Experience of managing complicated diverticulitis of colon: a retrospective case series from South Asian country.

OBJECTIVE: To assess the morbidity and mortality associated with complicated diverticulitis in Pakistan. METHODS: The retrospective case series was conducted at an urban tertiary care university hospital of Karachi, Pakistan, comprising data from December 1989 to November 2010. International Classification of Diseases codes for diverticular disease and diverticulitis with abscess, fistula, stricture, bowel obstruction and perforation were obtained from the medical record department. SPSS 19 was used for statistical analysis. RESULTS: A total of 60 (1.9%) cases with complicated diverticulitis were located from among 3170 records reviewed. Mean age was 62.7 +/- 13 years with male-to-female ratio being 36:24. In 37 (62%) patients, the diagnosis was established on computed tomography scan of the abdomen, followed by barium enema in 12 (20%) and colonoscopy in 11 (18%). Post-operative morbidity was observed in 24 (40%) and 7 (16%) expired within 28 days of surgery. Post-operative intra-abdominal sepsis, wound dehiscence and incisional hernia were significantly associated with generalised peritonitis (p < 0.05), while admission to intensive care unit was associated with age over 60 years and faecal peritonitis. Post-operative mortality was significantly associated with high American Society of Anaesthesiologists-score III and IV and age above 60 years. CONCLUSION: Complicated diverticulitis carries significant morbidity and mortality in Pakistani population. Since the trend is on the rise, therefore we propose a prospective multi-centre cohort study to understand the spectrum of disease, management and identification of risk factors to achieve the best possible outcomes in patients with complicated diverticulitis.

Routine screening for colon cancer after conservative treatment of diverticulitis.

BACKGROUND AND AIMS: It is generally advised to perform colonoscopy after conservatively treated diverticulitis because colon cancer may present itself with similar symptoms, laboratory and radiological results. With this study we investigated in what percentage of patients a malignancy was found by performing routine colonoscopy or radiologic imaging after a conservatively treated episode of diverticulitis, and whether this follow-up programme could be reserved for a selected group of patients. METHODS: In our hospital, routine colonoscopy or, as a second choice, radiologic imaging has been standard practice over the last decade. We collected all colonoscopy and radiologic imaging results that were conducted of all 516 patients who were diagnosed with diverticulitis in this period. RESULTS: Of those 516 patients, 378 had undergone colonoscopy, 45 radiologic imaging and 93 did not undergo any additional investigation. Eight cases of malignant neoplasia were found in those patients (2.1%), and an additional number of 40 adenomatous polyps (9.5%). Six out of 8 patients with colon cancer reported rectal blood loss, significant weight loss or persisting abdominal pain after being treated for diverticulitis. CONCLUSIONS: In patients who were conservatively treated with routine colonoscopy or radiologic imaging for apparent diverticulitis, a malignant tumour was found in the colon in 2.1% of them. If only performed in patients reporting alarm symptoms, a case of colon cancer would be missed in only 0.5% of patients conservatively treated for diverticulitis. Therefore, screening for colon cancer after conservative treatment of diverticulitis is only indicated in symptomatic patients.

Complicated sigmoid diverticulitis.

In medical practice, the colonic diverticulitis diagnosis is easy, based especially on a barium enema and an inferior digestive endoscopy, but the diverticulitis complications, especially metastatic infections, raise serious positive and differential diagnosis problems. We present the case of a 51 year old male who comes with hepatomegaly and multiple hepatic formations, in deteriorating clinical condition, context suggestive of secondary metastasis, but after investigation it was demonstrated they were of infectious nature, from a sigmoidian diverticulitic abscess. In this case, the hepatic biopsy was appropriate and it represented an important moment in the management of the patient.

[Diverticulosis--diverticulitis]. / Divertikulose--Divertikulitis.

Diverticular disease is a common disorder in the western world. The course of the illness is benign: At least 75% of all patients with diverticular disease remain asymptomatic life long. 10-20% develop clinical symptoms, usually painful diverticulitis. Diverticular disease is diagnosed clinically in most cases. Computed tomography (CT) has replaced contrast enema as the diagnostic procedure of choice for acute diverticulitis. Most patients with uncomplicated diverticulitis can be treated as outpatients Bowel rest, intravenous fluid therapy, broad spectrum antibiotics are treatment modelities if a patient has been hospitalized. Close follow-up is mandatory, especially in patients treated as outpatients. Failure to improve with conservative medical therapy warrants a diligent search for complications and surgical consultation. Surgery may be nessasary in a few of hospitalized patients. Commonly, the operation is performed in a single-stage procedure. Once the acute setting has passed, a colonoscopy should be electively performed to exclude competing diagnoses particularly colonic cancer.

Management of acute diverticulitis in the East Anglian region: results of a United Kingdom regional survey.

PURPOSE: Acute diverticulitis is the most common presentation of diverticular disease; however, no published guidelines for management are available in the United Kingdom. This survey was designed to assess the current United Kingdom regional practice compared with the guidelines published by The American Society of Colon and Rectal Surgeons. METHODS: A questionnaire survey focused on the management of acute diverticulitis was sent to all consultants, specialist registrars, and staff-grade surgeons in general surgery in one United Kingdom region. RESULTS: Eighty-two questionnaires were returned (80 percent). A majority (80 percent) would request routine blood tests, abdominal, and erect chest x-rays on arrival. Pethidine (56 percent) was the preferred analgesic, followed by morphine (40 percent). Ninety-four percent used an antibiotic combination of second/third-generation cephalosporin and metronidazole. Computerized tomography was the most commonly used initial investigation (42 percent). Forty percent use barium enema and 31 percent use a combination of barium enema and sigmoidoscopy as follow-up investigations. In patients older than aged 50 years, elective resection would be considered by a majority (51 percent) only when complications arose. In those aged 50 years or younger, 35 percent would resect only if complications arose with only 6 percent after a single episode of acute diverticulitis. CONCLUSIONS: There are major differences in the management of patients with acute diverticulitis in our current practice in one United Kingdom region compared with the guidelines published by The American Society of Colon and Rectal Surgeons, which are based on published literature. There is an urgent need to establish similar guidelines in the United Kingdom to improve the clinical outcome of patients with such a common condition.

Management of uncomplicated acute diverticulitis: results of a survey.

PURPOSE: A survey was conducted to document current medical treatment of patients with uncomplicated acute diverticulitis. METHODS: A survey was mailed to 667 fellows of The American Society of Colon and Rectal Surgeons certified by the American Board of Colon and Rectal Surgery. Queries were based on a clinical scenario of a patient with uncomplicated diverticulitis. RESULTS: Three hundred seventy-three surveys (56 percent) were returned completed. The majority (66 percent) chose an abdominal computed tomographic scan as the initial diagnostic test. One-half used a single intravenous antibiotic with second-generation cephalosporins (27 percent) and ampicillin/sulbactam (16 percent) being the most common. Oral antibiotics given at discharge were ciprofloxacin (18 percent), amoxicillin/clavulanate (14 percent), metronidazole (7 percent), and doxycycline (6 percent). Combinations chosen were ciprofloxacin/metronidazole (28 percent) and metronidazole/trimethoprim sulfamethoxazole (6 percent), whereas 21 percent chose a variety of other antibiotics. The majority (74 percent) prescribed oral antibiotics for 7 to 10 days. Dietary recommendations at discharge were low residue (68 percent), regular (21 percent), and high residue (10 percent). Half of those surveyed believed avoidance of seeds and nuts were of no value. Follow-up examinations chosen included sigmoidoscopy and barium enema (29 percent), colonoscopy (25 percent), sigmoidoscopy (17 percent), barium enema (13 percent), and other (16 percent). Sixty-five percent of colon and rectal surgeons claim to handle more than half of their patients with uncomplicated diverticulitis on an outpatient basis. CONCLUSION: Variations in the management of uncomplicated sigmoid diverticulitis are noted among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies. The survey results are compared with the conclusions reached in The American Society of Colon and Rectal Surgeons practice parameters. Documentation of practice pattern variation may serve as an educational tool for physicians to improve their quality and cost of medical care. Consideration should be given to better publicize already existing American Society of Colon and Rectal Surgeons practice parameters for this common entity.

[Diverticulosis and diverticulitis in the elderly]. / Divertikulose und Divertikulitis beim alten Menschen.

Diverticulosis of the colon is a disease that mainly affects the elderly, presenting in 10 to 20% of this age group. The most common complication--painful diverticular disease, is usually treated conservatively with a high-fiber diet, intermittent use of antispasmodics and possibly regulation of the stools. Diagnostic differentiation is best performed using ultrasonography of the bowel wall, supplemented where necessary by computer tomography and colonoscopy (sigmoidoscopy) or, where this latter is not possible, barium enema using Gastrografin. Conservative treatment of diverticulitis with antibiotics, bowel rest, possibly including parenteral alimentation, is usually applied for three to ten days. In the absence of a response to this treatment, frequent recurrence, immunosuppression or complications (perforation, peritonitis, enterovesicular fistula), surgery is indicated.

Diagnóstico y manejo de las fistulas vesicocolonicas / Diagnosis and management of vesicocolonic fistulae

En el período que va desde enero de 1993 a diciembre de 1996, se estudian 10 pacientes con fístula vesicocolónica secundaria a diverculitis ( 5 casos), cáncer de colon ( 2 casos), iatrogenia ( 2 casos) y dudoso ( 1 caso). Los síntomas de presentación fueron neumaturia, fecaluria, disuria e infección urinaria. Los exámenes complementarios para el diagnóstico fueron: cultivos de orina, cistografía, colon por enema , urograma exctretor, cistoscopia , fibrocolonoscopia, rectosigmoidescospia y TAC (tomogtafía axial computada). Entre ellos, los más concluyentes y efectivos para el diagnóstico de fístula vesicocolónica resultaron el cultivo fde orina, la cistografía y el colon por enema. El tratamiento en todos los casos fue la cirugía en todos los casos fue la cirugía en un tiempo con resección de la fístula y del segmento de colon afectado, la anastomosis terminoterminal del colon y el cierre simple de la pared de la vejiga. No se registraron recidivas de las fístulas durante el tiempo de observación del estudio

Diagnóstico y manejo de las fistulas vesicocolonicas / Diagnosis and management of vesicocolonic fistulae

En el período que va desde enero de 1993 a diciembre de 1996, se estudian 10 pacientes con fístula vesicocolónica secundaria a diverculitis ( 5 casos), cáncer de colon ( 2 casos), iatrogenia ( 2 casos) y dudoso ( 1 caso). Los síntomas de presentación fueron neumaturia, fecaluria, disuria e infección urinaria. Los exámenes complementarios para el diagnóstico fueron: cultivos de orina, cistografía, colon por enema , urograma exctretor, cistoscopia , fibrocolonoscopia, rectosigmoidescospia y TAC (tomogtafía axial computada). Entre ellos, los más concluyentes y efectivos para el diagnóstico de fístula vesicocolónica resultaron el cultivo fde orina, la cistografía y el colon por enema. El tratamiento en todos los casos fue la cirugía en todos los casos fue la cirugía en un tiempo con resección de la fístula y del segmento de colon afectado, la anastomosis terminoterminal del colon y el cierre simple de la pared de la vejiga. No se registraron recidivas de las fístulas durante el tiempo de observación del estudio(AU)

A successfully treated case of multiple liver abscesses accompanied by portal venous gas.

A case with multiple liver abscess accompanied by massive portal venous gas is reported. A 61-yr-old male was admitted because of left lower abdominal pain, fever, and diarrhea. Abdominal x-ray examination demonstrated multiple branching lucencies in the liver. Computed tomography revealed multiple liver abscesses and massive gas in the portal system as well as a thickened wall of the sigmoid colon. Enema study using contrast medium revealed a perforation of the sigmoid colon with diverticulitis. The outcome was favorable after sigmoid colectomy in addition to intensive treatment with antibiotics. Bacteroides fragilis, which produces gas (H2 and NH3) by fermentation, was isolated not only from the resected specimen but also from blood samples. Although the presence of portal venous gas is a sign of poor prognosis in patients with intestinal infectious diseases, the sensitive detection of hepatic portal venous gas by computed tomography and the appropriate treatment may improve the patient's prognosis.

Therapeutic options in acute diverticulitis.

Diverticulitis is a serious intra-abdominal infection that ultimately afflicts about one in four patients having colonic diverticulosis. The illness may be indolent or fulminant, depending on the degree of colonic spillage and its containment. Most patients require hospitalization, and medical therapy suffices in about three fourths. Those who fail aggressive medical management and those with recurrent acute attacks, diffuse peritonitis, abscess, persistent obstruction, or fistulization require surgical intervention. Abdominal CT scanning has supplanted the contrast enema as the acute diagnostic procedure of choice and allows guided percutaneous drainage of large abscesses in selected cases. This approach helps realize the surgical ideal of a single elective operation without a temporary colostomy. For those patients still requiring emergency surgery, the two-stage approach employing resection of the diseased colon at the initial operation is far superior to the older three-stage approach.

Colonic diverticulitis. Recognizing and managing its presentations and complications.

Diverticulitis usually manifests as pain of abrupt onset in the lower left quadrant. Complications may occur with or without an acute attack. Plain abdominal films are crucial for initial workup and follow-up. Endoscopic examination is often indicated, but barium enema study should usually be avoided during an acute attack. Computed tomography offers the best means of determining extracolonic extension of diverticulitis. Therapy is usually medical and consists of "resting" the bowel, administering antibiotics to resolve infection, and preventing or minimizing complications. Surgery is reserved for refractory, recurrent, or complicated disease.