Does the microbiome play a role in the pathogenesis of colonic diverticular disease? A systematic review.

BACKGROUND AND AIMS: The role of the microbiota in diverticulosis and diverticular disease is underexplored. This systematic review aimed to assess all literature pertaining to the microbiota and metabolome associations in asymptomatic diverticulosis, symptomatic uncomplicated diverticular disease (SUDD), and diverticulitis pathophysiology. METHODS: Seven databases were searched for relevant studies published up to September 28, 2022. Data were screened in Covidence and extracted to Excel. Critical appraisal was undertaken using the Newcastle Ottawa Scale for case/control studies. RESULTS: Of the 413 papers screened by title and abstract, 48 full-text papers were reviewed in detail with 12 studies meeting the inclusion criteria. Overall, alpha and beta diversity were unchanged in diverticulosis; however, significant changes in alpha diversity were evident in diverticulitis. A similar Bacteroidetes to Firmicutes ratio compared with controls was reported across studies. The genus-level comparisons showed no relationship with diverticular disease. Butyrate-producing microbial species were decreased in abundance, suggesting a possible contribution to the pathogenesis of diverticular disease. Comamonas species was significantly increased in asymptomatic diverticulosis patients who later developed diverticulitis. Metabolome analysis reported significant differences in diverticulosis and SUDD, with upregulated uracil being the most consistent outcome in both. No significant differences were reported in the mycobiome. CONCLUSION: Overall, there is no convincing evidence of microbial dysbiosis in colonic diverticula to suggest that the microbiota contributes to the pathogenesis of asymptomatic diverticulosis, SUDD, or diverticular disease. Future research investigating microbiota involvement in colonic diverticula should consider an investigation of mucosa-associated microbial changes within the colonic diverticulum itself.

HE INFLUENCE OF THE COVID-19 PANDEMIC ON THE DIVERTICULAR DISEASE COMPLICATIONS TREATMENT

Introduction. The COVID-19 pandemic affected not only the organization of the entire healthcare system, but also made adjustments to the diagnosis and treatment of a wide range of diseases, including diverticular disease. Aim. Analysis of the results of inpatient care for patients with acute diverticulitis during the COVID-2019 pandemic. Material and methods: From 2017 to January 2022, 244 patients with diverticular disease were treated in coloproctology clinic. During the pandemic period (March 2020 – December 2021) there were 15 patients with COVID-2019 associated pneumonia who developed complications of diverticular disease. Results and discussion. An increase of hospitalizations of patients with complicated forms of the disease was established, while patients with uncomplicated diverticular disease were hospitalized less frequently. There was also a decrease in the number of reconstructive surgeries in 2020. The most informative diagnostic tool that allows to verify complicated forms of diverticular disease and determines further treatment tactics, especially in the COVID-19 pandemic, is X-ray computed tomography with intravenous contrast, which was performed in 53.3% of patients. The number of urgent surgical interventions increased, including in patients with COVID-2019. During the pandemic, minimally invasive interventions began to be performed more often, allowing the patient to be treated as gently as possible. Moreover, drainage of abscess under ultrasound guidance is currently becoming a popular procedure even with large abscesses (>3 cm). This technology should be considered as bridge operation before a radical intervention, which implementation should be carried out after the stabilization of the general condition of the patient. Diffuse peritonitis in COVID-positive patients continues to be considered as an indication for emergency laparotomy. At the same time, Hartmann-type operations should be performed, refusing the extended intestinal resection and primary anastomosis. Conclusion. The COVID-19 pandemic has made adjustments to the organization of medical care for patients with diverticular disease. In this regard, it is advisable to conduct interdisciplinary multicenter research in order to study the influence of the pandemic on the course of the disease and take early measures to minimize the negative consequences of the pandemic. © 2022, LLC "IMC" Modern Clinical Medicine. All rights reserved.

Clostridium tertium Bacteremia: A Marker of an Underlying Perforated Colonic Diverticular Disease in a Non-Neutropenic Patient With COVID-19.

Clostridium tertium (C. tertium) is an aero-tolerant, gram-positive, endospore-forming, and non-exotoxin-producing bacillus that has colonized the gastrointestinal tract of animals and humans. It is considered a rare pathogen of humans, possibly because of its low virulence. Most C. tertium infections in the reviewed literatures were predominately reported among neutropenic hosts with hematological malignancies. A 66-year-old female patient with a past medical history of type II diabetes mellitus and chronic obstructive pulmonary disease was admitted with coronavirus disease 2019 (COVID-19) that initially required non-invasive ventilation. The patient developed septic shock due to C. tertium bacteremia. Computed tomography of the abdomen depicted free intraperitoneal gas and sigmoid colon perforation. Exploratory laparotomy revealed perforated sigmoid diverticulitis, and Hartmann's procedure was performed. The patient received a prolonged course of susceptibility-guided antibiotics to clear C. tertium bacteremia. The authors described a rare case of C. tertium bacteremia as a marker of underlying perforated colonic diverticulitis in a non-neutropenic patient with COVID-19 that necessitated operative procedure intervention for primary source control and an extended course of targeted antibiotic therapy to treat the Clostridial infection. Our case reaffirmed the available literature that suggested the presence of C. tertium bacteremia in non-neutropenic patients raises suspicion of an associated gastrointestinal tract pathology that should warrant a diagnostic workup to identify the infection source culprit.

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.