Management and ambulation of uncomplicated acute diverticulitis during the CoVID-19 Pandemic-a clinical audit in a district general hospital

Aims: To audit The management (ambulation versus admission) of acute diverticulitis presenting to a London DGH. Method(s): A retrospective clinical audit. Data On cases of acute diverticulitis presenting to The general surgical Department at Ealing Hospital were collected over a period of 92 days. The medical notes were screened and The indication for admission in hospital was recorded. Each admission was then assessed for compliance with standard criteria for appropriate admission, derived from national guidelines by NICE. Patients admitted despite not meting these criteria were deemed as inappropriate admissions. Result(s): mAll patient referrals to General Surgery at Ealing Hospital were screened from 1/7/21 to 30/9/21. 618 patients were identified. A total of 18 patients presented with radiologically-confirmed diverticulitis in this period (2.9%). Of these, 14 patients were admitted (77.8%). None of The patients ambulated met The criteria for admission. If The admitting teams were to adhere to National Guidelines, 15 of The 18 patients presented and 11 of The 14 patients admitted could have been safely ambulated. In inappropriately-admitted cases, none received surgical intervention. The mean number of days spent in hospital for inappropriate admissions was 3.27 (Range 1-8 days). This translates to 49 patient-days that could have been safely avoided according to national guidelines. The cost incurred by The NHS by The inappropriate admission of these patients is estimated at 78,400 p.a. Conclusion(s): Safe ambulation of patients presenting with acute uncomplicated diverticulitis can improve departmental efficacy, patient flow and ultimately reduce bed pressures and expenditure associated with hospital admissions.

COLONOSCOPY COMPLETION RATES AND PATIENT TOLERANCE AFTER COMPLICATED DIVERTICULITIS;IS CT COLONOSCOPY A BETTER OPTION?

Introduction ACPGBI and ESCP guidelines suggest colonic examination after acute complicated diverticulitis due to a higher prevalence of colorectal cancer (CRC), but colonoscopy in this cohort can be challenging. We examined completion rates, pain scores and analgesic use in endoscopic follow-up of complicated diverticulitis in a district general hospital. Methods Patients were identified from hospital records with a coded diagnosis of acute diverticulitis from 01/01/2021 - 01/ 07/2021. Electronic records were examined to identify those with complicated diverticulitis on CT who had not had surgery. The endoscopy system was interrogated from 01/01/2021 - 01/01/2022 for these patients. Information was collected on: whether colonoscopy was requested and performed, site reached, quality of mucosal views, pain scores (average of physician and nurse), analgesia and sedation use, and reason for incomplete colonoscopy. We gathered the same data for the preceding and/or succeeding patients on the endoscopy list for comparison. Results From 01/01/2021 - 01/07/2021 there were 49 cases of acute complicated diverticulitis;4 had emergency surgery. of the remaining 45 cases, 28 had a colonoscopy requested. By 01/01/2022, 17 had an colonoscopy (group 1), and the mean time from discharge to endoscopy was 108 days. These were compared to the 26 colonoscopies immediately preceding or succeeding the group 1 colonoscopies (group 2). Colonoscopy completion rates were lower in group 1, and reasons for incomplete examination were: patient discomfort x2, tight angulation x1, muscular hypertrophy x1. Reasons for incomplete examination in group 2 were: poor bowel prep x2. In group 1 the mean pain scores were higher, as was use of fentanyl and midazolam. Entonox use was about equivalent. Conclusions Endoscopic follow-up of complicated diverticulitis was not universal. There was a delay beyond the recommended follow-up at 6 weeks which corresponds with delays in endoscopy for other indications since the COVID-19 pandemic. Completion rates were lower for the complicated diverticulitis group and the procedure was more poorly tolerated. Colonoscopy completion rates have not been looked at specifically for complicated diverticulitis follow-up elsewhere. The completion rates in this sample are lower than those for the endoscopic follow-up of all diverticulitis in other studies. If these rates are found in a larger sample then alternative methods for examining the colon, such as CT colonoscopy, may be a more attractive option.

ATYPICAL PRESENTATION OF LEGIONNAIRES DISEASE WITH DIVERTICULITIS IN IMMUNOSUPPRESSED PATIENT

CASE: A 69-year-old male smoker with stage 3b prostate cancer managed with abiraterone and prednisone, prior severe COVID-19 pneumonia requiring mechanical ventilation, and history of perforated sigmoid diverticulitis presented with 3 days of anorexia, watery diarrhea, and left lower abdominal pain. Two weeks earlier he developed a mild dry cough without fever, dyspnea, or chest pain. There were no sick contacts or recent travel. He was afebrile, and initial routine chemistries and a complete blood count were unremarkable. An abdomino-pelvic CT revealed acute diverticulitis of the distal descending and sigmoid colon. A consolidation at the right lung base was also incidentally noted. Follow up imaging confirmed a multifocal pneumonia on chest Xray. Legionella antigen was detected in the urine. Metronidazole and levofloxacin were initiated with clinical improvement and the patient was discharged home to complete a 10-day course of antibiotics IMPACT/DISCUSSION: Legionella bacteria are gram negative organisms found widespread in soil and bodies of water including lakes, streams, and artificial reservoirs. Transmission is via inhalation of aerosols and a high innoculum is typically needed to cause infection. Host risk factors for infection include older age, impaired cellular immunity, smoking, male sex, and medical co-morbidities such as diabetes mellitus, renal, lung and cardiovascular disease. The two most commonly known syndromes associated with Legionella infection are Legionnaire's disease, a pneumonia occurring typically in the late summer or early autumn months (as in our patient), and Pontiac fever, an acute self- limited febrile illness. The mortality rate for hospitalized Legionnaire's is up to 10%. Extra-pulmonary manifestations are rare and can include skin and soft tissue infections, septic arthritis, endocarditis, myocarditis, peritonitis, pyelonephritis, meningitis, brain abscesses, and surgical site infections. The diagnosis of extra-pulmonary disease requires detection of Legionella at the affected site by culture or polymerase chain reaction. In the absence of a known local Legionella outbreak, our patient's age, sex, smoking status, and underlying immune suppression most likely increased his risk for this sporadic infection. We postulate that the acute diarrhea associated with Legionnaire's disease may have triggered inflammation of his diverticula or the acute diverticulitis was an extra-pulmonary manifestation. To our knowledge, we are the first to report a case of Legionnaire's disease presenting as acute diverticulitis. CONCLUSION: Legionnaire's is a typical disease with many atypical and extra-pulmonary presentations. We present a case of Legionnaire's disease masquerading as acute diverticulitis and urge timely consideration and testing for Legionella in at-risk patients presenting with predominantly GI symptoms and subtle or no respiratory complaints, as it can be life-saving.

INTERNATIONAL DIFFERENCES IN THE SURGICAL MANAGEMENT OF DIVERTICULITIS: AN AUDIT OF THE DAMASCUS MULTICENTER TRIAL

Purpose/Background: Reported international variability in the index management of acute diverticulitis may contribute to the observed differences in short-term outcomes and drive disparities in guidelines. Hypothesis/Aim: Goal: To compare international practices in initial surgical management for acute diverticulitis Hypothesis: Decision making varies by region in comparable patients, impacting outcomes and guidelines Methods/Interventions: The DAMASCUS study was a 6-month prospective, global observational study on the management and short-term outcomes of patients presenting with acute diverticulitis. For this study, baseline patient and disease covariates were reviewed from the RedCap database for initial surgical decision making by region (North America, Europe, UK, Australasia and Asia/Africa/South America [LMIC's]). The main outcome was the international variation in acute surgical management by region. Results/Outcome(s): Of 5659 patients enrolled internationally, 4472 (79%) were admitted on initial presentation and included in this analysis. The admission rate was significantly lower in North America, where only 39% were admitted (p<0.001). 28% (n=1558) reported a prior diverticular episode;North America had significantly higher rates of prior episodes (47%;p<0.01). Prior episodes were mostly >12 months before current presentation in all regions. 709 patients (15.9%) had emergency surgery for diverticulitis. Rates for surgery at initial presentation varied significantly from 6% (North America) to 24% (LMIC's). Surgery was CT-driven in 98%. 95 patients (13.4%) had a laparoscopic lavage/washout, while 614 (86.6%) had resectional surgery. The most common resection was a Hartmann's procedure (71.6%), performed significantly more than a segmental resection in all regions except Europe (P<0.001). A primary anastomosis was performed in 174 overall (28.3%);rates were similar across regions. An end colostomy- whether described as a Hartmann's, anterior resection, or sigmoid colectomy- was the most common stoma overall at 87.3% (P<0.001). Excluding the Hartmann procedures, 24.1% left a covering stoma. Europe and LMIC were significantly less likely to divert (p=0.002). All other regions were comparable. 67.8% left a surgical drain. Nearly all reported treatment was not affected by Covid 19 (98%). Limitations: Audit design, with differences in definitions of procedures and bias possible from who completed the audit. Conclusions/Discussion: The DAMASCUS study confirmed substantial geographical variation in the index surgical decision making for emergency diverticulitis cases. Despite colorectal expersite, a Hartmann's procedure with end colostomy remains the most common procedure in emergency cases. Lower stoma rates in LMIC may be related to less available resources for subsequent cases. Further analysis will be performed to determine whether such variation is associated with short term clinical outcomes.

Are we over-zealous in our management of acute diverticulitis?

Aims: Of the 25% of people with diverticula who develop symptomatic diverticular disease, approximately 75% will have at least one episode of diverticulitis. However according to the latest NICE guidance those with diverticulitis who are not systemically unwell may not require either admission or antibiotics. In the financially austere environment facing the NHS within the COVID 19 pandemic, prudence in such resource allocation is of vital importance. We aim to review management of patients with acute diverticulitis over a 6-month period in a district general hospital against the 2019 NICE guidelines. Methods: 29 patients presenting with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed. Biochemical markers, lactate and vital signs were used to assess if attending patients were systemically unwell. Results: 23 patients were admitted and 6 managed as outpatients via the surgical ambulatory unit. Of the 29 patient cohort, 9 (31%) were systemically unwell. All 9 unwell patients received antibiotics. Of the 20 patients not considered systemically unwell, 11 (55%) received antibiotics. 16 (80%) that were admitted did not require admission on retrospective review. Conclusion: Prompt administration of intravenous antibiotics for septic patients with diverticulitis reduces associated morbidity and mortality and the observed adherence to this principle is encouraging. For systemically well patients, increased clinical discernment is required to consider managing patients in the surgical ambulatory setting, avoiding unnecessary admissions. Similar caution must be used in appropriate use of antimicrobials to avoid unnecessary adverse consequences.

The Management of Acute Colonic Diverticulitis in the COVID-19 Era: A Scoping Review.

Background and Objective: During the COVID-19 pandemic, health systems worldwide made major changes to their organization, delaying diagnosis and treatment across a broad spectrum of pathologies. Concerning surgery, there was an evident reduction in all elective and emergency activities, particularly for benign pathologies such as acute diverticulitis, for which we have identified a reduction in emergency room presentation with mild forms and an increase with more severe forms. The aim of our review was to discover new data on emergency presentation for patients with acute diverticulitis during the Covid-19 pandemic and their current management, and to define a better methodology for surgical decision-making. Method: We conducted a scoping review on 25 trials, analyzing five points: reduced hospital access for patients with diverticulitis, the preferred treatment for non-complicated diverticulitis, the role of CT scanning in primary evaluation and percutaneous drainage as a treatment, and changes in surgical decision-making and preferred treatment strategies for complicated diverticulitis. Results: We found a decrease in emergency access for patients with diverticular disease, with an increased incidence of complicated diverticulitis. The preferred treatment was conservative for non-complicated forms and in patients with COVID-related pneumonia, percutaneous drainage for abscess, or with surgery delayed or reserved for diffuse peritonitis or sepsis. Conclusion: During the COVID-19 pandemic we observed an increased number of complicated forms of diverticulitis, while the total number decreased, possibly due to delay in hospital or ambulatory presentation because of the fear of contracting COVID-19. We observed a greater tendency to treat these more severe forms by conservative means or drainage. When surgery was necessary, there was a preference for an open approach or a delayed operation.

What paradigm shifts occurred in the management of acute diverticulitis during the COVID-19 pandemic? A scoping review.

BACKGROUND: Acute colonic diverticulitis (ACD) is common in Western countries, with its prevalence increasing throughout the world. As a result of the coronavirus disease 2019 (COVID-19), elective surgery and in-patients' visits have been cancelled or postponed worldwide. AIM: To systematically explore the impact of the pandemic in the management of ACD. METHODS: MEDLINE, Embase, Scopus, MedxRiv, and the Cochrane Library databases were searched to 22 December 2020. Studies which reported on the management of patients with ACD during the COVID-19 pandemic were eligible. For cross sectional studies, outcomes of interest included the number of hospital admission for ACD, as well as key features of disease severity (complicated or not) across two time periods (pre- and during lockdown). RESULTS: A total of 69 papers were inspected, and 21 were eligible for inclusion. Ten papers were cross sectional studies from seven world countries; six were case reports; three were qualitative studies, and two review articles. A 56% overall decrease in admissions for ACD was observed during lockdown, peaking 67% in the largest series. A 4%-8% decrease in the rate of uncomplicated diverticulitis was also noted during the lockdown phase. An initial non-operative management was recommended for complicated diverticulitis, and encouraged to an out-of-hospital regimen. Despite initial concerns on the use of laparoscopy for Hinchey 3 and 4 patients to avoid aerosolized contamination, societal bodies have progressively mitigated their initial recommendations as actual risks are yet to be ascertained. CONCLUSION: During the COVID-19 pandemic, fewer patients presented and were diagnosed with ACD. Such decline may have likely affected the spectrum of uncomplicated disease. Established outpatient management and follow up for selected cases may unburden healthcare resources in time of crisis.