Diverticulitis Journal Club Presentation

Journal Club Presentation on Diverticulitis

1. DIVERTICULITIS JOURNAL CLUB KIRENGO MRCS, MSC, MBA

2. INTRODUCTION Diverticulosis: presence of diverticula (sac-like protrusions of the colonic mucosa through weak points in the muscular wall) Diverticular dx: clinically significant and symptomatic diverticulosis due to diverticulitis or complications, diverticular bleeding, segmental colitis, or symptomatic uncomplicated diverticular disease Acute diverticulitis: inflammation, due to microperforation of a diverticulum Complicated diverticulitis: (approx. 12%) diverticulitis with either: bowel obstruction, stricture, abscess, fistula, or perforation Simple or uncomplicated diverticulitis: is without an associated complication Smoldering or chronic diverticulitis: diverticular inflammation that persists for weeks to months

3. EPIDEMIOLOGY Prevalence of diverticulosis inc with age; from <20% at 40y to 60% by 60y Western hemisphere- is predominantly left-sided In Asia, the prevalence is lower, & predominantly right-sided Approximately 4% of patients with diverticulosis develop diverticulitis

4. RISK FACTORS

5. PATHOGENESIS Diverticula: points of weakness in the bowel wall where blood vessels penetrate Bleed: Segmental weakness of the artery in the diverticular wall predisposes to rupture into the lumen Diverticulitis: Alterations in the gut microbiome and chronic inflammation Symptomatic uncomplicated diverticular disease: Altered colonic motility and visceral hypersensitivity

6. ACUTE DIVERTICULITIS PRESENTATION Abdominal pain is the most common complaint ( left sided in approx. 85%) Patients may present with right lower quadrant or suprapubic pain - redundant inflamed sigmoid colon or cecal diverticulitis Low-grade fever Nausea +/- vomiting Constipation or diarrhea Ongoing abdominal discomfort common after resolution of acute inflammation This Photo by Unknown Author is licensed under CC BY-NC

7. CLASSIFICATION

8. DIAGNOSIS Lower abdo pain/ tenderness OE Laboratory findings: inc WCC, CRP CT scan with contrast- high sensitivity and specificity for acute diverticulitis and can exclude other causes of abdominal pain Colonoscopy has no role in establishing the diagnosis of acute diverticulitis Consider at least six weeks after recovery Consider OP FIT test prior

9. DIFFERENTIAL DIAGNOSIS

10. TREATMENT

11. Indications for Ambulatory Management: Age: Patients younger than 80y who presented in good general health ASA: I/II CT indicating: Hinchey I to II Clinical: Absence of complications Social: Family support Patient's will: The patient agreed to receive home care and understood safety netting

12. Indications for Inpatient management Complicated diverticulitis Sepsis or systemic inflammatory response syndrome (SIRS) ie. Temperature >38° or <36° C, HR >90 (bpm), RR >20 , WCC >12 or <4, CRP >15 Severe abdominal pain or peritonitis Microperforation (eg, a few air bubbles outside of the colon without contrast extravasation or phlegmon) Age >80y Significant comorbidities (eg, diabetes mellitus with organic involvement [eg, retinopathy, angiopathy, nephropathy] Immunosuppression Intolerance of oral intake secondary to bowel obstruction or ileus Noncompliance with care/unreliability for return visits/lack of support system Failure of outpatient treatment

13. Inpatient management IV Abx Consider complete bowel rest >> restart liquid diet & advance as tolerated Consider discharge with oral antibiotics if improving Diverticular abscesses ≥4 cm should be drained percutaneously if feasible Consider surgery if unresponsive Frank perforation or obstruction requires surgery

14. Discharge criteria Normalization of vital signs Resolution of severe abdominal pain Resolution of significant leukocytosis Tolerance of oral diet

15. Antibiotics Versus No Antibiotics for Acute Uncomplicated Diverticulitis: A Systematic Review and Meta-analysis Madhav Desai, M.D., M.P.H. • Jihan Fathallah, M.D. • Venkat Nutalapati, M.D. • Shreyas Saligram, M.D., M.R.C.P.

16. ARTICLE PRESENTED: Title: Antibiotics Versus No Antibiotics for Acute Uncomplicated Diverticulitis: A Systematic Review and Meta-analysis Location of study: University of Kansas Medical Center, Kansas City, Kansas Authors: Madhav Desai, M.D., M.P.H., Jihan Fathallah, M.D., Venkat Nutalapati, M.D. Shreyas Saligram, M.D., M.R.C.P. Year of Publication: 2019 Ethics: N/A Conflict of interest: N/A Journal Publication: DISEASES OF THE COLON & RECTUM Citations: 66

17. LEVEL OF EVIDENCE

18. JOURNAL INTRO Diseases of the Colon & Rectum   W orld's leading publication in colorectal surgery, R anked top 10% of all peer-reviewed surgery journals

19. BACKGROUND Symptomatic diverticulosis; 5 th most common GI dx Can present as diverticular bleeding, acute or chronic diverticulitis, segmental colitis, or uncomplicated diverticulosis 15% - 20% with symptomatic disease diagnosed with acute diverticulitis Which is the most common cause of hospitalization from diverticulosis Mostly acute uncomplicated diverticulitis (AUD) Absence of bowel perforation, abscess/phlegmon, fistula, or bleeding

20. BACKGROUND Previous literature suggests high risk of recurrence and complications from acute diverticulitis Recent studies suggest natural history of sigmoid diverticulitis more benign Admin of abx considered cornerstone of Rx of AUD (admission >> IV Abx) Contrary to current American Gastroenterology Association guidelines ie . Abx should be used selectively No previous meta-analysis in a large cohort of patients to assess outcomes in AUD were abx vs observed without abx

21. UK NICE Guidelines ( July 2023) Arrange same-day hospital assessment  Offer oral ABX if the person is systemically unwell but does not meet the criteria for complicated acute diverticulitis For people who are systemically well: Consider a no antibiotic prescribing strategy Offer simple analgesia (e.g., paracetamol) — avoid NSAIDs and opioid analgesia if possible, potential inc. risk of diverticular perforation Don’t offer an aminosalicylate or antibiotics to prevent recurrent acute diverticulitis

22. METHODS

23. METHODS

24. Data analysis Sensitivity analysis by only incorporating RCTs to derive pooled rates of recurrent diverticulitis, total complications, & treatment failure The measure of effect of interest was the OR (an estimate of high chances of detection of intervention compared with control) 95% CI, P < 0.05 was considered statistically significant for all outcomes Corresponding forest plots were constructed for pooled estimates of these outcomes Student t test was used to assess any significance of difference between length of stay between the 2 groups. Publication bias was derived to assess for the role of any specific studies responsible using Cochrane guidelines and Review Manager software in the form of a funnel plot

25. RESULTS Literature review yielded a total of 2508 records 7 studies were eligible for the analysis 2 RCTs and 5 observational cohort or retrospective studies Total 2241 patients, 895 received Abx 1346 did not Average follow-up range 6 to 30 months

26. RESULTS

27. Primary outcome The pooled rate of recurrent diverticulitis was slightly higher among patients who received antibiotics compared with those who did not (12.6% vs 11.5%). no statistically significant difference between those who received antibiotics and those who did not ( p = 0.18) low heterogeneity in the inclusion studies, with I  2  of 30%.

28. Secondary Outcomes Pooled rate of total complications was higher among patients who had Abx compared (27.8% vs 19.8%) but no statistical difference between these 2 groups in pooled analysis ( p = 0.22) Similarly in treatment failure, & readmission rates, rate of sigmoid resection  sensitivity analysis by only incorporating RCTs not statistically significant difference

29. DISCUSSION

30. CONCLUSION There is evidence against the routine use of antibiotics Vs increased health care expenditure and the rise of antibiotic resistance The conservative treatment of AUD with no antibiotics should be the standard of care

31. CRITICAL APPRAISAL ISSUES WITH THE STUDY WAS THE OBJECTIVE CLEAR & DID THE STUDY ADDRESS IT? BIAS? CONCLUSION MAKE SENSE? APPLICABILITY OF STUDY TO OUR SETTING

32. STUDY LIMITATIONS A small number of studies Only 2 RCTs Heterogeneity of data – RCTs vs Observational Retrospective studies The study did not assess for author bias or the quality and certainty of the information from the studies Missing data: Reasons for the addition of antibiotics in the control group of patients were not clear and could have influenced outcomes Confounding factors not reported i.e. co-morbidities e.g. diabetes

33. THANK YOU ANY QUESTIONS