Diverticulitis in the Young

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Diverticulitis in the Young

• POW Journal Club
• 6 Nov 2006
• Camille Wu
• (Mentor Dr S Wong)

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• Diverticulitis in the young patient Is it
  different?
• A Lahat, Y Menachem, B Avidan, et al
• World Journal of Gastroenterology
• May 2006 12(18)2932-35

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Aim

• Prospectively study incidence and natural history
  in younger group
• Conflicting information in literature

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Methods

• All diverticulitis admissions 2000-2005
• Diagnosis based on
• Lower abdo pain
• Fever
• WCC
• CT diagnosis

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Methods

• Data collected
• Demographics
• Medical history
• Medications
• Physical findings
• Laboratory test results
• Radiology results
• Endoscopy results
• Treatment received

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Methods

• Follow-up
• During admission
• 6-monthly for 1 year
• Annually thereafter
• Visits / phone calls
• Data collected
• Pain /- fever
• Admissions
• Operations

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Methods

• 4 groups
• Sigmoid colectomy
• Further episode requiring admission
• Recurrent pain
• Asymptomatic
• Analysis
• Whole study population
• Age subgroups (lt and gt 45 y.o.)

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Results

• 207 patients
• 80 M 127 F

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Results

• Mild course 175 (85)
• Complications 32 (15)
• Peridiverticular air 20
• Abdominal abscess 6
• Free perforation 6
• Death 2

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Inpatient complications
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Follow-up

• 6 60 months (mean 30 months)
• Loss to follow-up
• Younger 4 (16)
• Older 23 (13)
• Deaths 3 (2)

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Follow-up
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Discussion

• Young patients
• 12 of diverticulitis
• Male predominance
• More severe course
• Higher complication rate
• Higher recurrence rate, hence.
• Higher sigmoidectomy rate

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Discussion

• Conflicting information in younger group
• severity and
• incidence of diverticulitis
• Recommendation for operation after 1-2 attacks

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Conclusion

• Acute diverticulitis generally mild
• In younger group,
• More aggressive
• More recurrence
• Male tendency
• Consider early surgical approach in young

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Critique

• Prospective study
• Variable follow-up
• 6 months to 5 years
• 13-15 loss to follow-up
• Small numbers in young group

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Critique

• Diagnostic criteria
• Supported by CT
• DD of irritable bowel syndrome / chronic pain
• In young group,
• Delayed diagnosis more severe disease at
  presentation?
• More operations because fitter?

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Review article

• Elective surgery after acute diverticulitis
• S Janes, A Meagher, FA Frizelle
• British Journal of Surgery 2005 92 133-42
• Incidence 25
• 1/3 recur after 1st attack
• Further 1/3 recur after 2nd attack

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Review article

• Perforation commonest at 1st attack
• After recovery, risk of needing urgent Hartmanns
  1 in 2000 patient-years of follow-up
• Risk of recurrence
• 10 1st year
• 3 per year thereafter

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Review article

• High complication rate after diverticular surgery
• 25 patients have ongoing symptoms after bowel
  resection
• NO evidence to support elective surgery after 2
  attacks

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Younger population

• Still controversial
• Disease appears more aggressive due to bias of
  later diagnosis and presentation?
• Little evidence to support early operation

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• Review article in detail.

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Introduction

• Current recommendation
• Colectomy after 2 attacks
• Not based on recent data

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Natural history

• Diagnostic criteria of diverticulitis
  inconsistent
• 25 need operation after 1st attack
• Risk of recurrence
• 10 1st year, 3 per year thereafter
• 1st attack most severe
• Risk of death unrelated diseases

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Complicated diverticulitis

• Conservative treatment successful in 70 - 100
• Readmission risk decreases with each subsequent
  attack
• Difficulty getting follow-up data
• Prospective data 120 pts at 5 years majority
  asymptomatic

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Pre-emptive resection

• 70 of ops for complicated disease did not have
  previous symptoms
• Elective ops
• do not prevent late complications
• do not reduce incidence of emergency ops
• 1 per 2000 patient-years follow-up will require
  emergency Hartmanns after 1 episode of
  diverticulitis

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Inconsistencies

• Diagnosis
• Correlation between
• Symptoms
• Histological findings
• Endoscopic findings
• Overlap of symptoms of irritable bowel

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Younger population

• Still controversial
• Disease appears more aggressive due to bias of
  later diagnosis and presentation?
• Little evidence to support early operation