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BMJ Clinical Evidence Mar 2011Diverticula (mucosal outpouching through the wall of the colon) are rare before the age of 40 years, after which prevalence increases steadily and reaches over 25% by 60... (Review)
Review
INTRODUCTION
Diverticula (mucosal outpouching through the wall of the colon) are rare before the age of 40 years, after which prevalence increases steadily and reaches over 25% by 60 years. However, only 10% to 25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: treatments for uncomplicated diverticular disease; treatments to prevent complications; and treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 16 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodics, elective surgery, increasing fibre intake with bran or ispaghula husk, lactulose, medical treatment, mesalazine, methylcellulose, rifaximin, and surgery.
Topics: Abdominal Pain; Acute Disease; Dietary Fiber; Diverticulitis; Diverticulosis, Colonic; Diverticulum; Humans
PubMed: 21401970
DOI: No ID Found -
International Journal of Colorectal... Apr 2024To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
To evaluate comparative outcomes of outpatient (OP) versus inpatient (IP) treatment and antibiotics (ABX) versus no antibiotics (NABX) approach in the treatment of uncomplicated (Hinchey grade 1a) acute diverticulitis.
METHODS
A systematic online search was conducted using electronic databases. Comparative studies of OP versus IP treatment and ABX versus NABX approach in the treatment of Hinchey grade 1a acute diverticulitis were included. Primary outcome was recurrence of diverticulitis. Emergency and elective surgical resections, development of complicated diverticulitis, mortality rate, and length of hospital stay were the other evaluated secondary outcome parameters.
RESULTS
The literature search identified twelve studies (n = 3,875) comparing NABX (n = 2,008) versus ABX (n = 1,867). The NABX group showed a lower disease recurrence rate and shorter length of hospital stay compared with the ABX group (P = 0.01) and (P = 0.004). No significant difference was observed in emergency resections (P = 0.33), elective resections (P = 0.73), development of complicated diverticulitis (P = 0.65), hospital re-admissions (P = 0.65) and 30-day mortality rate (P = 0.91). Twelve studies (n = 2,286) compared OP (n = 1,021) versus IP (n = 1,265) management of uncomplicated acute diverticulitis. The two groups were comparable for the following outcomes: treatment failure (P = 0.10), emergency surgical resection (P = 0.40), elective resection (P = 0.30), disease recurrence (P = 0.22), and mortality rate (P = 0.61).
CONCLUSION
Observation-only treatment is feasible and safe in selected clinically stable patients with uncomplicated acute diverticulitis (Hinchey 1a classification). It may provide better outcomes including decreased length of hospital stay. Moreover, the OP approach in treating patients with Hinchey 1a acute diverticulitis is comparable to IP management. Future high-quality randomised controlled studies are needed to understand the outcomes of the NABX approach used in an OP setting in managing patients with uncomplicated acute diverticulitis.
Topics: Humans; Neoplasm Recurrence, Local; Diverticulitis; Outcome Assessment, Health Care; Treatment Failure; Patient Readmission; Diverticulitis, Colonic; Acute Disease; Treatment Outcome
PubMed: 38578433
DOI: 10.1007/s00384-024-04618-7 -
BMJ Clinical Evidence Aug 2007Diverticula (mucosal outpouching through the wall of the colon) affect over 5% of adults aged 40 years and older, but only 10-25% of affected people will develop... (Review)
Review
INTRODUCTION
Diverticula (mucosal outpouching through the wall of the colon) affect over 5% of adults aged 40 years and older, but only 10-25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: treatments for uncomplicated diverticular disease; treatments to prevent complications; and treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to July 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 13 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodics, bran, elective surgery, increasing fibre intake, ispaghula husk, lactulose, medical treatment, mesalazine, methylcellulose, rifaximin, surgery.
Topics: Acute Disease; Diverticulitis; Diverticulitis, Colonic; Diverticulosis, Colonic; Diverticulum; Humans; Mesalamine
PubMed: 19454119
DOI: No ID Found -
International Journal of Colorectal... Jun 2023Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease. (Review)
Review
INTRODUCTION
Our aim was to determine the incidence of diverticulitis recurrence after sigmoid colectomy for diverticular disease.
METHODS
Consecutive patients who benefited from sigmoid colectomy for diverticular disease from January 2007 to June 2021 were identified based on operative codes. Recurrent episodes were identified based on hospitalization codes and reviewed. Survival analysis was performed and was reported using a Kaplan-Meier curve. Follow-up was censored for last hospital visit and diverticulitis recurrence. The systematic review of the literature was performed according to the PRISMA statement. Medline, Embase, CENTRAL, and Web of Science were searched for studies reporting on the incidence of diverticulitis after sigmoid colectomy. The review was registered into PROSPERO (CRD42021237003, 25/06/2021).
RESULTS
One thousand three-hundred and fifty-six patients benefited from sigmoid colectomy. Four hundred and three were excluded, leaving 953 patients for inclusion. The mean age at time of sigmoid colectomy was 64.0 + / - 14.7 years. Four hundred and fifty-eight patients (48.1%) were males. Six hundred and twenty-two sigmoid colectomies (65.3%) were performed in the elective setting and 331 (34.7%) as emergency surgery. The mean duration of follow-up was 4.8 + / - 4.1 years. During this period, 10 patients (1.1%) developed reccurent diverticulitis. Nine of these episodes were classified as Hinchey 1a, and one as Hinchey 1b. The incidence of diverticulitis recurrence (95% CI) was as follows: at 1 year: 0.37% (0.12-1.13%), at 5 years: 1.07% (0.50-2.28%), at 10 years: 2.14% (1.07-4.25%) and at 15 years: 2.14% (1.07-4.25%). Risk factors for recurrence could not be assessed by logistic regression due to the low number of incidental cases. The systematic review of the literature identified 15 observational studies reporting on the incidence of diverticulitis recurrence after sigmoid colectomy, which ranged from 0 to 15% for a follow-up period ranging between 2 months and over 10 years.
CONCLUSION
The incidence of diverticulitis recurrence after sigmoid colectomy is of 2.14% at 15 years, and is mostly composed of Hinchey 1a episodes. The incidences reported in the literature are heterogeneous.
Topics: Male; Humans; Middle Aged; Aged; Female; Incidence; Diverticulitis, Colonic; Retrospective Studies; Colectomy; Diverticulitis; Colon, Sigmoid; Diverticular Diseases; Sigmoid Diseases
PubMed: 37261498
DOI: 10.1007/s00384-023-04454-1 -
International Journal of Surgery... Oct 2018No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We... (Meta-Analysis)
Meta-Analysis
BACKGROUND
No consensus has been reached in the management of perforated diverticulitis. Many surgeons opt for a Hartmann's procedure to avoid the risk of an anastomotic leak. We hypothesise that resection with primary anastomosis is a safe alternative in selected patients. We aim to conduct a systematic review and meta-analysis on the available literature.
METHODS
Studies that compared emergency Hartmann's with primary anastomosis in perforated left sided colonic diverticulitis were systematically reviewed. The search strategy included all study types that compared primary anastomosis to Hartmann's in perforated diverticulitis and reported on morbidity and mortality. 5 databases (PubMed, MEDLINE via PubMed, OVID, EMBASE via OVID and The Cochrane Collaboration). The Cochrane's Bias Methods Group tool was used to assess the risk of bias and a meta-analysis of the relevant studies was conducted.
RESULTS
The review retrieved 1933 abstracts of which 14 studies (2 RCTs, 4 prospective non-randomised and 8 retrospective non-randomised) with 765 patients in total, 482 in the Hartmann's group and 283 in the primary anastomosis group, met the inclusion criteria. This showed a significantly lower mortality with primary anastomosis (10.6%) compared to Hartmann's (20.7%) (p = 0.0003). Morbidity was also significantly lower (41.8% vs. 51.2%) (p = 0.0483). The RR for mortality was 0.92 in favour of primary anastomosis (p = 0.0019). The average anastomotic leak rate was 5.9%.
CONCLUSION
Resection and primary anastomosis should be considered as a feasible and safe operative strategy in selected patients with perforated diverticulitis. There is however a paucity of high level evidence and further research is needed.
Topics: Adult; Anastomosis, Surgical; Bias; Diverticulitis, Colonic; Humans; Intestinal Perforation; Morbidity; Prospective Studies; Retrospective Studies
PubMed: 30165109
DOI: 10.1016/j.ijsu.2018.08.009 -
Annals of Internal Medicine Mar 2022Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.
BACKGROUND
Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.
PURPOSE
To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis.
DATA SOURCES
MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.
STUDY SELECTION
Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes.
DATA EXTRACTION
6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies.
DATA SYNTHESIS
Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies).
LIMITATIONS
The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect.
CONCLUSION
Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions.
PRIMARY FUNDING SOURCE
Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).
Topics: Acute Disease; Anti-Bacterial Agents; Diagnostic Imaging; Diverticulitis; Diverticulitis, Colonic; Humans
PubMed: 35038271
DOI: 10.7326/M21-1645 -
World Journal of Gastrointestinal... Mar 2021Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature.
BACKGROUND
Post-colonoscopy diverticulitis is increasingly recognized as a potential complication. However, the evidence is sparse in the literature.
AIM
To systematically review all available evidence to describe the incidence, clinical course with management and propose a definition.
METHODS
The databases PubMed, EMBASE and Cochrane databases were searched using with the keywords up to June 2020. Additional manual search was performed and cross-checked for additional references. Data collected included demographics, reason for colonoscopy, time to diagnosis, method of diagnosis (clinical imaging) and management outcomes.
RESULTS
A total of nine studies were included in the final systematic review with a total of 339 cases. The time to diagnosis post-colonoscopy ranged from 2 h to 30 d. Clinical presentation for these patients were non-specific including abdominal pain, nausea/vomiting, per rectal bleeding and chills/fever. Majority of the cases were diagnosed based on computed tomography scan. The management for these patients were similar to the usual patients presenting with diverticulitis where most resolve with non-operative intervention (, antibiotics and bowel rest).
CONCLUSION
The entity of post-colonoscopy diverticulitis remains contentious where there is a wide duration post-procedure included. Regardless of whether this is a true complication post-colonoscopy or a event, early diagnosis is vital to guide appropriate treatment. Further prospective studies especially registries should include this as a complication to try to capture the true incidence.
PubMed: 33763188
DOI: 10.4253/wjge.v13.i3.82 -
World Journal of Emergency Surgery :... Nov 2022There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is no sufficient overview of outcomes in right-sided and left-sided colonic diverticulitis (CD) following non-operative management. This systematic review was conducted to evaluate the recurrence/treatment failure in right-sided and left-sided CD.
METHODS
A systematic review was conducted following PRISMA guidelines. MEDLINE, Embase, and Cochrane Library from inception to Dec 2021 were searched. The study characteristics, recurrence/treatment failure, and risk factors for recurrence/treatment failure were extracted. Proportional meta-analyses were performed to calculate the pooled recurrent/treatment failure rate of right-sided and left-sided CD using the random effect model. Logistic regression was applied for the factors associated with the recurrence/treatment failure.
RESULTS
Thirty-eight studies with 10,129 patients were included, and only two studies comprised both sides of CD. None of the studies had a high risk of bias although significant heterogeneity existed. The pooled recurrence rate was 10% (95% CI 8-13%, I = 86%, p < 0.01) in right-sided and 20% (95% CI 16-24%, I = 92%, p < 0.01) in left-sided CD. For the uncomplicated CD, the pooled recurrence rate was 9% (95% CI 6-13%, I = 77%, p < 0.01) in right-sided and 15% (95% CI 8-27%, I = 97%, p < 0.01) in the left-sided. Age and gender were not associated with the recurrence of both sides. The treatment failure rate was 5% (95% CI 2-10%, I = 84%, p < 0.01) in right-sided and 4% (95% CI 2-7%, I = 80%, p < 0.01) in left-sided CD. The risk factors for recurrence and treatment failure were limited.
CONCLUSION
Non-operative management is effective with low rates of recurrence and treatment failure for both right-sided and left-sided CD although left-sided exhibits a higher recurrence. The recurrence rates did not differ between patients receiving antibiotics or not in uncomplicated CD. Age and sex were not associated with the recurrence although other risk factors were dispersing. Further risk factors for recurrence and treatment failure would be investigated for precise clinical decision-making and individualized strategy.
Topics: Humans; Diverticulitis, Colonic; Risk Factors; Anti-Bacterial Agents
PubMed: 36320045
DOI: 10.1186/s13017-022-00463-7 -
RMD Open Sep 2022Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively...
A systematic literature review informing the consensus statement on efficacy and safety of pharmacological treatment with interleukin-6 pathway inhibition with biological DMARDs in immune-mediated inflammatory diseases.
OBJECTIVES
Informing an international task force updating the consensus statement on efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) selectively targeting interleukin-6 (IL-6) pathway in the context of immune-mediated inflammatory diseases.
METHODS
A systematic literature research of all publications on IL-6 axis inhibition with bDMARDs published between January 2012 and December 2020 was performed using MEDLINE, EMBASE and Cochrane CENTRAL databases. Efficacy and safety outcomes were assessed in clinical trials including their long-term extensions and observational studies. Meeting abstracts from ACR, EULAR conferences and results on clinicaltrials.gov were taken into consideration.
RESULTS
187 articles fulfilled the inclusion criteria. Evidence for positive effect of IL-6 inhibition was available in various inflammatory diseases such as rheumatoid arthritis, juvenile idiopathic arthritis, giant cell arteritis, Takayasu arteritis, adult-onset Still's disease, cytokine release syndrome due to chimeric antigen receptor T cell therapy and systemic sclerosis-associated interstitial lung disease. Newcomers like satralizumab and anti-IL-6 ligand antibody siltuximab have expanded therapeutic approaches for Castleman's disease and neuromyelitis optica, respectively. IL-6 inhibition did not provide therapeutic benefits in psoriatic arthritis, ankylosing spondylitis and certain connective tissue diseases. In COVID-19, tocilizumab (TCZ) has proven to be therapeutic in advanced disease. Safety outcomes did not differ from other bDMARDs, except higher risks of diverticulitis and lower gastrointestinal perforations. Inconsistent results were observed in several studies investigating the risk for infections when comparing TCZ to TNF-inhibitors.
CONCLUSION
IL-6 inhibition is effective for treatment of several inflammatory diseases with a safety profile that is widely comparable to other bDMARDs.
Topics: Adult; Humans; Antirheumatic Agents; Interleukin-6; Ligands; Receptors, Chimeric Antigen; COVID-19 Drug Treatment
PubMed: 36260501
DOI: 10.1136/rmdopen-2022-002359 -
International Journal of Surgery... Feb 2016Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring... (Review)
Review
BACKGROUND
Diverticulitis is a common condition with a broad spectrum of disease severity. A scoring system has been proposed for diagnosing diverticulitis, and a number of scoring systems exist for predicting prognosis associated with severe complications of diverticulitis such as peritonitis. However, predicting disease severity has not received as much attention. Therefore, the aim of this review was to identify the factors that are predictive of severe acute diverticulitis.
METHODS
A systematic literature search was performed using Medline, PubMed, EMBASE, and the Cochrane Library to identify papers that evaluated factors predictive of severe diverticulitis. Severe diverticulitis was defined as complicated diverticulitis (associated with haemorrhage, abscess, phlegmon, perforation, purulent/faecal peritonitis, stricture, fistula, or small-bowel obstruction) or diverticulitis that resulted in prolonged hospital admission, surgical intervention or death.
RESULTS
Twenty one articles were included. Studies were categorised into those that identified patient characteristics (n = 12), medications (n = 5), biochemical markers (n = 8) or imaging (n = 3) as predictors. Predictors for severe diverticulitis included first episode of diverticulitis, co-morbidities (Charlson score ≥ 3), non-steroidal anti-inflammatory drug use, steroid use, a high CRP on admission and severe disease on radiological imaging. Age and gender were not associated with disease severity.
CONCLUSION
A number of predictors exist for identifying severe diverticulitis, and CT remains the gold standard for diagnosing complicated disease. Patients who present with identified risk factors for severe disease warrant early imaging, closer in-patient observation and a lower threshold for early surgical intervention. Patients without these factors may be suitable for outpatient-based treatment.
Topics: Acute Disease; Anti-Inflammatory Agents, Non-Steroidal; C-Reactive Protein; Comorbidity; Diverticulitis; Glucocorticoids; Humans; Severity of Illness Index; Tomography, X-Ray Computed
PubMed: 26777741
DOI: 10.1016/j.ijsu.2016.01.005