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. Diverticulitis in the young patient Is it different?A Lahat, Y Menachem, B Avidan, et alWorld Journal of GastroenterologyMay 2006; 12(18):2932-35. Aim. Prospectively study incidence and natural history in younger groupConflicting information in literature. Methods. All diverticulitis admis
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1. Diverticulitis in the Young POW Journal Club
6 Nov 2006
Camille Wu
(Mentor: Dr S Wong)
2. 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
3. Aim Prospectively study incidence and natural history in younger group
Conflicting information in literature
4. Methods All diverticulitis admissions 2000-2005
Diagnosis based on:
Lower abdo pain
Fever
WCC
CT diagnosis
5. Methods Data collected
Demographics
Medical history
Medications
Physical findings
Laboratory test results
Radiology results
Endoscopy results
Treatment received
6. Methods Follow-up
During admission
6-monthly for 1 year
Annually thereafter
Visits / phone calls
Data collected
Pain +/- fever
Admissions
Operations
7. Methods 4 groups
Sigmoid colectomy
Further episode requiring admission
Recurrent pain
Asymptomatic
Analysis
Whole study population
Age subgroups (< and > 45 y.o.)
8. Results 207 patients
80 M : 127 F
9. Results Mild course 175 (85%)
Complications 32 (15%)
Peridiverticular air 20
Abdominal abscess 6
Free perforation 6
Death 2
10. Inpatient complications
11. Follow-up 6 60 months (mean 30 months)
Loss to follow-up
Younger 4 (16%)
Older 23 (13%)
Deaths 3 (2%)
12. Follow-up
13. Discussion Young patients
12% of diverticulitis
Male predominance
More severe course
Higher complication rate
Higher recurrence rate, hence
.
Higher sigmoidectomy rate
14. Discussion Conflicting information in younger group:
severity and
incidence of diverticulitis
Recommendation for operation after 1-2 attacks
15. Conclusion Acute diverticulitis generally mild
In younger group,
More aggressive
More recurrence
Male tendency
Consider early surgical approach in young
16. Critique Prospective study
Variable follow-up
6 months to 5 years
13-15% loss to follow-up
Small numbers in young group
17. 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?
18. 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
19. 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
20. 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
21. Younger population Still controversial
Disease appears more aggressive due to bias of later diagnosis and presentation?
Little evidence to support early operation
22.
Review article in detail
.
23. Introduction Current recommendation
Colectomy after 2 attacks
Not based on recent data
24. 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
25. 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
26. 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
27. Inconsistencies Diagnosis
Correlation between
Symptoms
Histological findings
Endoscopic findings
Overlap of symptoms of irritable bowel
28. Younger population Still controversial
Disease appears more aggressive due to bias of later diagnosis and presentation?
Little evidence to support early operation