Systematic Review: Outpatient Management of Acute

Uncomplicated Diverticulitis (Int J Colorectal Dis (2014)29:775-781)

Mr John JacksonMr Nigel Noor

Mr Toby Hammond

Presentation Contents

• Background

• Methods

• Results

• Discussion

• Conclusions

Background

• Diverticular disease is common.

• Most frequent complication is acute diverticulitis.

• Acute diverticulitis is classified as either complicated or uncomplicated.

• The majority of patients present with uncomplicated disease.

Acute Uncomplicated Diverticulitis (AUD) Current Practice

• 87,202 acute admissions in England annually (HES data 2011-12)

• Traditional management involves Bowel Rest, IV fluids, IV antibiotics

• Significant clinical and financial implications

• Expert opinion - no evidence

Systematic Review: Methods• PRISMA guidelines

• Two researchers independently searched Medline, Embase and Cochrane Library databases

• Eligible studies: – Peer-reviewed articles investigating suitability of

ambulatory treatment protocols for AUD

– Search terms ‘Diverticulitis’, ‘Outpatient’, ‘Out-patient’, ‘Home’

Methods continued

Methods continued

The data sought from each study included:

• Type of study

• Selection criteria of Patients

• Imaging modality

• Nature of intervention

• Success rates

• Methods and duration of follow-up.

Results

• 9 studies identified

– 1 RCT, 7 Prospective cohort, 1 Retrospective cohort

AuthorReference

Year of publication

Study design(Level of evidence)

Management protocol Results

Alonso et al.8

2010 Prospective cohort(3)

7 days PO abxStep-wise progression to regular diet

70 patients68 patients treated without complication2 patients required admission

Ridgway et al.19

2009 Randomized controlled trial(2)

PO Group – PO abx, nil dietary restrictionsIV Group – IV abx, IV fluids only first 24 hours

PO Group – 41 patients, nil treatment failuresIV Group – 38 patients, nil treatment failures

Park et al.20

2011 Prospective cohort(3)

PO Group – 4 days PO abx, nil dietary restrictionsIV Group – 7-10 days IV abx, initial bowel rest

PO Group, 40 patients, nil treatment failuresIV Group – 63 patients, nil treatment failures

Rodríguez-Cerrillo et al.21

2010 Prospective cohort(3)

Initial home IV abx, conversion PO abx when clinical condition improved

24 patients, nil treatment failures

Martín Gil et al.22

2009 Prospective cohort(3)

7-10 days PO abxLiquid diet only first 3 days

74 patients,70 patients treated without complication4 patients required admission

Peláez et al.23

2006 Prospective cohort(3)

7 days PO abxClear liquid diet only first 2 days

40 patients,38 patients treated without complication2 patients required readmission

Mizuki et al.24

2005 Prospective cohort(3)

10 days PO abxSports drink first 3 days

70 patients68 patients treated without complication2 patients required hospitalization

Moya at al.25

2012 Prospective cohort(3)

PO Group – PO abx, immediate liquid dietIV Group – IV abx for at least 5 days, IV fluids only first 48 hrs

PO Group – 30 patients treated without complication, 2 patients required admissionIV Group – 44 patients, nil treatment failures

Al-Sahaf et al.26

2008 Retrospective cohort(3)

IV abx first 24 hrs, then conversion PO abx to complete 10 day courseStep-wise progression to regular diet

26 patients, nil treatment failures

Results

Diagnosis and Severity Staging:• 7 utilized CT• 1 utilized USS• 1 utilized clinical judgment alone.

Radiological Exclusion Criteria:• Free Perforation• Colonic obstruction• Abscess/Phlegmon ≥3cm

Results

Non Radiological Exclusion Criteria:• Age >80 or >90• Vomiting or Not tolerating Oral intake • Severe Sepsis• Medical Comorbidities• Immunocompromised• Lack of Understanding• Lack of social support• Patient preference

Results

AUD established• Immediate discharge on oral antibiotics/ 24 hours

IV abx & fluids• Analgesia and laxatives• Normal diet

Commonest Antibiotic Regimen• Metronidazole + Cephalosporin• Co-Amoxiclav

Results

1 RCT: IV abx & bowel rest vs oral abx & no dietary restrictions (Ridgway 2009 Colorectal Dis 11:941–946 )

1o outcome: resolution of symptoms

No advantage to former

Results

Follow up 4-10 days post discharge in the majority of studies.

To exclude bowel cancer, 1 month after acute episode

• Colonoscopy

• CT colonography,

• Barium Enema

Results

403/415 (97%) AUD patients successfully managed as outpatients.

Reasons for failure:• persistent abdominal tenderness• vomiting• fever• acopia

4 studies addressed cost benefit• savings 35 – 83%

Discussion

• AUD can be safely and effectively managed in the community.

• Economic benefits of such an approach were also demonstrated.

• Limitations

– high Risk of Bias across all the studies

– level II and III evidence.

Discussion

DIVER study - RCT:

98% patients successfully managed as outpatients

cost savings €1124.70/ patient

(Biondo, Ann Surg 2004)

AVOD study – RCT abx vs no abx for AUD:

no benefit for abx

(Chabok, Br J Surg. 2012)

Conclusion

• Current evidence shows ambulatory based approach for the majority of AUD patients is justified.

• Developed outpatient treatment algorithm based on these findings

Treatment Algorithm