Management of acute uncomplicated diverticulitis and adherence to current guidelines-a multicentre SNAPSHOT study.

PURPOSE: To explore whether previous participation in clinical studies increases adherence to management guidelines in acute uncomplicated diverticulitis (AUD). METHODS: This retrospective cohort study was designed to give a SNAPSHOT of the management of AUD at six hospitals, three of which had participated in the AVOD trial comparing antibiotic versus non-antibiotic treatment of AUD. Patients with AUD were included from March 2019 through June 2020 and followed for 90 days. The primary outcome was treatment of AUD categorised by antibiotic treatment and inpatient or outpatient management compared between AVOD and non-AVOD hospitals. Descriptive statistics were compiled, and differences between hospitals were assessed with Pearson's chi-squared test. RESULTS: The cohort included 449 patients with AUD of which 63% were women and the median age was 63 (IQR: 52-73) years. Patient characteristics were comparable across the hospitals. Antibiotics were administered to 84 (19%) patients and 113 (25%) patients were managed as inpatients. Management varied significantly between AVOD and non-AVOD hospitals. The mean proportion of patients treated with antibiotics was 7% at AVOD hospitals compared to 38% at non-AVOD hospitals (p < 0.001). The mean proportion of in-hospital management was 18% at AVOD hospitals versus 38% at non-AVOD hospitals (p < 0.001). CONCLUSION: Most patients with AUD were managed according to current guidelines. However, the management varies between hospitals and previous participation in clinical studies may increase knowledge of and adherence to guidelines.

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

INTRODUCTION: Diverticulitis and appendicitis are common emergency general surgical conditions. Both can be treated with antibiotics alone; however, no antibiotic regimen has been identified as superior to others. In this study, we review different antibiotic regimens and their rates of failure. METHODS: Retrospective cohort study of patients treated empirically with antibiotics for diverticulitis or appendicitis from January 1, 2018, to December 31, 2020, at an independent academic hospital in the Midwest. RESULTS: A total of 587 (appendicitis, n = 43; diverticulitis, n = 544) patients were included in the cohort. They were equally male (49%) and female (51%) with a median age of 59 y. Three major antibiotic classes were compared: cephalosporin + metronidazole (C + M), penicillins, and quinolone + metronidazole. Appendicitis patients were more likely to receive C + M for empiric treatment (73%, P < 0.001), while diverticulitis patients were more likely to receive quinolone + metronidazole (45%, P < 0.001). Patients empirically treated with antibiotics for appendicitis were more likely than those treated for diverticulitis to require additional antibiotics or procedure within 90 d (33% versus 13%, respectively; P = 0.005). Empiric treatment with C + M for diverticulitis was more likely to be associated with the need for additional antibiotics or procedures within 90 d than treatment with other regimens (P = 0.003). Choice of antibiotic for empiric treatment did not correlate with death at 90 d for appendicitis or diverticulitis. Diverticulitis patients who were initially treated as inpatients and were prescribed C + M at hospital discharge had a higher rate of death than those who were prescribed the other antibiotics (P = 0.04). CONCLUSIONS: Empiric antibiotic treatment of appendicitis is more likely to be associated with additional antibiotics or procedure when compared with diverticulitis; however, antibiotic choice did not correlate with any of the other outcomes. Empiric treatment with a C + M for diverticulitis was more likely to be correlated with the need for additional antibiotics or procedure within 90 d.

Level 1a Evidence Comparing Use of Antibiotics Versus No Antibiotics in Management of Acute Left-Sided Uncomplicated Diverticulitis.

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.

Diverticulitis cecal: un complejo desafío médico / Cecal diverticulitis: a complex medical challenge

Antecedentes: la diverticulitis cecal es una patología poco común en los países occidentales. Clínicamente es indistinguible de una apendicitis aguda. Objetivos: exhibir los resultados de acuerdo con diferentes abordajes terapéuticos. Material y métodos: se presentan cinco casos de diverticulitis cecal tratados en nuestra institución entre enero de 2013 y diciembre de 2015. Revisión retrospectiva de historias clínicas e imágenes. Revisión de la literatura. Resultados: fueron incluidos cinco pacientes. En cuatro hubo resolución quirúrgica y uno tuvo buena evolución con tratamiento médico. Conclusiones: si bien es poco frecuente, la diverticulitis cecal debe considerarse dentro de los diagnósticos diferenciales frente a un cuadro de dolor abdominal localizado en fosa ilíaca derecha acompañado de estudios por imágenes no categóricos de apendicitis aguda.

Background: cecal diverticulitis is a rare disease in western countries. It is clinically indistinguishable from acute appendicitis. Objetive: to show outcome with different therapeutic approaches. Material and methods: we present five cases of cecal diverticulitis treated at our institution between January 2013 and December 2015. Retrospective review of medical records and images. Review of the literature. Results: five patients were included. Four cases required surgical treatment while one patient resolved with medical treatment. Conclusions: Although it is rare, cecal diverticulitis must be considered within the differential diagnoses in the face of abdominal pain located in the right iliac fossa and non-categorical imaging of acute appendicitis.

Diverticulitis aguda: revisando antibióticos, seguimiento e indicación quirúrgica / Acute diverticulitis: reviewing antibiotics, follow-up and surgical indication

The presence of colonic diverticulae is a common occurrence in middle-aged and elderly patients. Most of them will remain asymptomatic for life; however, between 10-25% will go on to develop acute diverticulitis (AD). Traditionally, AD has been thought of as a disease having a bacterial etiology with a high recurrence rate and a significant proportion of underlying colorectal cancer. This has been the foundation for conventional treatment with antibiotics and an indication for resective surgery after a second episode. Also, a routine colonoscopy has been recommended on the resolution of inflammatory symptoms, to rule out malignancy. Recent evidence has questioned the appropriateness of this traditional approach to AD. In this review, we critically appraise the need for antibiotics, prophylactic surgery and endoscopic follow-up after AD.

La presencia de divertículos en el colon es un hallazgo frecuente en la población mayor de 60 años. Si bien la mayoría nunca presentará síntomas, 10-25% desarrollará una diverticulitis aguda (DA). Tradicionalmente se ha postulado que la DA es una enfermedad de etiología bacteriana, con una alta tasa de recurrencia, y un porcentaje importante de casos en que puede confundirse con un cáncer colorrectal. Debido a esto el manejo clásico incluye antibióticos e históricamente se ha recomendado una cirugía resectiva del segmento afectado después de un segundo episodio. También se ha tenido como dogma el realizar una colonoscopia de control una vez resuelto el episodio agudo, para descartar una neoplasia subyacente. Sin embargo, la nueva evidencia disponible ha cuestionado la idoneidad de este enfoque clásico frente a la DA. En esta revisión analizamos de manera crítica la necesidad del uso de antibióticos, la cirugía profiláctica y el control endoscópico posterior a DA.

Diagnóstico e tratamento da diverticulite aguda / Diagnosis and treatment of acute diverticulitis

Durante as últimas décadas, novos conhecimentos sobre a história natural da diverticulite aguda (DA) modificaram os paradigmas a respeito do tratamento. Estudos recentes demonstraram um papel menos importante da antibioticoterapia agressiva e intervenção cirúrgica na diverticulite crônica ou recorrente do que antes se achava necessário.1

During the last decades, new knowledge about the acute diverticulitis natural history have modified treatment paradigms. Recent studies demonstrate a smaller role for aggressive antibiotic and surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.