Lidewine Daniels

Systematic review of medical therapy to prevent recurrent diverticulitis

Aim and backgroundOne of today’s controversies remains the prevention of recurrent diverticulitis. Current guidelines advise a conservative approach, based on studies showing low recurrence rates and a high operative morbidity and mortality. Conservative measures in prevention recurrence are dietary advises and medical therapies, including probiotics and 5-aminosalicylic acid.ObjectivesThe aim of this systematic review is to assess whether medical or dietary therapies can prevent recurrent diverticulitis after a primary episode of acute diverticulitis.Method and search strategyWe searched different databases for papers published between January 1966 and January 2011.Study selectionClinical studies were eligible for inclusion if they assessed the prevention of recurrent diverticulitis with a medical or dietary therapy. Exclusion criteria were studies without a control group.ResultsThree randomized controlled trials (RCT), all with a Jadad quality score of 2 out of 5, were included in this systematic review. Mesalazine results in significantly less disease recurrence and fewer symptoms after an acute episode. The use of probiotics decreases symptoms but does not reduce recurrence. No difference in effect is seen when Balsalazide is added to probiotics compared to probiotics only. No relevant studies on dietary therapy/advices or antibiotics for prevention of recurrent diverticulitis were found.ConclusionThe evidence that supports medical therapy to prevent recurrent diverticulitis is of poor quality. Treatment with 5-aminosalicylic acid seems promising. Based on current data, no recommendation of any non-operative relapse prevention therapy for diverticular disease can be made.

Routine colonoscopy after left-sided acute uncomplicated diverticulitis: a systematic review

The use of routine colonoscopy after an episode of acute diverticulitis (AD) remains a point of debate. Most international and clinical practice guidelines advise endoscopy after conservatively treated diverticulitis. The rationale has always been to exclude an underlying malignancy or advanced colonic neoplasia (ACN). However, this is based merely on expert opinion. A recent article indicated that presently this may be different with increased use of abdominal CT imaging of diverticulitis. Furthermore, the yield of colonoscopy in patients after an episode of AD also casts doubt on current international practice. Routine colonoscopy after an uncomplicated episode of diverticulitis dates from a time where the diagnosis was primarily based on clinical examination and laboratory results with frequent use of barium enema. However, in today’s clinical practice, CT is widely used for the diagnosis of diverticulitis, with the possibility to assess potential adverse events such as abscess, fistula, obstruction, or perforation as well. Because of high sensitivity of 94%, a specificity of 99%, and a low interobserver variability, this modality is currently preferred for the diagnosis of diverticulitis, although US also has a good sensitivity. Nevertheless, it remains uncertain if the prevalence of colorectal carcinoma (CRC) and advanced adenoma (AA) in patients with imaging-proven diverticulitis is higher than in an average-risk population. Apart from diagnosing CRC, the detection of AA is of great importance because it bears the potential to progress to carcinoma. Colonoscopy is accompanied by such disadvantages as invasiveness and discomfort, potential adverse events such as perforation, and additional costs. It is important

A hypothesis: important role for gut microbiota in the etiopathogenesis of diverticular disease

Diseases of the Colon & ReCtum Volume 57: 4 (2014) Epidemiology, Terminology, and Pathophysiology of Diverticular Disease Diverticular disease (DD) inflicts a high socioeconomic burden on Western and industrialized countries because of an increasing incidence worldwide and, consequently, increasing admission rates and costs. DD is composed of a spectrum of conditions. Patients with diverticulosis have asymptomatic colonic diverticula. uncomplicated DD is defined as symptomatic disease, associated with mild symptoms, such as abdominal pain and/or change in bowel habit. Complicated DD is diverticulitis with severe clinical symptoms and evidence of inflammation. Complicated diverticulitis is accompanied by an abscess, perforation, peritonitis, fistula, bleeding, stricture, or obstruction. the epidemiology and pathophysiology are assumed to be clear and well understood. however, theories are currently shifting away from the traditional dogma stating that low dietary fiber predisposes to diverticulosis and fecalith obstruction of a diverticulum causes acute diverticulitis. DD was once regarded as a relatively asymptomatic disorder hampered by acute, often self-limited, attacks of diverticulitis. more recently, the chronic component in some patients with symptomatic DD received attention, and it was suggested this condition should be regarded as a form of inflammatory bowel disorder. new research implicates a role for low-grade inflammation and alterations of gut microbiota in this group of diseases. other than known factors, such as age, diet, fecalith entrapment, and bacterial overgrowth, gut microbiota may play a role in the development of diverticula and (complicated) DD. Microbiota as a New Player in the Field a new hypothesis encompasses the roles of altered gut microbiota and low-grade chronic inflammation leading to periods of symptomatic DD and perhaps even as triggers of acute diverticulitis. several lines of indirect evidence support a potential association between these factors and DD. the initial hypothesis by Painter and Burkitt with a key role for fiber deficiency in the etiology of DD, as well as outdated views on the pathogenesis of inflammation, needs some revision. Based on current literature, we aim to integrate know factors and the new player in the field, gut microbiota, and propose a valid hypothesis on the etiopathogenesis of DD in which an important role is reserved for the microbiome factor.

Hybrid treatment of aberrant right subclavian artery and its aneurysms.

Abstract Purpose: To describe two cases of aberrant right subclavian artery (ARSA) aneurysm treated with hybrid repair. Case reports: 77 year old woman with a symptomatic ARSA aneurysm was treated with endoluminal aortic stent graft exclusion and placement of a plug distal to the aneurysm. Ischemia of the right arm required immediate carotid-subclavian bypass. Postoperatively, mild signs of brain stem infarction were present with absent flow in the right vertebral artery. Because of preserved left vertebral and basilary artery flow no invasive therapy was undertaken. The patient recovered completely. A 51 year old woman with a symptomatic 37 mm diameter ARSA aneurysm underwent bilateral carotid-subclavian bypasses and subsequent endoluminal aortic stent graft exclusion of the ARSA’s origin. Recovery was uneventful. Conclusion: Hybrid techniques are less invasive valuable alternatives in the treatment of ARSA and its aneurysms. Great care should be taken to preserve the posterior cerebral and upper extremity circulation.

Overtreatment of Sigmoid Diverticulitis: Plea for a Less Aggressive Approach

A less invasive approach to the treatment of left-sided colonic diverticulitis has emerged in the last decade. The standard of care for perforated or complicated diverticulitis evolved from a Hartmann’s procedure, to resection and primary anastomosis, to treatment with antibiotics and percutaneous drainage in a carefully selected (Hinchey grade 2) patient subset. Recently, laparoscopic lavage emerged as a promising less invasive treatment for selected cases of Hinchey 3 patients. Likewise, for nonperforated or uncomplicated diverticulitis the approach is becoming less aggressive with a change from intravenous antimicrobial therapy, starvation and admission, to oral antibiotics and finally to observation and outpatient treatment. This less invasive or aggressive approach is due to expanding evidence on optimal treatment and is congruent with an increasing understanding that diverticulitis comprises different disease entities with heterogeneity between patients. The disease should be targeted by specific approaches, after a meticulous assessment of the diverticulitis stage, and tailored to an individual basis. Avoidance of overtreatment has obvious benefits: less in-hospital treatment, cost reduction, diminished development of antimicrobial resistance, reduction in complication rate and side effects and presumably a better quality of life for the patient. In conclusion, one might say we have overtreated the majority of diverticulitis patients for decades. More research is needed to explain the pathogenesis and multifactorial etiology and in the near future hopefully several unanswered questions regarding the optimal management of patients with different stages of diverticulitis will be answered by various ongoing trials.

External validation of two tools for the clinical diagnosis of acute diverticulitis without imaging

AIM External validation and comparison of the diagnostic accuracy of two predictive tools, the emergency department triad and the clinical scoring tool in diagnosing acute diverticulitis. METHODS Two derivation datasets were used crosswise for external validation. In addition, both tools were validated in a third independent cohort. Predictive values were reassessed and the Area Under the Curve expressed discriminatory capacity. Performance was compared by calculating positive predictive values of the emergency department triad in the validation cohorts and with a cut-off analysis for the clinical scoring tool at a positive predictive value of 90%. RESULTS Predictive value of the emergency department triad was comparable to the clinical scoring tool. The positive predictive value of the emergency department triad (97%) decreased in the clinical scoring tool cohort (81%) and was excellent in the independent cohort (100%), identifying 24%, 20% and 14% of the patients. A smaller proportion of patients with diverticulitis could be identified with the clinical scoring tool (6%, 19% and 9%). CONCLUSION The emergency department triad as well as the clinical scoring tool have significant predictive value in external cohorts of patients suspected of diverticulitis. These tools can be used to select patients in whom additional imaging to diagnose acute diverticulitis may be omitted.