Current indications and role of surgery in the management of sigmoid diverticulitis

Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations.Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis.Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended.Rather,a more individualized approach,taking into account frequency,severity of the attacks and their impact on quality of life,should guide the indication for surgery.On the other hand,complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation.Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis.There is not sufficient evidence supporting any changes in the approach to management in younger patients.Conversely,the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.

Prior abdominal surgery as a potential risk factor for colonic diverticulosis or diverticulitis

BACKGROUND Abnormal colonic pressure profiles have been associated with an increased risk of colonic diverticulosis.A surgical history is a known risk factor for abdominal adhesions and these may lead to increased intraluminal colonic pressure.AIM To assess whether previous abdominal surgery is associated with colonic divertic-ulosis or diverticulitis.METHODS We analyzed data from a study of patients undergoing colonoscopy for different indications from 2020 through 2021.Patients completed a structured question-naire concerning previous abdominal surgeries,dietary and lifestyle exposures including smoking,alcohol use and co-morbidities.RESULTS Three hundred and fifty-nine patients were included in the study.The mean age was 67.6 and 46%were females.Diabetes mellitus,hypertension,ischemic heart disease,chronic obstructive pulmonary disease,chronic renal failure,and body mass index were similar in the diverticulosis and control groups.The overall prevalence of colonic diverticulosis was 25%(91/359)and 48%of the patients had previous abdominal surgery.As expected,the prevalence of diverticulosis increased with age.There was no difference in the rate of previous abdominal surgery between patients with or without diverticulosis(49%vs 47%,P=0.78).In regards to specific surgeries,inguinal hernia repair was significantly associated with diverticulosis(52%vs 20%,P=0.001),but not diverticulitis.In contrast,appendectomy was not associated with diverticulosis(6%vs 14%,P=0.048).CONCLUSION These findings suggest that post-operative abdominal adhesions inducing high colonic intraluminal pressures do not appear to be the mechanism for diverticula formation.Rather,inguinal hernia and diverticulosis may share similar connective tissue pathologies with no causative relationship between them.

Endoscopic ultrasound-guided transrectal drainage of a pelvic abscess after Hinchey Ⅱ sigmoid colon diverticulitis: A case report

BACKGROUND Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound(EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization.CASE SUMMARY A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography(CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey Ⅱ diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient’s general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection.CONCLUSION We report the first successful management of a pelvic abscess in patient with Hinchey Ⅱ acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.

Diverticulitis is a population health problem:Lessons and gaps in strategies to implement and improve contemporary care

The disease burden of diverticulitis is high across inpatient and outpatient settings,and the prevalence of diverticulitis has increased.Historically,patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes.Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed,and many clinical practice guidelines(CPGs)have pivoted to recommend outpatient management and individualized decisions about surgery.Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States,suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease.In this review,we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Right sided diverticulitis in western countries:A review

BACKGROUND Although the treatment guidelines for left sided diverticulitis are clear,the management of right colonic diverticulitis is not well established.This disease can no longer be ignored due to significant spread throughout Asia.AIM To analyse epidemiology,diagnosis and treatment of right-sided diverticulitis in western countries.METHODS MEDLINE and PubMed searches were performed using the key words "rightsided diverticulitis","right colon diverticulitis","caecal diverticulitis","ascending colon diverticulitis" and "caecum diverticula" in order to find relevant articles published until 2021.RESULTS A total of 18 studies with 422 patients were found.Correct diagnosis was made only in 32.2%,mostly intraoperatively or via CT scan.The main reason for misdiagnosis was a suspected acute appendicitis(56.8%).The treatment was a nonoperative management(NOM)in 184 patients(43.6%)and surgical in 238 patients(56.4%),seven of which after NOM failure.Recurrence rate was low(5.45%),similar to eastern studies and inferior to left-sided diverticulitis.Recurrent patients were successfully conservatively retreated in most cases.CONCLUSION The management of right-sided diverticulitis is not well clarified in the western world and no selective guidelines have been considered even if principles are similar to those with left-sided diverticulitis.Wrong diagnosis is one of the most important problems and CT scan seems to be the best imaging modality.NOM offers a safe and effective treatment;surgery should be considered only in cases of complicated diverticulitis or if malignancy cannot be excluded.Further studies are needed to clarify the correct treatment.

Routine colonic endoscopic evaluation following resolution of acute diverticulitis:Is it necessary?

Diverticular disease incidence is increasing up to 65% by age 85 in industrialized nations,low fiber diets,and in younger and obese patients.Twenty-five percent of patients with diverticulosis will develop acute diverticulitis.This imposes a significant burden on healthcare systems,resulting in greater than 300000 admissions per year with an estimated annual cost of $3 billion USD.Abdominal computed tomography(CT) is the diagnostic study of choice,with a sensitivity and specificity greater than 95%.Unfortunately,similar CT findings can be present in colonic neoplasia,especially when perforated or inflamed.This prompted professional societies such as the American Society of Colon Rectal Surgeons to recommend patients undergo routine colonoscopy after an episode of acute diverticulitis to rule out malignancy.Yet,the data supporting routine colonoscopy after acute diverticulitis is sparse and based small cohort studies utilizing outdated technology.While any patient with an indication for a colonoscopy should undergo appropriate endoscopic evaluation,in the era of widespread use of high-resolution computed tomography,routine colonic endoscopic evaluation following resolution of acute uncomplicated diverticulitis poses additional costs,comes with inherent risks,and may require further study.In this manuscript,we review the current data related to this recommendation.

Qualitative and quantitative analyses of the bifidobacterial microbiota in the colonic mucosa of patients with colorectal cancer, diverticulitis and inflammatory bowel disease

AIM： To characterize the bifidobacterial microbiota of the colonic mucosa in patients with colon cancer, inflammatory bowel disease or diverticulitis. METHODS： A sample of the distal colonic mucosa was taken during surgery from a total of 34 patients, twenty-one with diagnosed colorectal cancer, nine with diverticulitis and four with inflammatory bowel disease, requiring surgery for their condition. Bacterial DNA was extracted from the resected mucosal samples and bifidobacterial mucosa-associated microbiota was qualitatively and quantitatively determined by means of qualitative and quantitative PCR. RESULTS： Bifidobacteria were found in 100% of the samples from patients with diverticulitis or IBD and a 76% of those suffering colon cancer. The species B. Iongum and B. bifidum were the most widely found, followed by B. animalis, B. catenulatum and B. adolescentis. B. breve, B. dentium and B. angulatum were not detected in any sample. A significantly higher occurrence of B. Iongum was observed in patients with diverticulitis than in those with colon cancer or IBD （100%, 62% and 75%, respectively, P 〈 0.05）. Similar results were obtained for B, animalis （56%, 0% and 25%, P 〈 0.05）, while B. adolescentis was only found in the mucosa from patients with colon cancer （5 out of 21, 24%）. At the quantitative level, patients with colon cancer or IBD showed lower counts of total Bifidobacterium （4.94 and 5.91 vs 6.96 log Cells/sample, respectively, P 〈 0.05） and of the species B. longum （4.05 and 4.79 vs 6.76, P 〈 0.05） than those with diverticulitis.CONCLUSION： Aberrancies in mucosa associated microbiota are present in different intestinal diseases. This may indicate a role of the microbiota in the pathogenesis of these diseases.

Differential diagnosis of left-sided abdominal pain:Primary epiploic appendagitis vs colonic diverticulitis

AIM:To investigate the clinical characteristics of left primary epiploic appendagitis and to compare them with those of left colonic diverticulitis.METHODS:We retrospectively reviewed the clinical records and radiologic images of the patients who presented with left-sided acute abdominal pain and had computer tomography(CT) performed at the time of presentation showing radiological signs of left primary epiploic appendagitis(PEA) or left acute colonic diverticulitis(ACD) between January 2001 and December 2011. A total of 53 consecutive patients were enrolled and evaluated. We also compared the clinical characteristics,laboratory findings,treatments,and clinical results of left PEA with those of left ACD.RESULTS:Twenty-eight patients and twenty-five patients were diagnosed with symptomatic left PEA and ACD,respectively. The patients with left PEA had focal abdominal tenderness on the left lower quadrant(82.1%). On CT examination,most(89.3%) of the patients with left PEA were found to have an oval fatty mass with a hyperattenuated ring sign. In cases of left ACD,the patients presented with a more diffuse abdominal tenderness throughout the left side(52.0%vs 14.3%; P = 0.003). The patients with left ACD had fever and rebound tenderness more often than those with left PEA(40.0% vs 7.1%,P = 0.004; 52.0% vs14.3%,P = 0.003,respectively). Laboratory abnormalities such as leukocytosis were also more frequently observed in left ACD(52.0% vs 15.4%,P = 0.006).CONCLUSION:If patients have left-sided localized abdominal pain without associated symptoms or laboratory abnormalities,clinicians should suspect the diagnosis of PEA and consider a CT scan.

Suspected uncomplicated cecal diverticulitis diagnosed by imaging:Initial antibiotics vs laparoscopic treatment

AIM:To compare the recurrence rate following initial antibiotic management to that following laparoscopic treatment for suspected uncomplicated cecal diverticulitis. METHODS: We examined the records of 132 patients who were diagnosed with uncomplicated cecal diverticulitis and a first attack during an 8-year period. The diagnosis of uncomplicated diverticulitis was made based on imaging findings, such as inflamed diverticulum or a phlegmon with cecal wall thickening. Concurrent appendiceal dilatation from 8 to 12 mm was observed in 36 patients (27%). One hundred and two patients were treated initially with antibiotics only, whereas 30 underwent laparoscopic treatment, including partial cecectomy (n=8) or appendectomy with diverticulectomy (n=9) or appendectomy alone (n =13). We compared clinical outcomes in both groups over a median follow-up period of 46 mo. RESULTS: All patients were successfully treated with initial therapy. Of the 102 patients who initially received only antibiotic treatment, 6 (6%) had a recurrence (3 in the cecum and 3 in the ascending colon or transverse colon) during the follow-up period. Five of these pa-tients were managed with repeated antibiotic treatmentand 1 underwent ileocolic resection for perforation. Of the 30 patients treated by the laparoscopic approach, 2 (7%) had a recurrence (ascending colon) which was treated with antibiotics. CONCLUSION: Initial antibiotic management for suspected uncomplicated cecal diverticulitis showed comparable effi cacy to laparoscopic treatment in the prevention of recurrence.

Extensive hepatic-portal and mesenteric venous gas due to sigmoid diverticulitis

Hepatic portal venous gas is most often associated with extensive bowel necrosis due to mesenteric infarction.Mortality exceeds 75% with this condition.The most common precipitating factors include ischemia,intra-abdominal abscesses and inflammatory bowel disease.In this report,we present a 75-year-old woman with extensive hepatic portal and mesenteric venous gas due to colonic diverticulitis.She had a 10-year history of type diabetes mellitus and hypertension.She was treated by sigmoid resection and Hartmann's procedure and discharged from the hospital without any complications.

Clinical and computed tomography findings of appendiceal diverticulitis vs acute appendicitis

AIM: To study the clinical features and computed tomography(CT) findings of appendiceal diverticulitis vs acute appendicitis.METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendectomy inour in stitution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis.RESULTS: Among 451 patients, 44(9.7%) were diagnosed to have appendiceal diverticulitis and 398(86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older(59 vs 37 years, P < 0.001) and had a longer duration of the illness(4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher(68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients(52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix(84% vs 12%, P < 0.001), absence of appendicolith(92% vs 52%, P = 0.005), and formation of abscess(68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients(24%).CONCLUSION: Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis.

Acute ulcerative jejunal diverticulitis:Case report of an uncommon entity

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations.Its reported incidence varies from 0.05% to 6%.Although there is no consensus on the management of asymptomatic jejunal diverticular disease,some complications are potentially life threatening and require early surgical treatment.We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome.Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography (CT).As a result of the clinical and biological signs of early peritonitis,an emergency surgical exploration was performed.The first jejunal loop showed clear signs of jejunal diverticulitis.Primary segmental jejunum resection with end-to-end anastomosis was performed.Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis.The patient made an excellent rapid postoperative recovery.Jejunal diverticulum is rare but may cause serious complications.It should be considered a possible etiology of acute abdomen,especially in elderly patients with unusual symptomatology.Abdominal CT is the diagnostic tool of choice.The best treatment is emergency surgical management.

Update on the management of sigmoid diverticulitis

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon.It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits.There has been a growing evolution in our understanding and the treatment guidelines for this disease.To provide an updated review of the epidemiology,pathogenesis,classification and highlight changes in the medical and surgical management of diverticulitis.Diverticulitis is increasingly being seen in young patients(<50 years).Genetic contributions to diverticulitis may be larger than previously thought.Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist.Computed tomography imaging represents the standard to classify the severity of diverticulitis.Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis.Non-operative management is primarily based on antibiotics and supportive measures,but antibiotics may be omitted in mild cases.Interval colonoscopy remains advisable after an acute attack,particularly after a complicated form.Acute surgery is needed for the most severe as well as refractory cases,whereas elective resections are individualized and should be considered for chronic,smoldering,or recurrent forms and respective complications(stricture,fistula,etc.)and for patients with factors highly predictive of recurrent attacks.Diverticulitis is no longer a disease of the elderly.Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease.Non-surgical management remains the appropriate treatment for greater than 70%of patients.In individuals with non-relenting,persistent,or recurrent symptoms and those with complicated disease and sequelae,a segmental colectomy remains the most effective surgical treatment in the acute,chronic,or elective-prophylactic setting.

Role of colonoscopy in patients with persistent acute diverticulitis

AIM： To identify patients with persistent acute diverticulitis who might benefit from an early colonoscopy during their first hospitalization. METHODS： All patients hospitalized between July 2000 and December 2006 for acute diverticulitis who underwent colonoscopy were included in the study. Patients were followed during hospitalization and after discharge. Patients were considered to have a persistent course of acute diverticulitis if symptoms continued after 1 wk of conventional treatment with 1V antibiotics, or if symptoms recurred within 2 mo after discharge. Patients were considered to benefit from an early colonoscopy if the colonoscopy was therapeutic or if it changed a patient＇s outcome. RESULTS： Three hundred and six patients were hospitalized between July 2000 and December 2006 with the diagnosis of acute diverticulitis. Two hundred and twenty four of these were included in the study group. Twenty three patients （10.3%） fulfilled the criteria for a persistent course of acute diverticulitis. Of them, four patients （17.4%） clearly benefited from an early colonoscopy; these patients＇ clinical course is described. None of the patients with a regular non-persistent course demonstrated any benefit from colonoscopy. CONCLUSION： Early colonoscopy detected other significant pathology, which accounted for the clinical presentation in 17% of patients with persistent acute diverticulitis. Therefore, we believe an early colonoscopy should be considered in all patients with a persistent clinical course.

Perforated midgut diverticulitis:Revisited

AIM:To study and provide data on the evolution of medical procedures and outcomes of patients suffering from perforated midgut diverticulitis. METHODS:Three data sources were used:the Medline and Google search engines were searched for case reports on one or more patients treated for perforated midgut diverticulitis (Meckel's diverticulitis excluded) that were published after 1995. The inclusion criterion was sufficient individual patient data in the article. Both indexed and non-indexed journals were used. Patients treated for perforated midgut diverticulitis at Vestfold Hospital were included in this group. Data on symptoms, laboratory and radiology results, treatment modalities, surgical access, procedures, complications and outcomes were collected. The Norwegian patient registry was searched to find patients operated upon for midgut diverticulitis from 1999 to 2007. The data collected were age, sex, mode of access, surgical procedure performed and number of patients per year. Historical controls were retrieved from an article published in 1995 containing pertinent individual patient data. Statistical analysis was done with SPSS software.RESULTS:GroupⅠ:106 patients (48 men) were found. Mean age was 72.2 ± 13.1 years (mean ± SD). Age or sex had no impact on outcomes (P = 0.057 and P = 0.771, respectively). Preoperative assessment was plain radiography in 53.3% or computed tomography (CT) in 76.1%. Correct diagnosis was made in 77.1% with CT, 5.6% without (P = 0.001). Duration of symptoms before hospitalization was 3.6 d (range:1-35 d), but longer duration was not associated with poor outcome (P = 0.748). Eighty-six point eight percent of patients underwent surgery, 92.4% of these through open access where 90.1% had bowel resection. Complications occurred in 19.2% of patients and 16.3% underwent reoperation. Distance from perforation to Treitz ligament was 41.7 ± 28.1 cm. At surgery, no peritonitis was found in 29.7% of patients, local peritonitis in 47.5%, and diffuse peritonitis in 22.8%. Peritonitis grade correlated with the reoperation rate (r = 0.43). Conservatively treated patients had similar hospital length of stay as operated patients (10.6 ± 8.3 d vs 10.7 ± 7.9 d, respectively). Age correlated with hospital stay (r = 0.46). No difference in outcomes for operated or nonoperated patients was found (P = 0.814). Group Ⅱ:113 patients (57 men). Mean age 67.6 ± 16.4 years (range: 21-96 years). Mean age for men was 61.3 ± 16.2 years, and 74.7 ± 12.5 years for women (P = 0.001). Number of procedures per year was 11.2 ± 0.9, and bowel resection was performed in 82.3% of patients. Group Ⅲ: 47 patients (21 men). Patient age was 65.4 ± 14.4 years. Mean age for men was 61.5 ± 17.3 years and 65.3 ± 14.4 years for women. Duration of symptoms before hospitalization was 6.9 d (range: 1-180 d). No patients had a preoperative diagnosis, 97.9% of patients underwent surgery, and 78.3% had multiple diverticula. Bowel resection was performed in 67.4% of patients, and suture closure in 32.6%. Mortality was 23.4%. There was no difference in length of history or its impact on survival between Groups Ⅰ and Ⅲ (P = 0.241 and P = 0.198, respectively). Resection was more often performed in Group Ⅰ (P = 0.01). Mortality was higher in Group Ⅲ (P = 0.002). CONCLUSION: In cases with contained perforation, conservative treatment gives satisfactory results, laparosco-py with lavage and drainage can be attempted and continued with a conservative course.

Perforated appendiceal diverticulitis associated with appendiceal neurofibroma in neurofibromatosis type 1

An appendiceal neurofibroma(ANF) is a rare neoplasm associated with neurofibromatosis type 1(NF-1),an inheritable neurocutaneous disorder that involves multiple systems including the intraabdominal organs.Appendiceal diverticulitis occasionally ruptures in the absence of intense abdominal pain,which can lead to serious consequences.Recent reports highlight the association between appendiceal diverticulum and appendiceal neoplasms; however,there is still little information on the association between appendiceal diverticulitis and ANF in NF-1.A 51-year-old Japanese male with NF-1 was referred to the division of surgery for mild right lower quadrant pain.It was suspected he had perforated acute appendicitis with periappendiceal abscess based on clinical manifestations and findings of computed tomography.An emergency appendectomy was conducted.The pathological examination revealed diffusely proliferated tumor cells of a neurofibroma,coexistent with multiple appendiceal diverticulums,leading to the diagnosis ofperforated appendiceal diverticulitis associated with ANF.Although he developed a remnant abscess,he recovered with the conservative treatments of antibiotics and drainage.This case suggests that appendiceal diverticulitis might be a complication of appendiceal involvement of NF-1,and that it occasionally ruptures in the absence of intense abdominal pain.Clinicians should recognize that NF-1 can cause various abdominal manifestations.

Epidemiological trends and geographic variation in hospital admissions for diverticulitis in the United States

AIM:To characterize the increasing incidence and geographic variation of acute diverticulitis.METHODS:Using the nationwide inpatient sample (NIS) we identified a cohort who had been admitted with diverticulitis between 1998 and 2005.We calculated age-,sex-,and region-specific rates of hospitalizations for diverticulitis over time.RESULTS:The age-adjusted hospitalization rate for diverticulitis increased from 61.8 per 100000 to 75.5 per 100 000 between 1998 and 2005,and increased similarly in both sexes.Diverticulitis-associated admissions were male-predominant in those younger than age 45 years but were female-predominant thereafter.Admission rates increased the most among those<45 years,while remaining unchanged for those≥65 years.By 2005,the majority of hospitalized patients were<65 years.Age-adjusted rates of diverticulitis-associated hospitalizations were lower in the West(50.4/100000) compared to the Northeast(77.7/100000),South (73.9/100000),and Midwest(71.0/100000).CONCLUSION:Diverticulitis-associated hospitalizations have steeply risen,especially in young adults.These epidemiological trends vary by geographic region and warrant further investigation into potential dietary and environmental etiologies.

Small bowel diverticulitis with severe anemia and abdominal pain

The current case report is related to a male patient with diabetes, obesity [body mass index(BMI) 33], hypertension and recurrence of anemia associated to melena and deep asthenia. M.P., a 60-year-old obese individual, was referred to our department by the primary care unit(PCU) of our hospital for severe anemia(Hemoglobin 6.5 g/d L) associated to episodes of melena and abdominal pain. In the past 5 mo the patient referred to the local hospital 3 times for episodes of melena(hemoglobin levels showed anemia 9.8 g/d L) but the main gastroenterological exams were completely negative(colonoscopy and gastroscopy). The PCU of our Hospital, after stabilization of the main parameters and blood transfusion for the low levels of hemoglobin, referred the patient to gastroenterologists: the patient was subjected to both colonoscopy and gastroscopy that were negative. Due to the condition of acute severe hemorrhage the patient, during the first 3 h from the access to the PCU, was subjected to arteriography that did not reveal any hemorrhagic foci or vascular alterations. The video capsule for the study of the small bowel showed the presence of blood beginning from the third portion of duodenum but deep gastroscopy did not reveal it. The patient was then subjected to double balloon endoscopy that revealed a severe diverticulosis of the small bowel with blood from the diverticula. The entero-tomografia computerizzata confirmed the diagnosis and revealed an extension of the diverticula for almost the entire small bowel(no diverticula in the colon). The patient was subjected to wide spectrum antibiotic therapy with resolution of the symptoms and stabilization of hemoglobin levels. The surgeon suggests no indication to surgery for the wide area involved from the disease and potential high risk of complication due to the high BMI. At home, the patient started a monthly therapy with rifaximin and probiotics associated to mesalazine. At present, after 12 mo from the last episode of hemorrhage, the patient is in good clinical condition, reduced his body weight of about 7 kg and the hemoglobin levels appear in slow progressive increase(last measurement 13.2 g/d L).

Management of Hinchey Ⅱ diverticulitis

Colonic diverticulosis can either be asymptomatic or present with complications resulting in significant morbidity and mortality.A key presentation of complicated disease is abscess formation(Hinchey type Ⅱ).The natural course of this is unclear and therefore treatments range from conservative approach with antibiotics and percutaneous guided drainage(PCD) to surgery.There is no clear consensus on the exact management strategy.A Medline based literature search specifically looking at studies dealing with Hinchey type Ⅱ diverticulitis and its management was carried out.For comparison,five-year retrospective data of diverticular abscesses from our institution was collected and the outcome analysed.Various studies have looked into this aspect of the disease,elaborating on the significance of the size and location of the abscesses,the role of PCD,recurrence rates and the controversies regarding the need for elective surgery.Conservative treatment with antibiotics alone is effective in a majority of cases with a role for PCD in large safely accessible abscesses.Variable recurrence rates have been reported in literature and elective surgery should be planned for selected groups of patients.

Should a colonoscopy be offered routinely to patients with CT proven acute diverticulitis? A retrospective cohort study and meta-analysis of best available evidence

BACKGROUND The current guidelines suggest that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The usefulness of routine endoscopic evaluation of CT proven diverticulitis remains unknown. AIM To establish whether routine colonoscopy should be offered to patients after an episode of diverticulitis. METHODS We performed a retrospective study, comparing two groups: a diverticulitis group and a control group. The diverticulitis group consisted of patients undergoing a colonoscopy after an episode of diverticulitis. The control group consisted of asymptomatic patients undergoing a screening sigmoidoscopy. We also performed a systematic review and meta-analysis. We searched electronic data resources to identify all relevant studies. The primary outcome was the number of adenomas found, while the secondary outcomes were the number of cancers and polyps identified, and the adenoma risk. RESULTS 68 and 1309 patients were included in the diverticulitis and control groups respectively. There was no difference in the risk of adenomas (5.9% vs 7.6%, P =0.59), non-advanced adenomas (5.9% vs 6.9%, P = 0.75), advanced adenomas (0% vs 0.8%, P = 1), cancer (0% vs 0.15%, P = 1.00), and polyps (16.2% vs 14.2%, P = 0.65) between both groups. Meta-analysis of data from 4 retrospective observational studies, enrolling 4459 patients, showed no difference between the groups in terms of risk of adenomas (RD =-0.05, 95%CI:-0.11, 0.01, P = 0.10), non-advanced adenomas (RD =-0.02, 95%CI:-0.08, 0.04, P = 0.44), advanced adenomas (RD =-0.01, 95%CI:-0.04, 0.02, P = 0.36), cancer (RD = 0.01, 95%CI:- 0.01, 0.03, P = 0.32), and polyps (RD =-0.05, 95%CI:-0.12, 0.02, P = 0.18). CONCLUSION Routine colonoscopy may not be appropriate in patients with acute diverticulitis. High quality prospective studies are required for more robust conclusions.