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Management of acute diverticulitis

Author/s: 
Zondervan, N., Snelgrove, R., Bradley, N.

1 Emergency department visits and hospital admissions for acute
diverticulitis have increased
Emergency department visits for acute diverticulitis increased by 26.8% to
113.9 visits per 100 000 from 2006 to 2013 in the United States.1
Hospital admissions for diverticulitis increased 7.5% annually from 190 per 100 000 in 2008 to
310 per 100 000 in 2015 in Europe; the increase occurred predominantly among
patients aged younger than 60 years.2 Insufficient consumption of dietary fibre
is associated with this rise.
2 Symptoms of diverticulitis may be driven by inflammation rather
than infection
Contemporary evidence shows that use of antibiotics in uncomplicated cases of
diverticulitis neither accelerates recovery nor improves outcomes.2
A recent
study has suggested that chronic inflammation secondary to environmental risk
factors and alterations of the gut microbiome are now favoured causes over
microperforation or bacterial translocation.3
3 Most patients with uncomplicated diverticulitis can be treated as
outpatients with nonopiate analgesia rather than antibiotics
Cross-sectional imaging that shows inflamed colonic diverticula without perforation or abscess defines uncomplicated diverticulitis. Two randomized controlled trials that compared antibiotic and nonantibiotic treatment reported
no difference in recovery time, treatment duration or rate of recurrence.4,5
Updated guidelines recommend reserving antibiotics for patients taking
immunosuppressive medications and those with sepsis.1,2 Treating symptoms
with nonopiate analgesics avoids worsening bowel function and contributing
to opiate dependence.
4 Evidence of complicated diverticulitis should prompt emergent
surgical assessment and antibiotic treatment
Complicated diverticulitis, defined as radiologic evidence of perforation or intraabdominal abscess, has a 30-day mortality rate of 8.7%.2
Antibiotic therapy is indicated, and many patients require admission to hospital.1
Percutaneous drainage
of large abscesses (> 3 cm) or emergency surgery may be required.2
5 Colonoscopy and elective colon resection are not routinely required
after resolution of uncomplicated diverticulitis
Only 8.7% of patients with uncomplicated diverticulitis will present to hospital
with a second episode.1
Elective surgery should be determined by frequency
and severity of symptoms, rather than prevention of future complications.2
Risk of malignant disease after uncomplicated left-sided diverticulitis is similar to that of the general population (1%), and standard colon cancer screening guidelines should be followed.1
Complicated diverticulitis warrants an
interval colonoscopy, typically 6 weeks after resolution.1

Keywords 
Colonoscopy abscess Anti-Bacterial Agents Bacterial translocation sepsis

Association Between Age and Complications After Outpatient Colonoscopy

Author/s: 
Causada-Calo, N., Bishay, K., Albashir, S., Mazroui, A.A., Armstrong, D.

Abstract

Importance: There are insufficient data describing the incidence and risk factors of postcolonoscopy complications in older individuals.

Objective: To assess the association between older age (≥75 years) and the risk of postcolonoscopy complications.

Design, setting, and participants: This population-based retrospective cohort study included adults (≥50 years) undergoing outpatient colonoscopy between April 2008 and September 2017, identified from Ontario administrative databases. Individuals with inflammatory bowel disease and hereditary colorectal cancer syndromes were excluded. The study population was subdivided into a colorectal cancer screening-eligible cohort (patients aged 50-74 years) and an older cohort (patients aged ≥75 years). The statistical analysis was conducted from December 2018 to September 2019.

Exposures: Older age (≥75 years).

Main outcomes and measures: The primary outcome was postcolonoscopy complications, defined as the composite of hospitalization or emergency department visits in the 30-day period after the outpatient colonoscopy. Secondary outcomes included incidence of surgically treated colorectal cancer and all-cause mortality at 30 days. Independent variables associated with postcolonoscopy complications were also assessed.

Results: The study sample included 38 069 patients; the mean (SD) age was 65.2 (10.1) years, there were 19 037 women (50.0%), and 27 831 patients (73.1%) underwent a first colonoscopy. The cumulative incidence of complications was 3.4% (1310 patients) in the overall population, and it was higher in individuals aged 75 years or older (515 of 7627 patients [6.8%]) than in screening-eligible cohort (795 of 30 443 patients [2.6%]) (P < .001). Independent risk factors for postcolonoscopy complications were age 75 years or older (odds ratio [OR], 2.3; 95% CI, 2.0-2.6), anemia (OR, 1.4; 95% CI, 1.2-1.7), cardiac arrhythmia (OR, 1.7; 95% CI, 1.2-2.2), congestive heart failure (OR, 3.4; 95% CI, 2.5-4.6), hypertension (OR, 1.2; 95% CI, 1.0-1.5), chronic kidney disease (OR, 1.8; 95% CI, 1.1-3.0), liver disease (OR, 4.7; 95% CI, 3.5-6.5), smoking history (OR, 3.2; 95% CI, 2.4-4.3), and obesity (OR, 2.3; 95% CI, 1.2-4.2). The number of previous colonoscopies was associated with a lower risk of complications (OR, 0.9; 95% CI, 0.7-1.0). The incidence of surgically treated colorectal cancer was higher in the older cohort than the screening-eligible cohort (119 patients [1.6%] vs 144 patients [0.5%]; P < .001). All-cause mortality rates were 0.1% overall (39 patients) and 0.1% (19 patients) for individuals aged 50 to 74 years and 0.2% (20 patients) for those aged 75 years and older (P < .001).

Conclusions and relevance: In this population-based cohort study of individuals living in southern Ontario, age of 75 years and older was associated with a higher risk of 30-day postprocedure complications after outpatient colonoscopy. These findings suggest that the decision to perform a colonoscopy should be carefully considered in patients older than 75 years, especially in the presence of comorbidities. Further studies are needed to better understand the benefits of invasive procedures as opposed to less invasive approaches for colorectal cancer screening and surveillance among older patients.

Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians

Author/s: 
Qaseem, A., Crandall, C.J., Mustafa, R.A., Hicks, L.A., Wilt, T.J., Clinical Guidelines Committee of the American College of Physicians

DESCRIPTION:

The purpose of this guidance statement is to guide clinicians on colorectal cancer screening in average-risk adults.

METHODS:

This guidance statement is derived from a critical appraisal of guidelines on screening for colorectal cancer in average-risk adults and the evidence presented in these guidelines. National guidelines published in English between 1 June 2014 and 28 May 2018 in the National Guideline Clearinghouse or Guidelines International Network library were included. The authors also included 3 guidelines commonly used in clinical practice. Web sites were searched for guideline updates in December 2018. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to evaluate the quality of guidelines.

TARGET AUDIENCE AND PATIENT POPULATION:

The target audience is all clinicians, and the target patient population is adults at average risk for colorectal cancer.

GUIDANCE STATEMENT 1:

Clinicians should screen for colorectal cancer in average-risk adults between the ages of 50 and 75 years.

GUIDANCE STATEMENT 2:

Clinicians should select the colorectal cancer screening test with the patient on the basis of a discussion of benefits, harms, costs, availability, frequency, and patient preferences. Suggested screening tests and intervals are fecal immunochemical testing or high-sensitivity guaiac-based fecal occult blood testing every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus fecal immunochemical testing every 2 years.

GUIDANCE STATEMENT 3:

Clinicians should discontinue screening for colorectal cancer in average-risk adults older than 75 years or in adults with a life expectancy of 10 years or less.

Keywords 
Colonoscopy Early Detection of Cancer
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