Acute left colonic diverticulitis in the emergency setting: from diagnosis to treatment

Sartelli, Massimo; Simone, Belinda DE; Catena, Fausto; Siquini, Walter; Vallicelli, Carlo

doi:10.23736/s2724-5691.23.09857-x

Cited by 3 publications

(7 citation statements)

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“…Their treatment is conservative in most cases, sometimes even handled as an outpatient [14,15]. In complicated forms with purulent or faecal peritonitis, extensive bowel perforation or widespread abdominal collections, surgery is mandatory [7][8][9]. The preferred treatment for localized abdominal abscesses, found in about 25% of complicated ADs, is still debated [4].…”

Section: Discussionmentioning

confidence: 99%

“…Currently, recent guidelines recommend antibiotic therapy for abscesses up to 3 or 4 cm in diameter. When reachable, PD is recommended for those larger than 3 or 4 cm [7][8][9]. Nevertheless, little evidence is available to support this.…”

Section: Discussionmentioning

confidence: 99%

“…It is usually diagnosed in approximately 15-20% [1][2][3][4] of AD cases, mostly using contrast-enhanced-computed-tomography scan (CTscan) [5]. DAs are classified according to location and size and the most widely used classifications for staging are the best-known Hinchey's [6] and the most recent one from the World Society of Emergency Surgery (WSES) [7]. According to Hinchey's modified classification, DA can be confined in pericolic fat, smaller than 5 cm (stage Ib) or distant intraabdominal/retroperitoneal at least 5 cm in size (stage II).…”

Section: Introductionmentioning

confidence: 99%

“…Elective surgery is considered for patients after the resolution of acute episodes and consists of colic resection and primary anastomosis (PA). The indication is based on the quality of life, the number of acute episodes and the wellness intervals, the immunity status and the acceptance of possible complications [7]. On the contrary, the indication for emergency surgery is accepted in case of severe complications of AD, such as extensive abdominal collections, or entero-visceral fistulas, as well as after the failure of conservative treatment, such as antibiotics or percutaneous drainage.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

et al. 2023

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Management of diverticular abscess (DA) is still controversial. Antibiotic therapy is indicated in abscesses ≤ 4 cm, while percutaneous drainage/surgery in abscesses > 4 cm. The study aims to assess the role of antibiotics and surgical treatments in patients affected by DA. We retrospectively analyzed 100 consecutive patients with DA between 2013 and 2020, with a minimum follow-up of 12 months. They were divided into two groups depending on abscess size ≤ or > 4 cm (group 1 and group 2, respectively). All patients were initially treated with intravenous antibiotics. Surgery was considered in patients with generalized peritonitis at admission or after the failure of antibiotic therapy. The primary endpoint was to compare recurrence rates for antibiotics and surgery. The secondary endpoint was to assess the failure rate of each antibiotic regimen resulting in surgery. In group 1, 31 (72.1%) patients were conservatively treated and 12 (27.9%) underwent surgery. In group 2, percentages were respectively 50.9% (29 patients) and 49.1% (28 patients). We observed 4 recurrences in group 1 and 6 in group 2. Recurrence required surgery in 3 patients/group. We administered amoxicillin-clavulanic acid to 74 patients, piperacillin-tazobactam to 14 patients and ciprofloxacin + metronidazole to 12 patients. All patients referred to surgery had been previously treated with amoxicillin-Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation clavulanic acid. No percutaneous drainage was performed in a hundred consecutive patients. Surgical treatment was associated with a lower risk of recurrence in patients with abscess > 4 cm, compared to antibiotics. Amoxicillin-clavulanic acid was associated with a higher therapeutic failure rate than piperacillin-tazobactam/ciprofloxacin + metronidazole.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

et al. 2023

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“…5 Contrast-enhanced abdominal computed tomography (CEACT) is still considered the criterion standard for the assessment of suspected acute diverticulitis. 6 In recent years, the use of point-of-care ultrasound (POCUS) has been introduced in the initial evaluation of a patient complaining of acute abdominal pain and, specifically, with suspected acute diverticulitis. 3,7 Staging of the disease, coupled with patient physiology, is a cornerstone in deciding the best strategy to adopt.…”

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confidence: 99%

Surgeon-performed ultrasound for the staging of acute diverticulitis: Preliminary results of a prospective study

Zago

Biloslavo

Mariani

et al. 2021

J Trauma Acute Care Surg

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Although contrast-enhanced abdominal computed tomography (CEACT) is still considered the criterion standard for the assessment of suspected acute diverticulitis, in recent years, the use of point-of-care ultrasound (POCUS) has been spreading more and more in this setting. The aim of this study was to compare CEACT to POCUS for the diagnosis and staging of suspected acute diverticulitis. METHODS:This is a prospective study conducted on 55 patients admitted to the emergency department of two Italian Hospitals with a clinical suspicion of acute diverticulitis between January 2014 and December 2017. All the patients included underwent POCUS first and CEACT immediately afterward, with the diagnosis and the staging reported according to the Hinchey (H) classification modified by Wasvary et al.[Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg. 1999;65:632-635.] Three surgeons performed all the POCUS, and the same two radiologists retrospectively analyzed all the CEACT images. The radiologists were informed of the clinical suspicion but unaware of the POCUS findings. The CEACTwas used as the criterion standard for the comparison. RESULTS:The final cohort included 30 females (55%) and 25 males (45%). The median age was 62 years (range, 24-88 years), and the median body mass index was 26 kg/m 2 (range, 19-42 kg/m 2 ). Forty-six of 55 patients had a confirmed diagnosis of acute diverticulitis on both POCUS and CEACT, whereas, in 7 patients, the diagnosis was not confirmed by both methods. Point-of-care ultrasound sensitivity and specificity were 98% and 88%, respectively. Point-of-care ultrasound positive and negative predictive values were 98% and 88%, respectively. Point-of-care ultrasound accuracy was 96%. Point-of-care ultrasound classified 33 H1a, 11 H1b, 1 H2, and 1 H3 acute diverticulitis. This staging was confirmed in all patients but three (93%) by CEACT. CONCLUSION:Point-of-care ultrasound appeared a reliable technique for the diagnosis and the staging of clinically suspected H1 and H2 acute diverticulitis. It could contribute in saving time and resources and in avoiding unnecessary radiation exposure to most patients.

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ACUTE UNCOMPLICATED DIVERTICULITIS: Guidelines on Diagnosis and Management: is everything fine?

Morini

2023

GHOA

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The transition from intravenous (IV) antibiotic therapy to oral therapy and the observation that in patients with acute uncomplicated diverticulitis (AUD), treatment with or without antibiotics gave similar results in both hospitalized and outpatients, opened the way for out-of-hospital treatment in selected patients with CT-confirmed diagnosis. Due to economic constraints and a growing demand for hospitalization, home hospital care (HAH) and other community-based services was supported to alleviate the burden on emergency departments (EDs). This resulted in significant cost savings for the National Health Service (NHS) but, in many countries, community services are not uniformly present, leading to health care inequality. Relationships between hospital and community doctors indicate poor professional communication. Shared guidelines could lead to increased adherence. Some conditional recommendations based on low-certainty evidence related to the diagnosis and management of AUD remain controversial. Even after recovery from an episode, the question of whether to pursue conservative management or elective surgery is still open for debate. The outpatient treatment is understood as referring to both patients managed by hospital doctors and those treated by general physicians in their office. On management and outcomes of patients with AUD diagnosis in primary care there is little data. AUD treatment without antibiotics encounters resistance in many countries for multiple reasons, including low implementation and uncertain dissemination of guidelines recommendations. This would require greater control and commitment on the part of Institutional bodies and scientific societies.

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Acute left colonic diverticulitis in the emergency setting: from diagnosis to treatment

Cited by 3 publications

References 50 publications

Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

Outcomes of surgical treatment of diverticular abscesses after failure of antibiotic therapy

Surgeon-performed ultrasound for the staging of acute diverticulitis: Preliminary results of a prospective study

ACUTE UNCOMPLICATED DIVERTICULITIS: Guidelines on Diagnosis and Management: is everything fine?

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