Diverticulitis in the Young

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 Hartmann�s = 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 Hartmann�s 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