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Background: Acute diverticulitis is commonly misdiagnosed among patients with acute abdominal pain in the emergency department (ED). There are predictive scores that assist in the diagnosis of acute left-sided diverticulitis, but no scoring system is available for diagnosing acute diverticulitis without regard to the affected side. Therefore, developing a predictive score for diagnosing acute diverticulitis that is not limited to the left side will guide physicians in making a diagnosis and increase the appropriateness of computed tomography. This study aimed to establish a predictive score for diagnosing acute diverticulitis. Method: This single-centre retrospective study included adult patients (≥ 18 years) who presented to the ED with acute abdominal pain. Multivariate logistic regression analysis was used to identify essential factors for diagnosing acute diverticulitis, and the Akaike information criterion was calculated to identify significant predictive factors for diagnosing acute diverticulitis using a clinical scoring system. Results: Of 424 patients who fulfilled the inclusion criteria, 72 (17%) were diagnosed with acute diverticulitis. The significant factors associated with acute diverticulitis were age ≥ 60 years (adjusted odds ratio (adj.OR) 2.23, 95% confidence interval (CI): 1.20 − 4.14, p = 0.01), duration of abdominal pain ≥ 48 h (adj.OR 2.64, 95% CI: 1.28 − 5.45, p = 0.017), history of a diverticulum (adj.OR 7.77, 95% CI: 3.27 − 18.45, p < 0.001), absence of nausea and vomiting (adj.OR 3.42, 95% CI: 1.65 − 7.10, p < 0.001), absence of anorexia (adj.OR 3.33, 95% CI: 1.34 − 8.33, p = 0.026), absence of tachycardia (adj.OR 3.51, 95% CI: 1.39 − 8.87, p = 0.003), and abdominal guarding (adj.OR 2.99, 95% CI: 1.52 − 5.91, p = 0.002). These predictive factors were converted into predictive scores for diagnosing acute diverticulitis. For the score of ≥ 4, the sensitivity and specificity were 73.24% (95% CI: 0.61–0.83) and 80.40% (95% CI: 0.76–0.84), respectively, and the negative predictive value was 93.71% (95% CI: 0.90–0.96). No significant signs, symptoms, or laboratory findings were associated with complicated diverticulitis. Conclusion: Predictive factors for diagnosing acute diverticulitis included age ≥ 60 years, duration of abdominal pain ≥ 48 h, history of a diverticulum, abdominal guarding, and absence of nausea and vomiting, anorexia, and tachycardia. A predictive score ≥ 4 suggested the presence of acute diverticulitis. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic lavage and drainage (LLD) emerged as an alternative to Hartmann's procedure (HP) for patients with diverticulitis and uncontained perforation. Although initially popular as a less invasive approach, its use in modern practice is in question. This summary will review the available literature to show techniques, outcomes, and indications. Methods: The literature was reviewed for relevant case studies, randomized trials, prospective series, retrospective analyses, and meta-analyses to define peritoneal lavage and determine the clinical outcomes of peritoneal lavage. Results: LLD can be considered on an individual basis for Hinchey III diverticulitis (purulent peritonitis), but there are several contraindications. The extent of adhesionolysis (limited versus extensive) as well as the management of sites of perforation found during surgery are debated. Most surgeons continue lavage with warm saline until water runs clear and place drains in the operation. Three randomized controlled trials (RCTs), the LADIES, SCANDIV, and DILALA trials compared LLD with either resection and anastomosis or Hartmann's procedure. One other RCT (the LapLAND trial) is still with results pending. The LADIES trial studied LLD versus primary anastomosis and resection in Hinchey III diverticulitis and was terminated early secondary to higher 30-day morbidity in the LLD arm; however, 3-year data showed no significant difference in morbidity and mortality. The SCANDIV trial compared LLD with resection in acute diverticulitis (Hinchey I–III) and saw no difference in 90-day morbidity or mortality; however, it noted higher rates of reoperation in the LLD group. The DILALA trial compared Hinchey III diverticulitis patients undergoing LLD with open HP and found that the LLD group had a lower rate of reoperation at 2 years, but no difference in rates of readmission or mortality. Conclusions: Debate still remains over the technique of LLD and specific indications, as well as outcomes compared with resection and primary anastomosis or HP. [ABSTRACT FROM AUTHOR]

Introduction: Acute diverticulitis represents a significant disease burden in the United States and developed world. This article examines current trends in the treatment of acute diverticulitis and concentrates on the utility of antibiotics in acute uncomplicated cases managed in the outpatient setting. Methods: The literature was reviewed for randomized controlled trials (RCTs) to discern the best practice and recommendations for antibiotics for diverticulitis. The time period included relevant RCTs after 2000. Results: Four recent RCTs examine the use of antibiotics in acute uncomplicated diverticulitis. The AVOD study was an RCT that managed inpatients with either antibiotics or IV fluids alone and demonstrated non-inferiority of non-antibiotic management with respect to recovery, complication rates, or recurrence. The DIABLO trial randomized first episodes of acute uncomplicated diverticulitis admitted to the hospital with antibiotics or supportive care and found no difference in morbidity or mortality between the two groups and longer hospital stay for patients treated with antibiotics. The DINAMO study examined outpatients managed with antibiotics by mouth or without and found no difference in morbidity in 90 day follow-up. The STAND study was the only of these four to use a placebo and found no difference between hospital stay or other adverse events at 30 days. In response to this, the ASCRS, AAFP and other societies now recommend against the routine use of antibiotics in acute uncomplicated diverticulitis. Conclusions: Several quality studies found similar outcomes in cases of acute uncomplicated diverticulitis treated with or without antibiotics. Based on these findings, societal guidelines do not recommend routine antibiotics for acute diverticulitis. [ABSTRACT FROM AUTHOR]

Introduction: Our aim was to assess the impact of the Diagnostic and Therapeutic Assistance Pathway (PDTA) developed for acute diverticulitis (AD) on the management of patients with AD and referring to the emergency room (ER) in a referral center. Methods: This retrospective study includes all patients diagnosed with AD and referring to the ER between January 1, 2021, and December 31, 2022 (after approval of PDTA), compared to the same period of 2015–2019. Length of stay in ER, medical and surgical management, and length in hospital stay (in days) were also measured according to the type of disease (uncomplicated vs. complicated). Results: ER admission due to AD during the period 2015–2019 was 240 ± 13 cases per year, while it was 290 cases in 2022 (p = 0.05). After adopting the PDTA, the rate of length of stay in ER >24 h for AD was significantly reduced (p = 0.01); the median rate of hospital admission for AD was significantly reduced (p < 0.05); the rate of medical treatment of uncomplicated disease was increased (p = 0.01), while the rate of surgical management was decreased (p = 0.05); the rate of medical treatment of complicated disease was increased (p = 0.01), while the rate of surgical management was decreased (p = 0.001); the hospital stay was significantly reduced in both uncomplicated (p = 0.05) and complicated (p = 0.05) AD. Conclusions: The development and the routine use of a PDTA dedicated to AD have significantly improved the management of these patients, reducing the ER stay, the surgical procedures, and the overall hospital stay. [ABSTRACT FROM AUTHOR]

This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America. In this paper, the panel provides recommendations for diagnostic imaging of suspected acute diverticulitis. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. [ABSTRACT FROM AUTHOR]

Abstract Background Acute diverticulitis is commonly misdiagnosed among patients with acute abdominal pain in the emergency department (ED). There are predictive scores that assist in the diagnosis of acute left-sided diverticulitis, but no scoring system is available for diagnosing acute diverticulitis without regard to the affected side. Therefore, developing a predictive score for diagnosing acute diverticulitis that is not limited to the left side will guide physicians in making a diagnosis and increase the appropriateness of computed tomography. This study aimed to establish a predictive score for diagnosing acute diverticulitis. Method This single-centre retrospective study included adult patients (≥ 18 years) who presented to the ED with acute abdominal pain. Multivariate logistic regression analysis was used to identify essential factors for diagnosing acute diverticulitis, and the Akaike information criterion was calculated to identify significant predictive factors for diagnosing acute diverticulitis using a clinical scoring system. Results Of 424 patients who fulfilled the inclusion criteria, 72 (17%) were diagnosed with acute diverticulitis. The significant factors associated with acute diverticulitis were age ≥ 60 years (adjusted odds ratio (adj.OR) 2.23, 95% confidence interval (CI): 1.20 − 4.14, p = 0.01), duration of abdominal pain ≥ 48 h (adj.OR 2.64, 95% CI: 1.28 − 5.45, p = 0.017), history of a diverticulum (adj.OR 7.77, 95% CI: 3.27 − 18.45, p

BACKGROUND: Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma. METHODS: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement. RESULTS: A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma. CONCLUSIONS: The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Acute diverticulitis (AD) is associated with relevant morbidity/mortality and is increasing worldwide, thus becoming a major issue for national health systems. AD may be challenging, as clinical relevance varies widely, ranging from asymptomatic picture to life-threatening conditions, with continuously evolving diagnostic tools, classifications, and management. A 33-item-questionnaire was administered to residents and surgeons to analyze the actual clinical practice and to verify the real spread of recent recommendations, also by stratifying surgeons by experience. CT-scan remains the mainstay of AD assessment, including cases presenting with recurrent mild episodes or women of child-bearing age. Outpatient management of mild AD is slowly gaining acceptance. A conservative management is preferred in non-severe cases with extradigestive air or small/non-radiologically drainable abscesses. In severe cases, a laparoscopic approach is preferred, with a non-negligible number of surgeons confident in performing emergency complex procedures. Surgeons are seemingly aware of several options during emergency surgery for AD, since the rate of Hartmann procedures does not exceed 50% in most environments and damage control surgery is spreading in life-threatening cases. Quality of life and history of complicated AD are the main indications for delayed colectomy, which is mostly performed avoiding the proximal vessel ligation, mobilizing the splenic flexure and performing a colorectal anastomosis. ICG is spreading to check anastomotic stumps' vascularization. Differences between the two experience groups were found about the type of investigation to exclude colon cancer (considering the experience only in terms of number of colectomies performed), the size of the peritoneal abscess to be drained, practice of damage control surgery and the attitude towards colovesical fistula. [ABSTRACT FROM AUTHOR]

Introduction: Colonic Diverticular Disease (CDD) is a multifactorial inflammatory disease. Acute diverticulitis (AD), with extraluminal free air (both pericolic and distant), represents about 15% of radiological scenarios and remains a therapeutic challenge for surgeons. Currently, the WSES guidelines suggest trying a conservative strategy both in the presence of pericolic and distant free extraluminal air, even if both have respectively weak recommendation based on low/very low‐quality evidence. Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyzes guidelines. PubMed/MEDLINE, Scopus, Web of Science, and Embase databases were used to identify articles of interest. Results: A total of 2380 patients with AD and extraluminal free air (both pericolic and distant) who underwent nonoperative management (NOM) were analyzed. Of the 2380 patients, 2095(88%) were successfully treated with NOM, while 285 (12%) patients failed. A total of 1574 (93.1%) patients with pericolic extraluminal free air had a successful NOM with 6.9% (117) failure rates, while 135 (71.1%) patients with distant extraluminal free air had a successful NOM with 28.9% (55) failure rates. Regarding distant recurrence, we recorded a rate of 18.3% (261/1430), while a rate of 11.3% (167/1472) was recorded for patients undergoing elective surgery. Conclusion: NOM for patients with AD and extraluminal free air (both pericolic and distant) seems to be feasible and safe despite a higher failure rate in the distant subgroup, which remains the most challenging clinical scenario to deal with through conservative treatment. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic left colectomy has emerged as a potential alternative to open surgery for the treatment of acute diverticulitis. However, the evidence on the safety and efficacy of this approach is still subject to debate. Aim: This review aims to provide a comprehensive overview of the techniques, outcomes and complications associated with laparoscopic left colectomy for acute diverticulitis. Methods: A systematic review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that met the inclusion criteria were analyzed for patient demographics, surgical techniques, outcomes and complications. Results: A total of 23 studies involving a total of 3,214 patients who underwent laparoscopic left colectomy for acute diverticulitis was conducted. The majority of studies reported favorable outcomes for laparoscopic left colectomy, with patients experiencing shorter hospital stays, less postoperative pain and a faster return to normal activities. Specifically, the studies reported an average hospital stay of 5-7 days for laparoscopic left colectomy patients compared to 7-10 days for open colectomy patients. Additionally, laparoscopic patients reported lower pain scores and required fewer pain medications, with a reduced need for opioid analgesics. However, there were also some complications reported in these studies, including anastomotic leakage, wound infections and intra-abdominal abscesses. The overall incidence of complications was relatively low, ranging from 4-18% depending on the study. The risk of complications was generally higher in patients with severe acute diverticulitis or those undergoing emergency surgery. Conclusion: Laparoscopic left colectomy is a safe and effective approach for the treatment of acute diverticulitis, offering several potential benefits compared to open surgery. However, there is a need for further research to clarify the optimal patient selection criteria, surgical techniques and management of complications. [ABSTRACT FROM AUTHOR]

Introduction: Symptomatic uncomplicated diverticular disease (SUDD) is a clinical condition included in the spectrum of symptomatic diverticular disease. The symptom profile associated with SUDD is highly heterogeneous, as there are currently discordant definitions, that encompass many clinical scenarios. Areas covered: We conducted a narrative review to assess the symptom profile and diagnostic criteria of SUDD based on the available evidence. A thorough literature search was performed on PubMed following the SANRA scale. Abdominal pain, regardless of its duration and location, emerges as the cardinal symptom of SUDD, suggesting that it should be central to its diagnosis. Although abdominal bloating and changes in bowel habits are commonly reported, they do not appear to be specifically attributable to SUDD. Other issues considered are the possible overlap with irritable bowel syndrome and the identification of a subcategory of SUDD patients with chronic symptoms following an episode of acute diverticulitis. Expert opinion: The future agenda should include the development of shared diagnostic criteria for SUDD, including well-defined inclusion and exclusion clinical features and symptom patterns. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The aims of the present study are to compare the severity of acute diverticulitis in the first episode and in later bouts, and to determine whether there are risk factors for the presence of free perforation at the onset of diverticulitis. A single-center retrospective study was conducted of patients who developed a first episode of acute diverticulitis between January 2011 and August 2021 diagnosed by computed tomography and followed up for at least 1 year. Free perforation was considered to be present in patients with diverticulitis stage III and IV according to the Hinchey classification (modified by Wasvary). The analysis included 394 patients (224 men and 170 women) with a mean age of 58 years. Forty-eight patients (12.2%) presented free perforation at some point in the course of the disease, 43 during the first episode and 5 during subsequent bouts. The perforation subgroup showed higher rates of stoma creation and mortality (relative risks of 12.3 and 23.5, respectively). In the multivariate analysis, age (OR: 1.041 95% CI 1.016–1.067), lung disease (OR 2.154 95% CI 1.038–4.472) and immunosuppression (OR: 2.812 95% CI 1.315–6.015) were independent factors for free perforation at diverticulitis onset. Free perforation occurs more frequently during the first episode of acute diverticulitis. Older patients, immunosuppressed patients and those with respiratory disease have a greater risk of presenting freely perforated diverticulitis. Therefore, it is essential to maintain a high level of clinical suspicion in these patients to activate early focus control and thus avoid fatal outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The recurrence of acute diverticulitis (AD) of the colon is frequent and leads to hospital readmissions and the need for elective surgery in selected cases. It is important to individualize risk factors and develop predictive tools for their identification. Materials and methods: This prospective observational study included 368 patients who were diagnosed with AD between 2016 and 2021 in a tertiary general university hospital during their first episode and who had a good response to antibiotic, percutaneous, or peritoneal lavage treatment. Univariate and multivariate Cox regression analyses of the variables associated with recurrence were performed. Subsequently, a predictive risk score was developed and validated through survival studies. Results: After a median follow‐up of 50 months, there were 71 (19.3%) cases of recurrence out of a total of 368 patients. The mean time of recurrence was 15 months, and 73.3% of cases of recurrence occurred before 2 years of follow‐up. Recurrence was independently associated with presentation with colonic perforation in the antimesenteric location (HR 3.67 95% CI [1.59–8.4]) and a CRP level greater than 100 mg/dl (HR 1.69 95% CI [1.04–2.77). A score with 5 variables was created that differentiated two risk groups: intermediate risk (0–3 points), with 19% recurrence and high risk (more than 3 points), with 42% recurrence. Conclusions: The risk of recurrence after the first episode of diverticulitis can be estimated using predictive scores. The detection of high‐risk patients facilitates the individualization of follow‐up and treatment. [ABSTRACT FROM AUTHOR]

Purpose: Emergency treatment of acute diverticulitis remains a hazy field. Despite a number of clinical studies, randomized controlled trials (RCTs), guidelines and surgical societies recommendations, the most critical hot topics have yet to be addressed. Methods: Literature research from 1963 until today was performed. Data regarding the principal RCTs and observational studies were summarized in descriptive tables. In particular we aimed to focus on the following topics: the role of laparoscopy, the acute care setting, the RCTs, guidelines, observational studies and classifications proposed by literature, the problem in case of a pandemic, and the importance of adapting treatment /place/surgeon conditions. Results: In the evaluation of these points we did not try to find any prospective evolution of the concepts achievements. On the contrary we simply report the individuals strands of research from a retrospective point of view, similarly to what Steve Jobes said: "you can't connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future". We have finally obtained what can be defined "a narrative review of the literature on diverticulitis". Conclusions: Not only evidence-based medicine but also the contextualization, as also the role of 'competent' surgeons, should guide to novel approach in acute diverticulitis management. [ABSTRACT FROM AUTHOR]

This article discusses the management of acute diverticulitis (AD) based on a consensus among colorectal surgeons in Switzerland. AD is a common condition that can lead to complications such as abscesses, perforation, fistulas, obstruction, and bleeding. The study found that abdominal CT is the recommended imaging modality for diagnosing AD, and complicated diverticulitis was defined by the presence of specific criteria. The article also discusses non-operative and operative treatments, as well as indications for elective surgery. However, there was no consensus on surgical management in the emergency setting. The study highlights the need for further research and the importance of considering individual patient factors in decision-making. [Extracted from the article]

Stenosis is a rare complication of acute diverticulitis, difficult to differentiate from colon cancer. We present a 63-year-old woman with right lumbar pain radiating to the back. A sigmoid stenosis was detected by magnetic resonance imaging. Three biopsies were performed, all of which were negative for malignancy. From CT images with data of circumferentially thickened intestinal wall along 6 cm, stenosing the lumen enlarged regional lymph nodes. A sigmoid resection was performed and the results of histological examination showed complicated diverticulitis of the large intestine with exacerbation, abscending and spread of the inflammatory process with involvement of the pericolic tissues. Given the high risk of developing a malignant process in patients with acute diverticulitis and the slightest doubt should be followed by surgical treatment. [ABSTRACT FROM AUTHOR]

The differential diagnosis for left lower quadrant pain is wide and conditions range from the benign and self-limited to life-threatening surgical emergencies. Along with patient history, physical examination, and laboratory tests, imaging is often critical to limit the differential diagnosis and identify life-threatening abnormalities. This document will discuss the guidelines for the appropriate use of imaging in the initial workup for patients who present with left lower quadrant pain, patients with suspected diverticulitis, and patients with suspected complications from diverticulitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. [ABSTRACT FROM AUTHOR]

Background/Aim: The diagnostic score models (DMs) for patients with acute diverticulitis (AcDi) have been rarely evaluated. Therefore, we tried to develop diagnostic models (DMs) to enhance the diagnostic accuracy (DA) of AcDi. Patients and Methods: In this AAP (acute abdominal pain) cohort, 30 AcDi patients were compared to 1,303 non- AcDi patients, with regard to their i) clinical symptoms (n=22), ii) signs and tests (n=14) as well as iii) laboratory analyses (n=3). The triage was performed at patient arrival to the emergency department (ED) (triage I) and at follow-up (triage II) before final decision. The triage included a suggested diagnosis of the AAP patient. Bivariate random effects metaanalysis was performed separately for 1) the pooled symptoms (n=22), 2) signs & tests (n=17) as well as 3) pooled DMs (IV) with different cut-offs (with or without triage) to assess the diagnostic accuracy (DA) in detection of AcDi by HSROC (hierarchical summary receiver operating characteristic) curves. Results: In the conventional receiver operating characteristic (ROC) analysis (for test optimization and finding optimal cut-off points), the area under curve (AUC) reached the following values for AcDi: i) DM without triage, AUC=0.843, ii) DM with triage I, AUC=0.866 and iii) DM with triage I and II, AUC=0.926. In the HSROC analysis, the AUC values for detection of AcDi were as follows; i) pooled clinical symptoms, AUC=0.540, ii) pooled clinical signs & tests, AUC=0.556 and iii) pooled DMs globally, AUC=0.853. In roccomp analysis for differences in AUC values: i) and iii) p<0.0001; between ii) and iii) p<0.0001. Conclusion: As confirmed by ROC and HSROC analysis, the new DMs with triage mode proved to be far superior in their DA for AcDi as compared to both symptoms and signs & tests. In the lack of earlier studies, these data report the first evidence that the DM including triage at an ED could improve the detection of AcDi. [ABSTRACT FROM AUTHOR]

Background and aims: acute diverticulitis is one of the most frequent gastrointestinal diseases classically diagnosed by computed tomography as a mandatory imagining technique; there is, however, increasing evidence that abdominal ultrasound may be, at least, as useful as computed tomography. The main aim of this study was to evaluate the clinical utility of abdominal ultrasound as a first-line imaging technique for the diagnosis of acute left-sided diverticulitis suitable for ambulatory management. Material and methods: a retrospective observational cohort study with consecutive non-random sampling was performed at a third level hospital, including all patients with diagnosis of acute left-sided diverticulitis confirmed by imaging technique and subsequent outpatient management within a 2-year period. Results: a total of 103 patients were included, 54.37 % diagnosed by abdominal ultrasound and 46.63 % by computed tomography. Ambulatory management was successful in 94.2 % (n = 97) of the cases, with only 6 readmissions (5.8 %), no difference between imaging techniques was observed. There was no statistically significant differences in the ambulatory management failure rate between both groups (p >0.05). Conclusions: abdominal ultrasound is a safe and feasible technique that could be used as a first-line imaging technique for the diagnosis of non-complicated acute left-sided diverticulitis when performed by an expert operator. Moreover, in outpatient management, it presented similar clinical success and no higher readmission rate than those diagnosed by computed tomography. [ABSTRACT FROM AUTHOR]

Background: The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease. Aim: To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis. Methods: This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Results: We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05). Conclusions: Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management. [ABSTRACT FROM AUTHOR]

Acute diverticulitis is inflammation of a colon diverticulum; it represents a major cause of morbidity and mortality. The alteration of gut microbiota contributes to the promotion of inflammation and the development of acute diverticulitis disease. Probiotics can modify the gut microbiota, so they are considered a promising option for managing diverticulitis disease. This study aimed to investigate the potential protective effect of probiotics, alone or in combination with amoxicillin, on the experimentally induced model of acute diverticulitis disease. Forty-two rats were divided into seven groups as follows: control group: received water and food only; DSS group: received 3% dextran sulfate sodium (DSS) daily for 7 days; LPS group: injected with lipopolysaccharide (LPS) enema at the dose of (4 mg/kg); probiotics group: treated with probiotics (Lactobacillus acidophilus and Bifidobacterium lactis) each of which (4 × 108 CFU suspended in 2 ml distilled water) orally for 7 days; DSS/LPS group: received DSS and LPS; DSS/LPS treated with probiotics group; DSS/LPS treated with probiotics and amoxicillin group. The results revealed that both treatments (probiotics and probiotics-amoxicillin) attenuated DSS/LPS-induced diverticulitis, by restoring the colonic antioxidant status, ameliorating inflammation (significantly reduced TNF-α, interleukins, interferon-γ, myeloperoxidase activity, and C-reactive protein), decreasing apoptosis (through downregulating caspase-3), and reduction of the colon aerobic bacterial count. These probiotic strains were effective in preventing the development of the experimentally induced acute diverticulitis through the anti-inflammatory and immunomodulatory effects and have affected gut microbiota, so they can be considered a potential option in treating acute diverticulitis disease. [ABSTRACT FROM AUTHOR]

Background: Immunocompromised patients with acute diverticulitis are at increased risk of morbidity and mortality. The aim of this study was to compare clinical presentations, types of treatment, and outcomes between immunocompromised and immunocompetent patients with acute diverticulitis. Methods: We compared the data of patients with acute diverticulitis extracted from the Web-based International Registry of Emergency Surgery and Trauma (WIRES-T) from January 2018 to December 2021. First, two groups were identified: medical therapy (A) and surgical therapy (B). Each group was divided into three subgroups: nonimmunocompromised (grade 0), mildly to moderately (grade 1), and severely immunocompromised (grade 2). Results: Data from 482 patients were analyzed—229 patients (47.5%) [M:F = 1:1; median age: 60 (24–95) years] in group A and 253 patients (52.5%) [M:F = 1:1; median age: 71 (26–94) years] in group B. There was a significant difference between the two groups in grade distribution: 69.9% versus 38.3% for grade 0, 26.6% versus 51% for grade 1, and 3.5% versus 10.7% for grade 2 (p < 0.00001). In group A, severe sepsis (p = 0.027) was more common in higher grades of immunodeficiency. Patients with grade 2 needed longer hospitalization (p = 0.005). In group B, a similar condition was found in terms of severe sepsis (p = 0.002), quick Sequential Organ Failure Assessment score > 2 (p = 0.0002), and Mannheim Peritonitis Index (p = 0.010). A Hartmann's procedure is mainly performed in grades 1–2 (p < 0.0001). Major complications increased significantly after a Hartmann's procedure (p = 0.047). Mortality was higher in the immunocompromised patients (p = 0.002). Conclusions: Immunocompromised patients with acute diverticulitis present with a more severe clinical picture. When surgery is required, immunocompromised patients mainly undergo a Hartmann's procedure. Postoperative morbidity and mortality are, however, higher in immunocompromised patients, who also require a longer hospital stay. [ABSTRACT FROM AUTHOR]

Background and Objectives: It is crucial to quickly identify those patients who need immediate treatment in order to avoid the various complications related to acute diverticulitis (AD). Although several studies evaluated the neutrophil-to-lymphocyte ratio (NLR) suggesting its predictive value in assessing the severity of AD, results have been inconclusive. Therefore, we aimed to assess the relationship between the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR), and systemic immune inflammation (SII) with the severity of AD, the ability to predict the presence or absence of complications, and the recurrence rate, based on the values of inflammatory markers. Materials and Methods: We retrospectively reviewed 147 patients diagnosed with AD between January 2012 to February 2023. Patients were divided into 2 groups, uncomplicated and complicated AD. The characteristics and full blood count between both groups were compared. Results: A total of 65 (44.22%) patients were classified as having complicated AD. The area under the ROC curve (AUROC) defining a Hinchey score ≥ 1b was as follows: SII, 0.812 (95% confidence interval (CI), 0.73 –0.888); NLR, 0.773 (95% CI, 0.676–0.857); PLR, 0.725 (95% CI, 0.63–0.813); MLR: 0.665 (95% CI, 0.542 –0.777). An SII cutoff value of > 1200 marked the highest yield for diagnosing complicated AD, with a sensitivity of 82% and a specificity of 76%. The cumulative recurrence rate was not significantly different in the groups of SII ≥ median vs. SII < median (p = 0.35), NLR ≥ median vs. NLR < median (p = 0.347), PLR ≥ median vs. PLR < median (p = 0.597), and MLR ≥ median vs. MLR < median (p = 0.651). Conclusions: Our study indicates that SII, NLR, and PLR are statistically significant and clinically useful classifying ratios to predict higher Hinchey scores. However, they cannot predict recurrences. [ABSTRACT FROM AUTHOR]

Background and Objectives: Therapeutic management of patients with complicated acute diverticulitis remains debatable. The primary objective of this study is to identify predictive factors for the failure of conservative treatment of Hinchey IIa and IIb diverticular abscesses. Materials and Methods: This is a retrospective cohort study that included patients hospitalized from 1 January 2014 to 31 December 2022 at the Emergency Surgery Department of the Cagliari University Hospital (Italy), diagnosed with acute diverticulitis complicated by Hinchey grade IIa and IIb abscesses. The collected variables included the patient's baseline characteristics, clinical variables on hospital admission, abscess characteristics at the contrast-enhanced CT scan, clinical outcomes of the conservative therapy, and follow-up results. Univariable and multivariable logistic regression models were used to identify prognostic factors of conservative treatment failure and success. Results: Two hundred and fifty-two patients diagnosed with acute diverticulitis were identified from the database search, and once the selection criteria were applied, 71 patients were considered eligible. Conservative treatment failed in 25 cases (35.2%). Univariable analysis showed that tobacco smoking was the most significant predictor of failure of conservative treatment (p = 0.007, OR 7.33, 95%CI 1.55; 34.70). Age (p = 0.056, MD 6.96, 95%CI −0.18; 0.99), alcohol drinking (p = 0.071, OR 4.770, 95%CI 0.79; 28.70), platelets level (p = 0.087, MD −32.11, 95%CI −0.93; 0.06), Hinchey stage IIa/IIb (p = 0.081, OR 0.376, 95%CI 0.12; 1.11), the presence of retroperitoneal air bubbles (p = 0.025, OR 13.300, 95%CI 1.61; 291.0), and the presence of extraluminal free air at a distance (p = 0.043, OR 4.480, 95%CI 1.96; 20.91) were the other variables possibly associated with the risk of failure. In the multivariable logistic regression analysis, only tobacco smoking was confirmed to be an independent predictor of conservative treatment failure (p = 0.006; adjusted OR 32.693; 95%CI 2.69; 397.27). Conclusion: The role of tobacco smoking as a predictor of failure of conservative therapy of diverticular abscess scenarios highlights the importance of prevention and the necessity to reduce exposure to modifiable risk factors. [ABSTRACT FROM AUTHOR]

Diverticula are the most common incidental finding during routine colonoscopy, and their prevalence increases with patient age. The term "diverticular disease" encompasses the range of clinical manifestations and complications that can occur with colonic diverticula, including diverticular bleeding, diverticulitis-associated strictures, and acute diverticulitis. Colonoscopy is a vital tool in the diagnosis and management of diverticular disease and can be useful in a variety of regards. In this editorial, we concisely delineate the current approach to and practices in colonoscopic management of diverticular disease. In particular, we discuss treatment options for diverticular bleeding, propose consideration of colonic stenting as a bridge to surgery in patients with diverticulitis-associated strictures, and the need for diagnostic colonoscopy following an episode of acute diverticulitis in order to rule out underlying conditions such as colonic malignancy or inflammatory bowel disease. In addition, we offer practical tips for performing safe and successful colonoscopy in patients with dense diverticulosis coli.

Management of diverticular abscess (DA) is still controversial. Antibiotic therapy is indicated in abscesses ≤ 4 cm, while percutaneous drainage/surgery in abscesses > 4 cm. The study aims to assess the role of antibiotics and surgical treatments in patients affected by DA. We retrospectively analyzed 100 consecutive patients with DA between 2013 and 2020, with a minimum follow-up of 12 months. They were divided into two groups depending on abscess size ≤ or > 4 cm (group 1 and group 2, respectively). All patients were initially treated with intravenous antibiotics. Surgery was considered in patients with generalized peritonitis at admission or after the failure of antibiotic therapy. The primary endpoint was to compare recurrence rates for antibiotics and surgery. The secondary endpoint was to assess the failure rate of each antibiotic regimen resulting in surgery. In group 1, 31 (72.1%) patients were conservatively treated and 12 (27.9%) underwent surgery. In group 2, percentages were respectively 50.9% (29 patients) and 49.1% (28 patients). We observed 4 recurrences in group 1 and 6 in group 2. Recurrence required surgery in 3 patients/group. We administered amoxicillin-clavulanic acid to 74 patients, piperacillin-tazobactam to 14 patients and ciprofloxacin + metronidazole to 12 patients. All patients referred to surgery had been previously treated with amoxicillin-Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation clavulanic acid. No percutaneous drainage was performed in a hundred consecutive patients. Surgical treatment was associated with a lower risk of recurrence in patients with abscess > 4 cm, compared to antibiotics. Amoxicillin-clavulanic acid was associated with a higher therapeutic failure rate than piperacillin-tazobactam/ciprofloxacin + metronidazole. [ABSTRACT FROM AUTHOR]

39-year-old male patient with a history of post operated atypical meningioma, currently being treated with radiotherapy. He was admitted to the emergency room with 3 days of abdominal pain located in the left hemiabdomen, which radiated to the left lower limb, associated with unquantified fever. On physical examination, the abdomen is soft, depressible, with pain in the left iliac fossa. A plain abdominal X-ray was performed, showing no intestinal obstructive pattern or other pathological findings. He was evaluated by Surgery Department, who requested a abdomen computed tomography (CT) to rule out acute diverticulitis. The CT shows in the anterior aspect of the wall of the proximal third of the sigmoid colon an ovoid image with fat density, surrounded by a thin hyperdense ring, associated with marked localized striation of the pericolonic fat and thickening of the parietal and transversalis peritoneal fasciae in relation to an acute epiploic appendagitis type process. The patient was given symptomatic treatment with improvement and discharge with analgesics and oral anti-inflammatory drugs. [ABSTRACT FROM AUTHOR]

Acute diverticulitis of the colon is a disease with increasing frequency, encountered by general practitioners and gastroenterologists, and also by surgeons under circumstances of emergency, not only in Western countries, but also in Bulgaria. An international multidisciplinary team of experts, according to their shared experience and the results of studies published in the medical literature, updated the consensus guidelines on diagnosis and behavior in respect of the various manifestations of acute diverticulitis. [ABSTRACT FROM AUTHOR]

Introduction: Growing evidence supports the role of the intestinal microbiome in the development of different intestinal and extraintestinal diseases. Diverticular disease (DD) is one of the most common disorders in western countries. In the last years, different articles have suggested a possible role of the intestinal microbiome in DD pathogenesis and in the development of acute diverticulitis (AD). This systematic review aimed to clarify the current knowledge on the role of the intestinal microbiome in colonic diverticulitis in different stages according to the 2009 PRISMA guidelines. Materials and Methods: Two independent reviewers searched the literature in a systematic manner through online databases, including Medline, Scopus, Embase, Cochrane Oral Health Group Specialized Register, ProQuest Dissertations and Theses Database, and Google Scholar. Patients with any stage of disease were included. The Newcastle-Ottawa scale for case-control and cohort studies was used for the quality assessment of the selected articles. Results: Overall, nine studies were included in the review. Only one article was focused on patients with AD, while all other articles only considered patients with DD without acute inflammation signs. Enterobacteriaceae seems to be the microbiota most associated with the disease, followed by Bifidobacteria. Conclusions: All the included studies showed great heterogeneity in population characteristics and sampling methods. Therefore, given the high prevalence of colonic diverticulitis in the general population, further studies are needed to clarify the role of the intestinal microbiome, paving the way to new target therapies with important social implications. [ABSTRACT FROM AUTHOR]

There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis. [ABSTRACT FROM AUTHOR]

The two most common abdominal infections in emergency departments (ED) are acute appendicitis (AA) and sigmoid diverticulitis (AD). The frequency of ED visits for diverticulitis has increased strongly in many countries during recent decades. The aim of this study was to analyze the nationwide changes in AD rate requiring hospital admission compared to AA during a 10-year study period. Register data of AD and AA in the whole of Finland were obtained between the years 2009 and 2018. Changes in the incidence and surgical treatment of AD in the whole country were compared to those of AA. Patient demographics and treatment of AD were analyzed in greater detail from a smaller cohort (n = 614). The incidence of AD increased from 262 to 413 cases (58%) per 100,000 inhabitants during 10 years and emergency surgery for AD decreased from 27 to 24 cases per 100,000 (11%). The incidence of AA remained stable and varied from 118 to 124 annual cases per 100,000 inhabitants. In a patient cohort of AD (n = 614), most of the patients (68%) had only one episode of diverticulitis during 10 years; 16% were operated urgently, with a mortality of 8%. Disease-specific mortality increased from 0% to 5.7% along with patient age when comparing the age groups <50 years and > 70 years, respectively. Our study indicates that the incidence of acute diverticulitis is still increasing and is now 2–3 times higher than that of appendicitis in emergency departments. [ABSTRACT FROM AUTHOR]

Background/Aim: Acute diverticulitis represents a common surgical condition and one of the leading gastrointestinal causes of surgical admissions in Western societies. Complicated diverticulitis increases the length of the hospital stay and the risk of requiring surgical intervention. In areas of limited availability or long waiting times for CT scanning, biochemical predictors of complicated diverticulitis might be valuable. In the available literature, there is no consensus on cut-off values of C-reactive protein or the value of a white cell count in the diagnosis of complicated diverticulitis. Additional studies among different populations are required to add to the existing literature to reach a consensus on diagnostic cutoff levels of inflammatory markers to diagnose complicated diverticulitis. The aim of the present study is to evaluate the predictive value of a white cell count and C-reactive protein, and their sensitivity and specificity in differentiating complicated from uncomplicated diverticulitis. Methods: This case-control study was performed for patients with acute diverticulitis in Lyell McEwin Hospital in Adelaide, South Australia. Data were collected for consecutive patients admitted from January 2015 to December 2017. Patients with acute diverticulitis confirmed by computed tomography were included in the study. Data of patients with complicated diverticulitis were compared to those of patients with uncomplicated diverticulitis as a control group. Patient characteristics, symptoms, number of attacks of diverticulitis, presence of immunosuppression, past history of complicated diverticulitis, inflammatory markers (white cell count and C-reactive protein), and computed tomography findings were collected and compared. Results: A total of 106 consecutive cases were recruited for the period from 2015 to 2017. There were 44 cases of complicated diverticulitis and 62 cases with uncomplicated diverticulitis (control group). A white cell count (WCC) and C-reactive protein (CRP) were collected at the time of presentation from the clinical records and pathology reports. A receiver operating characteristic (ROC) analysis was performed and multiple cut-off values for both WCC and CRP were reported. For WCC, the area under curve (AUC) was 0.69 (0.582-0.797) with a P-value of 0.001. At a cut-off of 14, sensitivity was found to be 56.8% and specificity of 80.7%. The sensitivity gradually decreased and specificity gradually increased as the cut-off value increased. At 18 the sensitivity was 25% and specificity was 79%. The positive predictive value for the study sample at WCC of 18 × 109/L or above is 79.5%. For CRP, the AUC was 0.828 (0.729-0.927) with a P-value of <0.001. At a cut-off value of 100 mg/L, the sensitivity was 72.7% and specificity was 80.6%. Sensitivity gradually decreased and specificity increased as the cut-off increased in value. At 160 mg/L, sensitivity was 36.36% and specificity was 97.22% with a positive predictive value of 76%. Conclusion: Contrary to what has been previously reported in the literature, we found that WCC remains a significant test in diagnosing complicated diverticulitis. A high cut-off value of 18 × 109/L is useful in predicting complicated diverticulitis with high positive predictive value. When compared to WCC, CRP is a more sensitive test in detecting complicated diverticulitis. We recognized a cut-off value of 160 mg/L to be a significant value to rule in complicated diverticulitis with a significant positive predictive value. WCC and CRP are very specific predictors of complicated diverticulitis with high positive predictive value at high cut-off values of 18 × 109/L and 160 mg/L, respectively. [ABSTRACT FROM AUTHOR]

Purpose: Recently, treatment of Hinchey III diverticulitis by laparoscopic peritoneal lavage has been questioned. Moreover, long-term outcomes have been scarcely reported. Primary outcome was to determine the recurrence rate of diverticulitis after a successful laparoscopic peritoneal lavage in Hinchey III diverticulitis. Secondary outcomes were identification of associated risk factors for recurrence and elective sigmoidectomy rate. Methods: A retrospective cohort study in a tertiary referral center was performed. Patients with Hinchey III diverticulitis who underwent a successful laparoscopic peritoneal lavage between June 2006 and December 2019 were eligible. Diverticulitis recurrence was analyzed according to the Kaplan–Meier and log-rank test, censoring for death, loss of follow-up, or elective sigmoid resection in the absence of recurrence. Risk factors for recurrence were identified using Cox regression analysis. Results: Sixty-nine patients had a successful laparoscopic peritoneal lavage (mean age: 63 years; 53.6% women). Four patients had an elective sigmoid resection without recurrences. Recurrence rate was 42% (n = 29) after a median follow-up of 63 months. The cumulative global recurrence at 1, 3, and 5 years was 30% (95% CI, 20–43%), 37.5% (95% CI, 27–51%), and 48.9% (95% CI, 36–64%), respectively. Smoking (HR, 2.87; 95% CI, 1.22–6.5; p = 0.016) and episodes of diverticulitis prior to laparoscopic peritoneal lavage (HR, 5.2; 95% CI, 2.11–12.81; p < 0.001) were independently associated with an increased risk of recurrence. Conclusions: Diverticulitis recurrence after a successful laparoscopic peritoneal lavage is high, decreasing after the first year of follow-up. Smoking and previous episodes of acute diverticulitis independently increase the risk of new episodes of diverticulitis. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of our study is to determine whether patients with acute uncomplicated diverticulitis with micro-perforation should really be treated as patients without perforation and to identify differences in recurrence rates, complications and mode of treatment Material and Methods: A total of 47 patients with a diagnosis of acute diverticulitis were admitted to the hospital for a three-year period from 01.01.2018 to 01.01.2020 in the Department of General, Visceral and Emergency Surgery at UMHATEM "Pirogov". Of those hospitalized, women were 21 (44.68%), men 26 (55.32%). The age in this retrospective analysis varied from 27 to 81 years (average 51.3 years). Results: All patients had leukocytosis, abdominal pain, and tenderness. From the group of 47 patients hospitalized with acute diverticulitis, twenty-five (53.19%) were diagnosed with micro-perforation by pneumoperitoneum data from X-ray and CT or free intraperitoneal fluid from ultrasound. The other three (6.38%) were identified intraoperatively (by laparoscopy or laparotomy) based on an indication of peritoneal irritation. The remaining 19 (40.43%) with mild symptoms for conservative management (38.89%) - through physical examination, laboratory data and imaging diagnostic methods (X-ray, ultrasound and CT). Of the 28 operated, 13 patients had laparoscopy performed lavage and drainage, with the remaining 15 (with laparotomy) - had Hartmann's procedure. Conclusion: Acute diverticulitis with micro-perforation showed no significant differences in the complications and course of antibiotic therapy compared to the group of acute diverticulitis without micro-perforation. Neither group required surgery after one-month discharge. Accordingly, to these outcomes, the mode of treatment should be identical.

Abstract Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.

Aim: The pathogenesis of acute diverticulitis (AD) remains incompletely understood, despite it being one of the most common gastrointestinal conditions worldwide. The aim of this study was to investigate the role of the colonic microbiome in the pathogenesis of AD. Method: A prospective case–control study was performed, comparing the microbiome of AD patients with that of controls, using 16S rRNA sequencing of rectal swab samples. Results: The microbiome of individuals with AD showed lower diversity than that of controls. There were significant compositional differences observed, with a lower abundance of commensal bacterial families and genera such as Lachnospiraceae, Ruminococcus and Faecalibacterium in AD patients compared with controls, and there was an increase in several genera with known pathogenic roles including Fusobacteria, Prevotella and Paraprevotella. Conclusion: This is the largest study to date to examine the microbiota of AD patients, and adds evidence to the proposed hypothesis that alterations in the colonic microbiome play a role in the pathogenesis of AD. [ABSTRACT FROM AUTHOR]

Acute diverticulitis disease is associated with inflammation and infection in the colon diverticula and may lead to severe morbidity. This study aimed to evaluate and compare the protective effects of amoxicillin antibiotic, either alone or in combination with probiotics (Lactobacillus acidophilus and Bifidobacterium lactis), in a rat model of acute diverticulitis disease. Acute diverticulitis was induced, in albino rats, by adding 3% weight/volume of dextran sulfate sodium (DSS) to the rats' drinking water; daily for 7 days, in addition to injecting lipopolysaccharide (LPS) enema (4 mg/kg). The impact of treatments was assessed by measuring the physiological and immunological parameters and evaluating colon macroscopic and microscopic lesions. The results showed that both treatments (especially probiotics with amoxicillin) alleviated the adverse effects of DSS and LPS. This was obvious through the modulation of the rats' body weight and the colon weight-to-length ratio. Also, there was a significant (p < 0.001) decrease in the colon macroscopic lesion score. The pro-inflammatory cytokines [(TNF)-α, (IL)-1β, (IFN)-γ, and (IL)-18]; in the colon tissue; were significantly (p < 0.001) decreased. Also, both treatments significantly ameliorated the elevation of myeloperoxidase activity and C-reactive protein levels, in addition to improving the histopathological alterations in the colon tissue. In conclusion, amoxicillin and probiotics–amoxicillin were effective in preventing the development of experimentally induced acute diverticulitis, through their anti-inflammatory and immunomodulatory effects. Furthermore, this study has explored the role of probiotics in preventing DSS/LPS-induced acute diverticulitis, so it can be applied as a promising treatment option for acute diverticulitis disease. [ABSTRACT FROM AUTHOR]

Gut microbiota (GM) composition and its imbalance are crucial in the pathogenesis of several diseases, mainly those affecting the gastrointestinal tract. Colon diverticulosis and its clinical manifestations (diverticular disease, DD) are among the most common digestive disorders in developed countries. In recent literature, the role of GM imbalance in the onset of the different manifestations within the clinical spectrum of DD has been highlighted. This narrative review aims to summarize and critically analyze the current knowledge on GM dysbiosis in diverticulosis and DD by comparing the available data with those found in inflammatory bowel disease (IBD). The rationale for using probiotics to rebalance dysbiosis in DD is also discussed. [ABSTRACT FROM AUTHOR]

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize "when" to safely perform a colonoscopy in the different DD settings and "why". [ABSTRACT FROM AUTHOR]