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
Male sex, White
race, smoking, and
obesity
Constipation and
low dietary fiber
intake do not
appear to be
associated with an
inc risk of
diverticulosis
Diet and lifestyle
factors are
associated with an
increased risk of
diverticulitis (diet
high in red meat
and low in fiber)
Diverticular
bleeding more
common in patients
using aspirin and
NSAIDS

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

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
IBS or IBD
Colorectal ca
Acute appendicitis
Colitis
AAA
Gynae: tubo-ovarian abscess, ovarian cyst, ovarian torsion, ectopic pregnancy
Urology:- stones, cystitis, UTI

10. TREATMENT
Conservative Rx successful >70%
Most patients who are appropriate for outpatient management
Evidence suggest against antibiotic treatment in uncomplicated
Pain control with oral analgesics (eg, acetaminophen, ibuprofen, or oxycodone)
Consider liquid diet and reassessed clinically in 2-3 days
Patients not improving with op therapy are admitted for Rx

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
• World's leading publication
in colorectal surgery,
• Ranked top 10% of all
peer-reviewed surgery
journals

19. BACKGROUND
• Symptomatic diverticulosis; 5th 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 Sys review and meta-analysis
according to Cochrane and
PRISMA
Literature search -
PubMed/Medline, Embase,
Scopus, and Cochrane from the
beginning of indexing for each
database to Dec 31, 2017
Inclusion criteria:
RCTs or observational studies
with a control group comparing
the use of antibiotics versus no
antibiotics (monitoring only) in
the management of AUD and
reporting outcomes of interest
(total complications, treatment
failure, length of hospitalization,
recurrent diverticulitis, sigmoid
resection, and mortality rate)
among both groups

23. METHODS
Exclusion:
• no control arm (monitoring alone or no-antibiotics group),
• case reports/series, editorials,
• review articles, and studies not providing outcomes of interest
• Studies of patients with severe or complicated diverticulitis (perforation, fistula, or abscess formation)
Study quality was assessed using Newcastle–Ottawa scale
Collected data:
• on demographic variables
• primary outcome: pooled rates of recurrent diverticulitis
• Secondary outcomes: pooled rates of total complications, treatment failure, readmission, and sigmoid
resection rates

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
This meta-analysis of ≈2200 patients finds no significant difference in important clinical outcomes when abx were not
used in subjects with AUD
Readmission rates and sigmoid resection rates were not significantly different
Patients can be observed in a monitored setting off abx
Most cases of AUD are still treated with abx despite evidence recent studies showing no difference in recovery or
complications
Abx were later added in 25 (2.7%) of 906 patients who were initially observed off abx, but, reasons are unclear and not
mentioned in any of the studies
Patients not treated with antibiotics had a significantly lower median hospital stay
Treating AUD conservatively can lessen the financial health care burden, accompanied with no increase in
complications or treatment failure

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