hinchey I-II) is used more and more conservative treatments consisting of guided percutaneous drainage combined with antibiotics. Resection with primary anastomosis with or without diverting ileostomy is preferable to Hartmann's procedure in case of perforated diverticulitis with peritonitis (Hinchey III-IV), using the latter only in the case of comorbidities, severe sepsis, hemodynamic instability or longtime feculent peritonitis (Hinchey IV). Recently, laparoscopic peritoneal lavage was introduced in the treatment of diverticulitis. CONCLUSIONS Thanks to the progress made in conservative and interventional treatment and laparoscopic surgery, an increasingly less invasive treatment is proposed in the management of acute diverticulitis. KEY WORDS Acute diverticulitis, Laparoscopic surgery, Surgical treatment.
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24
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Ma W, Jovani M, Liu PH, Nguyen LH, Cao Y, Tam I, Wu K, Giovannucci EL, Strate LL, Chan AT. Association Between Obesity and Weight Change and Risk of Diverticulitis in Women. Gastroenterology 2018; 155:58-66.e4. [PMID: 29614301 PMCID: PMC6035062 DOI: 10.1053/j.gastro.2018.03.057] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/14/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS There is little evidence that adiposity associates with diverticulitis, especially among women. We conducted a comprehensive evaluation of obesity, weight change, and incidence of diverticulitis in a large cohort of women. METHODS We conducted a prospective cohort study of 46,079 women enrolled in the Nurses' Health Study who were 61-89 years old and free of diverticulitis, diverticular bleeding, cancers, or inflammatory bowel disease at baseline (in 2008). We used Cox proportional hazards models to examine the associations among risk of incident diverticulitis and body mass index (BMI), waist circumference, waist to hip ratio, and weight change from age 18 years to the present. The primary end point was first incident diverticulitis requiring antibiotic therapy or hospitalization. RESULTS We documented 1084 incident cases of diverticulitis over 6 years of follow-up, encompassing 248,001 person-years. After adjustment for other risk factors, women with a BMI ≥35.0 kg/m2 had a hazard ratio for diverticulitis of 1.42 (95% confidence interval [CI], 1.08-1.85) compared to women with a BMI <22.5 kg/m2. Compared to women in the lowest quintile, the multivariable hazard ratios among women in the highest quintile were 1.35 (95% CI, 1.02-1.78) for waist circumference and 1.40 (95% CI, 1.07-1.84) for waist to hip ratio; these associations were attenuated with further adjustment for BMI. Compared to women maintaining weight from age 18 years to the present, those who gained ≥20 kg had a 73% increased risk of diverticulitis (95% CI, 27%-136%). CONCLUSIONS During a 6-year follow-up period, we observed an association between obesity and risk of diverticulitis among women. Weight gain during adulthood was also associated with increased risk.
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Affiliation(s)
- Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manol Jovani
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Po-Hong Liu
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Long H Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yin Cao
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Public Health Sciences, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Idy Tam
- Tufts University School of Medicine, Boston, Massachusetts
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Edward L Giovannucci
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lisa L Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts.
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Dahl C, Crichton M, Jenkins J, Nucera R, Mahoney S, Marx W, Marshall S. Evidence for Dietary Fibre Modification in the Recovery and Prevention of Reoccurrence of Acute, Uncomplicated Diverticulitis: A Systematic Literature Review. Nutrients 2018; 10:nu10020137. [PMID: 29382074 PMCID: PMC5852713 DOI: 10.3390/nu10020137] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022] Open
Abstract
In practice, nutrition recommendations vary widely for inpatient and discharge management of acute, uncomplicated diverticulitis. This systematic review aims to review the evidence and develop recommendations for dietary fibre modifications, either alone or alongside probiotics or antibiotics, versus any comparator in adults in any setting with or recently recovered from acute, uncomplicated diverticulitis. Intervention and observational studies in any language were located using four databases until March 2017. The Cochrane Risk of Bias tool and GRADE were used to evaluate the overall quality of the evidence and to develop recommendations. Eight studies were included. There was "very low" quality evidence for comparing a liberalised and restricted fibre diet for inpatient management to improve hospital length of stay, recovery, gastrointestinal symptoms and reoccurrence. There was "very low" quality of evidence for using a high dietary fibre diet as opposed to a standard or low dietary fibre diet following resolution of an acute episode, to improve reoccurrence and gastrointestinal symptoms. The results of this systematic review and GRADE assessment conditionally recommend the use of liberalised diets as opposed to dietary restrictions for adults with acute, uncomplicated diverticulitis. It also strongly recommends a high dietary fibre diet aligning with dietary guidelines, with or without dietary fibre supplementation, after the acute episode has resolved.
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Affiliation(s)
- Camilla Dahl
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Megan Crichton
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Julie Jenkins
- Department of Nutrition and Dietetics, Robina Hospital, Robina, QLD 4226, Australia.
| | - Romina Nucera
- Department of Nutrition and Dietetics, Robina Hospital, Robina, QLD 4226, Australia.
| | - Sophie Mahoney
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Wolfgang Marx
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
- School of Allied Health, La Trobe University, Melbourne, VIC 3086, Australia.
| | - Skye Marshall
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
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26
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Iannone A, Ruospo M, Wong G, Barone M, Principi M, Di Leo A, Strippoli GFM. Mesalazine for People with Diverticular Disease: A Systematic Review of Randomized Controlled Trials. Can J Gastroenterol Hepatol 2018; 2018:5437135. [PMID: 30320044 PMCID: PMC6167594 DOI: 10.1155/2018/5437135] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 08/12/2018] [Accepted: 08/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms. AIM We systematically reviewed current evidence on benefits and harms of mesalazine versus all other treatments in people with diverticular disease. METHODS We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov for studies published to July 2018. We estimated risk ratios (RR) for dichotomous outcomes (disease remission/recurrence, acute diverticulitis in symptomatic uncomplicated diverticular disease, need for surgery/hospitalization, all-cause/disease-related mortality, adverse events), mean differences (MD) or standardized MD (SMD) for continuous outcomes (quality of life, symptoms score, time to recurrence/remission), and their 95% confidence intervals (CI) using random-effects models. We quantified heterogeneity by Chi2 and I2 tests. We performed subgroup analyses by disease subtype, comparator, follow-up duration, mesalazine dose, and mode of administration. RESULTS We identified 13 randomized trials (n=3028 participants). There was a higher likelihood of disease remission with mesalazine than controls in acute uncomplicated diverticulitis (1 trial, 81 participants, RR=2.67, 95%CI=1.05-6.79), but not in symptomatic uncomplicated diverticular disease (1 trial, 123 participants, RR=1.04, 95%CI=0.81-1.34). There was a lower likelihood of disease recurrence with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 216 participants, RR=0.52, 95%CI=0.28-0.97), but not in acute uncomplicated diverticulitis (7 trials, 2196 participants, RR=0.90, 95%CI=0.61-1.33). There was no difference in the likelihood of developing acute diverticulitis in symptomatic uncomplicated diverticular disease between the two groups (3 trials, 484 participants, RR=0.26, 95%CI=0.06-1.20). There was a higher global symptoms score reduction with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 326 participants, SMD=-1.01, 95%CI=-1.51,-0.52) and acute uncomplicated diverticulitis (2 trials, 153 participants, SMD=-0.56, 95%CI=-0.88,-0.24). CONCLUSIONS Mesalazine may reduce recurrences in symptomatic uncomplicated diverticular disease. There is uncertainty on the effect of mesalazine in achieving diverticular disease remission. Mesalazine may not prevent acute diverticulitis in symptomatic uncomplicated diverticular disease.
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Affiliation(s)
- Andrea Iannone
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Marinella Ruospo
- 2Diaverum Medical Scientific Office, Lund, Sweden
- 3Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Germaine Wong
- 4Sydney School of Public Health, University of Sydney, Australia
- 5Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
| | - Michele Barone
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Mariabeatrice Principi
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Alfredo Di Leo
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Giovanni F. M. Strippoli
- 2Diaverum Medical Scientific Office, Lund, Sweden
- 4Sydney School of Public Health, University of Sydney, Australia
- 6Diaverum Academy, Lund, Sweden
- 7Section of Nephrology, Department of Emergency and Organ Transplantation, University of Bari, Italy
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Kubo H, Asai G, Haraguchi K, Shibahara Y, Kihara T, Yamakawa G, Kira F, Higashi H, Morishita S, Fujie H, Matsumoto M, Shimura W. Liver Abscess and Portal Vein Thrombosis Due to Ileal Diverticulitis Mediated by Barium Fluoroscopy. Intern Med 2017; 56:3255-3259. [PMID: 29021445 PMCID: PMC5742403 DOI: 10.2169/internalmedicine.9223-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of liver abscess and portal vein thrombosis, which occurred due to diverticulitis at the terminal ileum in a 59-year-old man. The patient underwent a barium fluoroscopic examination 1 month before presenting to our hospital. He also showed liver dysfunction due to thrombosis at the superior mesenteric and portal veins. His inflammation gradually subsided after the initiation of treatment, but the recovery was not sufficient. Thus, surgery was performed. The patient condition improved after surgery and he was discharged. Barium examinations are relatively safe, but can sometimes cause severe adverse effects in patients with certain risk factors, and an appropriate diagnosis and treatment are necessary when symptoms appear.
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Affiliation(s)
- Haremaru Kubo
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Genki Asai
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Kou Haraguchi
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Yu Shibahara
- Department of Surgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Toshihiro Kihara
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Genta Yamakawa
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Fumitaka Kira
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Hisato Higashi
- Department of Surgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Shinji Morishita
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Hajime Fujie
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Masao Matsumoto
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
| | - Wahei Shimura
- Department of Gastroenterology, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Japan
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Cuomo R, Barbara G, Annibale B. Rifaximin and diverticular disease: Position paper of the Italian Society of Gastroenterology (SIGE). Dig Liver Dis 2017; 49:595-603. [PMID: 28215517 DOI: 10.1016/j.dld.2017.01.164] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
Abstract
Management of diverticular disease has significantly improved in the last decade. Antibiotic treatment is used for symptom relief and prevention of complications. In Italy, the non-absorbable antibiotic rifaximin is one of the most frequently used drugs, and it is perceived as the reference drug to treat symptomatic diverticular disease. Its non-systemic absorption and high faecal concentrations have oriented rifaximin use to the gastrointestinal tract, where rifaximin exerts eubiotic effects representing an additional value to its antibiotic activity. This position paper was commissioned by the Italian Society of Gastroenterology governing board for a panel of experts (RC, GB, BA) to highlight the indications for treatment of diverticular disease. There is a lack of rationale for drug use for the primary prevention of diverticulitis in patients with diverticulosis; thus, rifaximin use should be avoided. The cyclic use of rifaximin, in association with high-fibre intake, is safe and useful for the treatment of symptomatic uncomplicated diverticular disease, even if the cost-efficacy of long-term treatment remains to be determined. The use of rifaximin in the prevention of diverticulitis recurrence is promising, but the low therapeutic advantage needs to be verified. No evidence is available on the efficacy of rifaximin treatment on acute uncomplicated diverticulitis.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Science and Translational Medicine Department, Sapienza University, Rome, Italy.
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Festa V, Spila Alegiani S, Chiesara F, Moretti A, Bianchi M, Dezi A, Traversa G, Koch M. Retrospective comparison of long-term ten-day/month rifaximin or mesalazine in prevention of relapse in acute diverticulitis. EUROPEAN REVIEW FOR MEDICAL AND PHARMACOLOGICAL SCIENCES 2017; 21:1397-1404. [PMID: 28387885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Diverticular disease (DD) of the colon has an increasing burden on health services. The effectiveness of rifaximin for the treatment of DD, is not yet established. The aim of this study is to assess the impact of long-term treatment with rifaximin or mesalazine in a 10-day schedule for the prevention of recurrent diverticulitis. PATIENTS AND METHODS This is a retrospective study. We identified all consecutive patients with DD and previous acute diverticulitis (AD) in our outpatients' database; 124 patients, were included. The recommended therapy consisted of a ten-day/month treatment with either rifaximin (400 mg bid), or mesalazine (2.4 g/daily). Primary end point was AD recurrence. RESULTS Between 2010 and 2014, 72 patients were treated with rifaximin and 52 with mesalazine. During a median follow-up of 15 months (range 1-50), we observed 21 episodes of AD among users of either rifaximin (n=7; 0.54 per 100 person-months), or mesalazine group (n=14; 1.46 per 100 person-months). Kaplan-Meier survival estimates of recurrent AD significantly differed between rifaximin and mesalazine groups (p=0.015). The multivariate Cox regression analysis showed that AD recurrence was significantly associated with therapy (rifaximin vs. mesalazine, adjusted HR 0.27; 95% CI: 0.10 to 0.72), age and gender. CONCLUSIONS Long-term treatment with rifaximin in a 10-day schedule appears more effective than mesalazine in preventing recurrent AD.
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Affiliation(s)
- V Festa
- Gastroenterology and Liver Unit, S. Filippo Neri General Hospital, Rome, Italy.
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30
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Auer S. [Not Available]. Rev Med Suisse 2016; 12:2188. [PMID: 28707837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Silva Auer
- Policlinique mèdicale universitaire, Lausanne
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Fernández López AJ, González Valverde M, Martínez Sanz N, Tamayo Rodríguez ME, Albarracín Marín Blázquez A. Acute abdomen from duodenal diverticulitis. A case report. Rev Esp Enferm Dig 2016; 108:661-662. [PMID: 27701888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Duodenal diverticula are a rare, usually asymptomatic clinical condition. When a complication arises clinical suspicion is key for the diagnosis. On occasion these patients receive a delayed diagnosis and undergo inadequate medical therapy. We report the case of a patient with evidence of duodenal diverticulitis in association with gallbladder inflammation by contiguity, as well as his diagnosis and management.
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Briongos-Figuero LS, Bachiller-Luque P, Pastor-Mancisidor L, Carreres-Rodríguez A, Mena-Martín FJ. [Cerebellar syndrome induced by metronidazole: a rare side effect]. Rev Neurol 2016; 62:333-334. [PMID: 26988172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Humes D, Spiller RC. Colonic diverticular disease: medical treatments for acute diverticulitis. BMJ Clin Evid 2016; 2016:0405. [PMID: 26854496 PMCID: PMC4745836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Diverticula (mucosal outpouchings through the wall of the colon) are rare before the age of 40 years, after which prevalence increases steadily and reaches over 25% by 60 years. However, only 10% to 25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses. METHODS AND OUTCOMES We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of medical treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS At this update, searching of electronic databases retrieved 193 studies. After deduplication and removal of conference abstracts, 75 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 37 studies and the further review of 38 full publications. Of the 38 full articles evaluated, four systematic reviews and one RCT were added at this update. We performed a GRADE evaluation for two PICO combinations CONCLUSIONS In this systematic overview, we categorised the efficacy for one comparison based on information about the effectiveness and safety of medical treatment (mesalazine, antibiotics [any] only) versus placebo or no treatment.
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Affiliation(s)
- David Humes
- Department of Surgery, University of Nottingham, Nottingham, UK
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Nespoli L, Lo Bianco G, Uggeri F, Romano F, Nespoli A, Bernasconi DP, Gianotti L. Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis. World J Gastroenterol 2015; 21:8366-8372. [PMID: 26217088 PMCID: PMC4507106 DOI: 10.3748/wjg.v21.i27.8366] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 03/24/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.
METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay.
RESULTS: Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03).
CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.
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Chang SS, Hu HY. Long-term use of steroids protects from the development of symptomatic diverticulitis requiring hospitalization in the Asian population. PLoS One 2015; 10:e0124598. [PMID: 25919040 PMCID: PMC4412717 DOI: 10.1371/journal.pone.0124598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 11/30/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The pathophysiology of diverticulitis is poorly understood. Factors such as physical inactivity, constipation, obesity, smoking, and the use of nonsteroidal antiinflammatory drugs (NSAIDs) have been associated with an increased risk of diverticular disease. To evaluate whether patients exhibiting long-term steroid use are at increased risk of colonic diverticulitis. METHOD We conducted a population-based, nested case-control study. Data were retrospectively collected from the National Health Insurance Research Database. The study cohort comprised patients diagnosed with diverticulitis, identified using inpatient discharge records using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes (562.11 and 562.13), and those who were administered one or more prescriptions for corticosteroids for systemic use. Control patients were matched to cases by age, sex, NSAID use, laxative drug use, and index date. We enrolled 690 patients with colonic diverticulitis and 2760 in the control group. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression. RESULTS Compared with steroid nonusers, the adjusted ORs were 0.60 (95% CI = 0.35-1.06) and 0.80 (95% CI = 0.64-1.008) in current steroid users and previous steroid users, respectively. In addition, the adjusted ORs were 0.55 (95% CI = 0.31-0.98), 0.57 (95% CI = 0.31-0.98), and 0.44 (95% CI = 0.22-0.86) for steroid use duration more than half time by an exposure period of 90 days, 180 days, and 365 days before the claim date of colonic diverticulitis, respectively. CONCLUSIONS The results indicated that long-term steroid use within one year is associated with lower risk of colonic diverticulitis.
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Affiliation(s)
- Shen-Shong Chang
- Division of Gastroenterology, Taipei City Hospital Yang-Ming Branch, Taipei, Taiwan
- Department of Internal Medicine, Taipei City Hospital Yang-Ming Branch, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Yun Hu
- Institute of Public Health and Department of Public Health, National Yang-Ming University, Taipei, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
- * E-mail:
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Arsic I, Cuk P, Nielsen MF, Al Karim EBA. [Jejunal diverticulitis as the cause of acute abdomen]. Ugeskr Laeger 2014; 176:V02130111. [PMID: 25497619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We present two patients with jejunal diverticulitis. Diverticula in jejunum and ileum are very rare, occurring with an incidence of 0.07-2% in the gastrointestinal tract. They are often associated with unspecific symptoms as intermittent abdominal pain, nausea and diarrhoea. The treatment of mild diverticular disease is intravenous fluids and antibiotics. If there is an occurrence of peritonitis as a complication of jejunal diverticulitis, laparatomy may be indicated. Both of the patients received a conservative treatment with intravenous fluids and antibiotics with good response.
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Butt WT, Rauf A, Abbasi TR, Mahmood S, Geoghegan J. Caecal diverticulitis: a rare cause of right iliac fossa pain. Ir Med J 2014; 107:291-292. [PMID: 25417391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We present a case of a young boy with an unusual cause of right iliac fossa pain. His history, examination and laboratory investigations suggested a diagnosis of acute appendicitis. However preoperative abdominal CT revealed an inflamed solitary caecal diverticulum and a normal appendix. He was subsequently treated conservatively and recovered well, saving him from undergoing a general anaesthetic and abdominal surgery.
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Abstract
PURPOSE OF REVIEW Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach. METHODS Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion. RESULTS Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %. CONCLUSION Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.
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Affiliation(s)
- J D Jackson
- Barts and The London School of Medicine and Dentistry, London, UK,
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39
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Snajdauf M, Adámek S. [Are antibiotics necessary in the treatment of uncomplicated diverticulitis?]. Rozhl Chir 2013; 92:544-548. [PMID: 24295475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION This paper deals with the results of recently published studies on the importance of the use of antibiotics in the treatment of uncomplicated diverticulitis. It is based on the articles available in the Medline database. CONCLUSION The prevalence of diverticulosis in the developed countries of the Western world is increasing and, along with it, the costs of treatment of diverticulitis. The use of antibiotics in the treatment of uncomplicated diverticulitis does not reduce the incidence of complications or shorten the treatment, nor does it reduce the risk of recurrence.
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Evaristo-Méndez G, Sánchez-Hernández AT, Melo-Velázquez A, Ventura-Sauceda FA, Sepúlveda-Castro RR. [Sigmoido-buttock fistula by diverticulitis: report of a rare complication]. CIR CIR 2013; 81:158-162. [PMID: 23522319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION The complicated diverticulitis of the colon is characterized by its association with abscesses, bleeding, stenosis, perforation, obstruction or fistula. We report a case of spontaneous sigmoido-cutaneous fistula from diverticulitis to an unusual place in the gluteal region. CLINICAL CASE A 59-year-old male patient presented an inflammatory wound in left buttock without response to the conservative medical treatment. The fistulography, colonoscopy, barium enema and computed tomography showed a sigmoido-cutaneous fistula to the left buttock from diverticulitis. The biopsy of the lesion ruled out malignancy. We performed an elective sigmoid resection with primary colorectal anastomosis, partial fistulectomy and injection of a fibrin sealant in the residual tract. DISCUSSION The colon-cutaneous fistulas from diverticulitis are relatively rare. We report a spontaneous fistula with origin in a single diverticulum in the sigmoid colon and that drained through the piriform fossa of the pelvic floor to the skin of the left buttock. CONCLUSIONS A high index of suspiscion is necessary to not confuse the colo-buttock fistula with local abscesses.
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Affiliation(s)
- Gerardo Evaristo-Méndez
- Departamento de Cirugía General, Hospital Regional "Dr. Valentín Gómez Farías," Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Zapopan, Jalisco, México.
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Reviewers question the use of antibiotics for uncomplicated diverticulitis. BMJ 2012; 345:e7825. [PMID: 23169806 DOI: 10.1136/bmj.e7825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
BACKGROUND Diverticulitis is an inflammatory complication to the very common condition diverticulosis. Uncomplicated diverticulitis has traditionally been treated with antibiotics with reference to the microbiology, extrapolation from trials on complicated intra-abdominal infections and clinical experience. OBJECTIVES To assess the effects of antibiotic interventions for uncomplicated diverticulitis on relevant outcome. SEARCH METHODS Studies were identified by computerised searches of the The Cochrane Library (CENTRAL), MEDLINE and EMBASE. Ongoing trials were identified and reference lists of identified trials and relevant review articles were screened for additional studies. SELECTION CRITERIA RCTs including all types of patients with a radiological confirmed diagnosis of left-sided uncomplicated diverticulitis. Interventions of antibiotics compared to any other antibiotic treatment (different regime, route of administration, dosage or duration of treatment), placebo or no antibiotics. Outcome measures were complications, emergency surgery, recurrence, late complications and duration of hospital stay and recovery of signs of infection. DATA COLLECTION AND ANALYSIS Two authors performed the searches, identification of RCTs, trial assessment and data extraction. Disagreements were resolved by discussion or involvement of a third part. Authors of trials were contacted to obtain additional data if needed or were contacted for preliminary results of ongoing trials. Effect estimates were extracted as relative risks (RR). MAIN RESULTS Three RCTs were identified. A qualitative approach with no meta analysis was performed because of variety in interventions between included studies. Interventions compared were antibiotics to no antibiotics, single to double compound antibiotic therapy and short to long IV administration. None of the studies found significant difference between the tested interventions. Risk of bias varied from low to high. The newest RCT overall had the best quality and statistical power. AUTHORS' CONCLUSIONS The newest evidence from one RCT says there is no significant difference between antibiotics versus no antibiotics in the treatment of uncomplicated diverticulitis. Previous RCTs have only suggested a non-inferiority between different antibiotic regimes and treatment lengths. This new evidence needs confirmation from more RCTs before it can be implicated safely in clinical guidelines. Ongoing RCTs will be published in the years to come and more are needed. The role of antibiotics in the treatment of complicated diverticulitis has not been investigated yet.
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Affiliation(s)
- Daniel M Shabanzadeh
- Department of Surgical Gastroenterology K, Bispebjerg Hospital, Copenhagen NV, Denmark.
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Ruiz-Tovar J, Beni R, Gras M. New therapeutic weapon in the treatment of refractory acute diverticulitis. Surg Infect (Larchmt) 2012; 13:278-9. [PMID: 22870902 DOI: 10.1089/sur.2011.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Razdan R, Oatis K, Specht N. Recurrent duodenal diverticulitis after surgical resection of the diverticulum: a case report and literature review. Conn Med 2011; 75:469-472. [PMID: 21980677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Duodenal diverticulitis has been considered a rare entity. The diagnosis with computed tomography has become a fast and noninvasive means of detection and guide to management. Cases of surgically resected duodenal diverticula reforming and reinfecting are rarer yet, often presenting with similar symptoms. Duodenal diverticulitis can present with a wide range of symptoms mimicking anything from gastritis to acute abdomen, or as in the case of our patient, as mid abdominal pain with newly developed liver abscess. According to the literature, duodenal diverticula are incidentally discovered at a rate of 5% to 10% in living adults and in up to 22% at autopsy.
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Boermeester MA, Stoker J. [Accurate predictors for acute diverticulitis]. Ned Tijdschr Geneeskd 2011; 155:A2848. [PMID: 21262029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In a relatively high percentage of patients with a clinically suspected diverticulitis a different diagnosis is established after imaging tests, such as 'appendicitis' or 'intestinal obstruction'. The clinical diagnosis 'acute diverticulitis' is correct for between 43% and 68% of suspected patients. Strongly predictive variables for the diagnosis are tenderness in the left lower abdomen only, CRP > 50 mg/l and absence of vomiting. This triad has a positive predictive value of 97% (95% CI: 83-99) for the final diagnosis 'diverticulitis'. The negative predictive value is much lower, namely 47%: the absence of 1 of the 3 factors does not (sufficiently) exclude 'diverticulitis'. This triad can be an easy-to-use decision rule to rule in diverticulitis.
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Rodríguez-Cerrillo M, Poza-Montoro A, Fernandez-Diaz E, Romero AI. Patients with uncomplicated diverticulitis and comorbidity can be treated at home. Eur J Intern Med 2010; 21:553-4. [PMID: 21111943 DOI: 10.1016/j.ejim.2010.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 09/01/2010] [Accepted: 09/02/2010] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients with uncomplicated diverticulitis and comorbidity are usually hospitalized. We analyze the efficacy and safety of treating these patients in Hospital at Home. METHODS Prospective study since January 2007 to December 2009. Patients were transferred to the Hospital at Home after 12-24h at Emergency Department Observation Ward. All patients were treated with intravenous antibiotic until clinical condition improved. RESULTS 176 patients were diagnosed with uncomplicated diverticulitis at the Emergency Department. 18% of them (33) had comorbidity. Twenty four patients were transferred to the Hospital at Home (seventeen patients had cardiopathy, four diabetes mellitus and three chronic renal failure). Mean age was 73.4 years. All patients had abdominal pain and 29.1% fever; 45.8% presented with leucocytosis. 20.8% had a previous history of diverticulitis. Mean stay of patients was 9 days. All patients had a favorable course. The home treatment was successfully completed in 100% of patients. 95% of the patients expressed their satisfaction with this type of treatment. CONCLUSIONS Treatment of patients with uncomplicated diverticulitis and comorbidity at home after a short period of observation in Hospital is safe and effective.
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Abstract
PURPOSE Many patients with acute diverticulitis can be managed as outpatients, but the success rate of this approach has not been thoroughly studied. We analyzed a large cohort of patients treated on an outpatient basis for an initial episode of acute diverticulitis to test our hypothesis that outpatient treatment of acute diverticulitis is highly effective. METHODS We analyzed patients within the Kaiser Permanente Southern California system (from 2006 to 2007) who were diagnosed with an initial episode of diverticulitis during an emergency room visit and subsequently discharged home. Each patient underwent a computed tomography (CT) scan for diagnosis or for confirmation of a diagnosis, and each radiologic report was evaluated regarding the presence of free fluid, phlegmon, perforation, and abscess. Treatment failure was defined as a return to the emergency room or an admission for diverticulitis within 60 days of the initial evaluation. RESULTS Our study included 693 patients, of whom 54% were women, the average age was 58.5 years, and 6% failed treatment. In multivariate analysis, women (odds ratio, 3.08 [95% CI, 1.31-7.28]) and patients with free fluid on CT scan (odds ratio, 3.19 [95% CI, 1.45-7.05]) were at significantly higher risk for treatment failure. Age, white blood cell count, Charlson score, and duration of antibiotics were not significant predictive factors. CONCLUSIONS In a retrospective analysis, among a cohort of patients who were referred for outpatient treatment, we found that such treatment was effective for the vast majority (94%) of patients. Women and those with free fluid on CT scan appear to be at higher risk for treatment failure.
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Affiliation(s)
- David A Etzioni
- Department of Colorectal Surgery, University of Southern California, Los Angeles, California 90033, USA.
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48
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Hudson CM. You're the flight surgeon: diverticulitis. ACTA ACUST UNITED AC 2010; 81:82-3. [PMID: 20058745 DOI: 10.3357/asem.23006.2009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Probiotics are preparations containing viable microorganisms that confer potential health benefits for the host. Alteration of bacterial flora both in terms of specific content and concentration may be beneficial in many gastrointestinal disorders. Probiotics are widely used for the management of these conditions in many countries. However, mechanisms of probiotics are incompletely understood. Benefits observed clinically with one species or combinations of species can not be generalized. The optimal dose of treatment has to be determined. Although probiotics are generally regarded safe, caution is needed when using these supplements routinely. It has been proved, that severe adverse events can occur as a complication of probiotic treatment. This review summarizes the recent knowledge concerning the use of probiotics in gastrointestinal disorders.
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Affiliation(s)
- Gábor Lakatos
- Semmelweis Egyetem, Altalános Orvostudományi Kar II. Belgyógyászati Klinika Budapest Szentkirályi u. 46. 1088 Budapest.
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Martín Gil J, Serralta De Colsa D, García Marín A, Vaquero Rodríguez A, Rey Valcárcel C, Pérez Díaz MD, Sanz Sánchez M, Turégano Fuentes F. [Safety and efficiency of ambulatory treatment of acute diverticulitis]. Gastroenterol Hepatol 2009; 32:83-7. [PMID: 19231679 DOI: 10.1016/j.gastrohep.2008.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 10/07/2008] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management. OBJECTIVE To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients. METHODS We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7-10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month. RESULTS The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery. CONCLUSIONS In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs.
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Affiliation(s)
- Jorge Martín Gil
- Servicio de Cirugía General y del Aparato digestivo II, Sección de Cirugía de Urgencias, Hospital General Universitario Gregorio Marañón, Madrid, España.
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