BACKGROUND: Uncomplicated colonic diverticulitis is common. There is no consensus regarding the most appropriate management. Some authors have reported the efficacy and safety of observational management, and others have argued for a more aggressive approach with oral or intravenous antibiotic treatment.
OBJECTIVE: The purpose of this study was to perform an updated meta-analysis of the different management strategies for uncomplicated diverticulitis with 2 separate meta-analyses.
DATA SOURCES: MEDLINE, Embase, and Cochrane databases were used.
STUDY SELECTION: All randomized clinical trials, prospective, and retrospective comparative studies were included.
INTERVENTIONS: Observational and antibiotics treatment or oral and intravenous antibiotics treatment were included.
MAIN OUTCOME MEASURES: Successful management (emergency management, recurrence, elective management) was measured.
RESULTS: After review of 293 identified records, 11 studies fit inclusion criteria: 7 studies compared observational management and antibiotics treatment (2321 patients), and 4 studies compared oral and intravenous antibiotics treatment (355 patients). There was no significant difference between observational management and antibiotics treatment in terms of emergency surgery (0.7% vs 1.4%; p = 0.1) and recurrence (11% vs 12%; p = 0.3). In this part, considering only randomized trials, elective surgery during the follow-up occurred more frequently in the observational group than the antibiotic group (2.5% vs 0.9%; p = 0.04). The second meta-analysis showed that failure and recurrence rates were similar between oral and intravenous antibiotics treatment (6% vs 7% (p = 0.6) and 8% vs 9% (p = 0.8)).
LIMITATIONS: Inclusion of nonrandomized studies, identification of high risks of bias (selection, performance, and detection bias), and presence of heterogeneity between the studies limited this work.
CONCLUSIONS: Observational management was not statistically different from antibiotic treatment for the primary outcome of needing to undergo surgery. However, in patients being treated by antibiotics, our studies demonstrated that oral administration was similar to intravenous administration and provided lower costs. Although it may be difficult for physicians to do, there is mounting evidence that not treating uncomplicated colonic diverticulitis with antibiotics is a viable treatment alternative.
BACKGROUND: In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting.
METHODS: A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment.
RESULTS: This systematic review included 21 studies including 1781 patients who had outpatient management of AD including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data.
CONCLUSIONS: The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.
BACKGROUND: The shift from routine antibiotics towards omitting antibiotics for uncomplicated acute diverticulitis opens up the possibility for outpatient instead of inpatient treatment, potentially reducing the burden of one of the most common gastrointestinal diseases in the Western world.
PURPOSE: Assessing the safety and cost savings of outpatient treatment in acute colonic diverticulitis.
METHODS: PubMed and EMBASE were searched for studies on outpatient treatment of colonic diverticulitis, confirmed with computed tomography or ultrasound. Outcomes were readmission rate, need for emergency surgery or percutaneous abscess drainage, and healthcare costs.
RESULTS: A total of 19 studies with 2303 outpatient treated patients were included. These studies predominantly excluded patients with comorbidity or immunosuppression, inability to tolerate oral intake, or lack of an adequate social network. The pooled incidence rate of readmission for outpatient treatment was 7% (95%CI 6-9%, I
CONCLUSION: Outpatient treatment of uncomplicated diverticulitis resulted in low readmission rates and very low rates of complications. Furthermore, healthcare cost savings were substantial. Therefore, outpatient treatment of uncomplicated diverticulitis seems to be a safe option for most patients.
Acute diverticulitis occurs in up to 25% of patients with diverticulosis. The majority of cases are mild or uncomplicated and it has become a frequent reason for consultation in the emergency department. On the basis of the National Inpatient Sample database from the USA, 86% of patients admitted with diverticulitis were treated with medical therapy. However, several recent studies have shown that outpatient treatment with antibiotics is safe and effective. The aim of this systematic review is to update the evidence published in the outpatient treatment of uncomplicated acute diverticulitis. We performed a systematic review according to the PRISMA guidelines and searched in MEDLINE and Cochrane databases all English-language articles on the management of acute diverticulitis using the following search terms: 'diverticulitis', 'outpatient', and 'uncomplicated'. Data were extracted independently by two investigators. A total of 11 articles for full review were yielded: one randomized controlled trial, eight prospective cohort studies, and two retrospective cohort studies. Treatment successful rate on an outpatient basis, which means that no further complications were reported, ranged from 91.5 to 100%. Fewer than 8% of patients were readmitted in the hospital. Intolerance to oral intake and lack of family or social support are common exclusion criteria used for this approach, whereas severe comorbidities are not definitive exclusion criteria in all the studies. Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective, and economically efficient when applying an appropriate selection in most reviewed studies.
IMPORTANCE: Diverticulitis is a common disease. Recent changes in understanding its natural history have substantially modified treatment paradigms. OBJECTIVE: To review the etiology and natural history of diverticulitis and recent changes in treatment guidelines. EVIDENCE REVIEW: We searched the MEDLINE and Cochrane databases for English-language articles pertaining to diagnosis and management of diverticulitis published between January 1, 2000, and March 31, 2013. Search terms applied to 4 thematic topics: pathophysiology, natural history, medical management, and indications for surgery. We excluded small case series and articles based on data accrued prior to 2000. We hand searched the bibliographies of included studies, yielding a total of 186 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines. FINDINGS: Eighty articles met criteria for analysis. The pathophysiology of diverticulitis is associated with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment. Several studies examined histologic commonalities with inflammatory bowel disease and irritable bowel syndrome but were focused on associative rather than causal pathways. The natural history of uncomplicated diverticulitis is often benign. For example, in a cohort study of 2366 of 3165 patients hospitalized for acute diverticulitis and followed up for 8.9 years, only 13.3% of patients had a recurrence and 3.9%, a second recurrence. In contrast to what was previously thought, the risk of septic peritonitis is reduced and not increased with each recurrence. Patient-reported outcomes studies show 20% to 35% of patients managed nonoperatively progress to chronic abdominal pain compared with 5% to 25% of patients treated operatively. Randomized trials and cohort studies have shown that antibiotics and fiber were not as beneficial as previously thought and that mesalamine might be useful. Surgical therapy for chronic disease is not always warranted. CONCLUSIONS AND RELEVANCE: Recent studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.
BACKGROUND: Diverticular disease of the colon is a common disorder, characterized by recurrent symptoms and complications such as diverticulitis, requiring hospital admissions and surgery.
OBJECTIVE: This study aimed to systematically review the evidence for medical therapy of diverticular disease in reducing symptoms and preventing acute diverticulitis.
DATA SOURCES: MEDLINE and Embase databases (1966 to February 2010).
STUDY SELECTION: The studies selected were prospective clinical trials on uncomplicated diverticular disease of the colon.
INTERVENTIONS: Four investigators independently reviewed articles, extracted data, and assessed study quality according to standardized criteria.
MAIN OUTCOME MEASURES: The main outcomes measured were improvement in symptoms, complete remission of symptoms, and prevention of acute diverticulitis.
RESULTS: We identified 31 studies, including 6 placebo-controlled trials. The methodological quality of these studies was suboptimal. Only 10 trials provided a detailed description of the patient history, 8 assessed symptoms by the use of a validated questionnaire, and 14 appropriately defined inclusion and exclusion criteria. Only one long-term double-blind placebo-controlled study was identified. This reported a significant improvement in symptoms and greater prevalence of symptom-free patients at 1 year with fiber plus rifaximin in comparison with fiber alone. The efficacy of treatment in preventing acute diverticulitis was evaluated in 11 randomized trials. Four trials compared rifaximin plus fiber vs fiber alone and failed to show a significant difference between treatments. However, cumulative data from these trials revealed a significant benefit following rifaximin and fiber (1-year rate of acute diverticulitis: 11/970 (1.1%) vs 20/690 (2.9%); P = .012), but with a number needed to treat of 57, to prevent an attack of acute diverticulitis.
LIMITATIONS: : Heterogeneity of the study design, patients' characteristics, regimens and combination of studied treatment, and outcome reporting precluded the pooling of results and limited interpretation.
CONCLUSIONS: The treatment for diverticular disease relies mainly on data from uncontrolled studies. Treatment showed some evidence of improvement in symptoms, but its role in the prevention of acute diverticulitis remains to be defined.
Uncomplicated colonic diverticulitis is common. There is no consensus regarding the most appropriate management. Some authors have reported the efficacy and safety of observational management, and others have argued for a more aggressive approach with oral or intravenous antibiotic treatment.
OBJECTIVE:
The purpose of this study was to perform an updated meta-analysis of the different management strategies for uncomplicated diverticulitis with 2 separate meta-analyses.
DATA SOURCES:
MEDLINE, Embase, and Cochrane databases were used.
STUDY SELECTION:
All randomized clinical trials, prospective, and retrospective comparative studies were included.
INTERVENTIONS:
Observational and antibiotics treatment or oral and intravenous antibiotics treatment were included.
MAIN OUTCOME MEASURES:
Successful management (emergency management, recurrence, elective management) was measured.
RESULTS:
After review of 293 identified records, 11 studies fit inclusion criteria: 7 studies compared observational management and antibiotics treatment (2321 patients), and 4 studies compared oral and intravenous antibiotics treatment (355 patients). There was no significant difference between observational management and antibiotics treatment in terms of emergency surgery (0.7% vs 1.4%; p = 0.1) and recurrence (11% vs 12%; p = 0.3). In this part, considering only randomized trials, elective surgery during the follow-up occurred more frequently in the observational group than the antibiotic group (2.5% vs 0.9%; p = 0.04). The second meta-analysis showed that failure and recurrence rates were similar between oral and intravenous antibiotics treatment (6% vs 7% (p = 0.6) and 8% vs 9% (p = 0.8)).
LIMITATIONS:
Inclusion of nonrandomized studies, identification of high risks of bias (selection, performance, and detection bias), and presence of heterogeneity between the studies limited this work.
CONCLUSIONS:
Observational management was not statistically different from antibiotic treatment for the primary outcome of needing to undergo surgery. However, in patients being treated by antibiotics, our studies demonstrated that oral administration was similar to intravenous administration and provided lower costs. Although it may be difficult for physicians to do, there is mounting evidence that not treating uncomplicated colonic diverticulitis with antibiotics is a viable treatment alternative.
