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Colonic Diverticulitis: Diagnostic and Therapeutic Aspects
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm , Centre for Clinical Research, County of Västmanland.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aims of this thesis were to evaluate diagnostic and therapeutic aspects of colonic diverticulitis.

In the first study, a systematic review of the literature was performed to evaluate radiological diagnostics for patients with acute left-sided diverticulitis. Forty-nine relevant articles were found and read in full and data were extracted or calculated. Twenty-nine of these were excluded. The best evidence for the diagnosis of diverticulitis in the literature was to be found with US. Only one small study of good quality was found for both CT and MRI.

In the second paper, a prospective multicentre study was performed to determine the faecal carriage of antibiotic-resistant bacteria and antibiotic treatment in 208 surgical patients with acute intra-abdominal infections. The highest rates of resistance among Enterobacteriaceae were detected for ampicillin (54%), tetracycline (26%), cefuroxime (26%) and trimethoprim-sulfamethoxazole (20%). The prevalence of decreased susceptibility (I + R) for the other antibiotics tested was for ciprofloxacin 20%, piperacillin-tazobactam 17%, cefotaxime 14%, ertapenem 12%, gentamicin 3% and imipenem 0%. ESBL- and AmpC producing Enterobacteriaceae were found in samples from 13 patients (6.3%).  We found high rates of resistance among Enterobacteriaceae against antibiotics which were commonly used in Sweden.

In the third paper, a multicentre randomized study was performed to investigate the need of antibiotic treatment in acute uncomplicated diverticulitis. Six hundred and twenty-three patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics. Complications were found in six patients (1.9%) in the no antibiotic and three (1.0%) in the antibiotic group (p=0.302). The median hospital stay was three days in both groups. Recurrent diverticulitis follow-up was similar in both groups (16%, p=0.895). We conclude that antibiotic treatment for acute uncomplicated diverticulitis neither accelerated recovery nor prevented complications or recurrence. Based on the results, antibiotics should therefore be reserved mainly for the treatment of complicated diverticulitis.

The fourth paper presents a prospective observational study performed in two centres to evaluate CT colonography in the follow-up of acute diverticulitis as regards patient acceptance and diagnostic accuracy in 108 patients. Patients experienced colonoscopy as more painful (p<0.001) and uncomfortable (p<0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a level of relatively good agreement (К= 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (К= 0.17). We concluded that CTC was less painful and unpleasant. CTC detected diverticulosis with good accuracy while the accuracy of detection of small polyps was poor. CTC could be an alternative, especially in cases of incomplete colonoscopy or in a situation with limited colonoscopy resources.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2012. , 74 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 739
National Category
Clinical Medicine
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-168282ISBN: 978-91-554-8268-8 (print)OAI: oai:DiVA.org:uu-168282DiVA: diva2:492370
Public defence
2012-03-17, Aulan ingång 21, Västmanlandssjukhus, Västerås, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-02-24 Created: 2012-02-07 Last updated: 2012-03-01Bibliographically approved
List of papers
1. Acute colonic diverticulitis: a systematic review of diagnostic accuracy
Open this publication in new window or tab >>Acute colonic diverticulitis: a systematic review of diagnostic accuracy
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2007 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 9, no 6, 480-488 p.Article, review/survey (Refereed) Published
Abstract [en]

Objective To appraise the literature on the diagnosis of acute colonic diverticulitis by ultrasound (US), computed tomography (CT), barium enema (BE) and magnetic resonance imaging (MRI).

Method The databases of Pub Med, the Cochrane Library and EMBASE were searched for articles on the diagnosis of diverticulitis published up to November 2005. Studies where US, CT, BE, or MRI were compared with a reference standard on consecutive or randomly selected patients were included. Three examiners independently read the articles according to a prespecified protocol. In case of disagreement consensus was sought. The level of evidence of each article was classified according to the criteria of the Centre for Evidence-Based Medicine (CEBM), Oxford, UK.

Results Forty-nine articles relevant to the subject were found and read in full. Twenty-nine of these were excluded. Among the remaining 20 articles, only one study, evaluating both US and CT reached level of evidence 1b according to the CEBM criteria. Two US studies and one MRI study reached level 2b. The remaining studies were level 4.

Conclusion The best evidence for diagnosis of diverticulitis in the literature is on US. Only one small study of good quality was found for CT and for MRI-colonoscopy.

Keyword
Acute Disease, Barium Sulfate/diagnostic use, Diverticulitis; Colonic/*diagnosis/radiography/ultrasonography, Enema, Humans, Magnetic Resonance Imaging, Sensitivity and Specificity, Tomography; X-Ray Computed
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-16030 (URN)10.1111/j.1463-1318.2007.01238.x (DOI)17573739 (PubMedID)
Available from: 2008-04-08 Created: 2008-04-08 Last updated: 2017-12-08Bibliographically approved
2. Prevalence of fecal carriage of antibiotic-resistant bacteria in patients with acute surgical abdominal infections
Open this publication in new window or tab >>Prevalence of fecal carriage of antibiotic-resistant bacteria in patients with acute surgical abdominal infections
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2010 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 45, no 10, 1203-1210 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE:

Antibiotic resistance is increasing worldwide. The aims of the current study were to determine the fecal carriage of antibiotic-resistant bacteria and antibiotic treatment in surgical patients admitted to hospital due to acute intra-abdominal infections.

MATERIALS AND METHODS:

Eight Swedish surgical units participated in this prospective multicenter investigation. Rectal swabs were obtained on admission to hospital. Cultures were performed on chromogenic agar and antibiotic susceptibility testing was performed using the disk diffusion method. Extended-spectrum beta-lactamase (ESBL)-phenotype was confirmed by Etest.

RESULTS:

Rectal samples were obtained and analyzed from 208 patients with intra-abdominal surgical infections. Surgery was performed in 134 patients (65%). Cephalosporins were the most frequently used empirical antibiotic therapy. The highest rates of resistance among Enterobacteriaceae were detected for ampicillin (54%), tetracycline (26%), cefuroxime (26%) and trimethoprim-sulfamethoxazole (20%). The prevalence of decreased susceptibility (I + R) for the other antibiotics tested was for ciprofloxacin 20%, piperacillin-tazobactam 17%, cefotaxime 14%, ertapenem 12%, gentamicin 3% and imipenem 0%. ESBL-producing Enterobacteriaceae were found in samples from 10 patients (5%). Three patients had five E. coli isolates producing AmpC enzymes.

CONCLUSIONS:

This study shows a high rate of resistance among Enterobacteriaceae against antibiotics which are commonly used in Sweden and should have implications for the future choice of antibiotics for surgical patients.

Keyword
Abdominal infection, antibiotics, antibiotic resistance, bacteria, resistance
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-133102 (URN)10.3109/00365521.2010.495417 (DOI)000282151500010 ()20521871 (PubMedID)
Available from: 2010-11-02 Created: 2010-11-02 Last updated: 2017-12-12Bibliographically approved
3. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis
Open this publication in new window or tab >>Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis
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2012 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 99, no 4, 532-539 p.Article in journal (Refereed) Published
Abstract [en]

Background: The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.

Methods: This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.

Results: Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1.9 per cent) who received no antibiotics and in three (1.0 per cent) who were treated with antibiotics (P = 0.302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0.881).

Conclusion: Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

Keyword
Colonic Diverticulitis
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-167955 (URN)10.1002/bjs.8688 (DOI)000303150400013 ()22290281 (PubMedID)
Conference
5th Annual Scientific Meeting of the European-Society-of-Coloproctology, 24 september 2010, Sorrento Italy
Available from: 2012-02-07 Created: 2012-02-02 Last updated: 2017-12-08Bibliographically approved
4. CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy
Open this publication in new window or tab >>CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy
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2013 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 48, no 8, 979-986 p.Article in journal (Refereed) Published
Abstract [en]

Objective. The aim of this study was to assess CT-colonography (CTC) in the follow-up of diverticulitis regarding patient acceptance and diagnostic accuracy for diverticular disease, adenomas and cancer, with colonoscopy as a reference standard. Methods. A prospective comparative study where half of the patients underwent colonoscopy first, followed immediately by CTC. The other half had the examinations in the reverse order. Patient experiences and findings were registered after every examination, blinded to the examiner. Results. Of a total of 110 consecutive patients, 108 were included in the study, with a median age of 56 years (range 27-84). The success rate was 91% for colonoscopy and 86% for CTC. Examination time was 25 mm for both methods. The mean time for CTC evaluation was 20 mm. Eighty-three per cent of the patients received sedation during colonoscopy. Despite this, patients experienced colonoscopy as more painful (p < 0.001) and uncomfortable (p < 0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a good agreement (kappa = 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (kappa = 0.17). No cancer was found. Conclusion. CTC was less painful and unpleasant and can be used for colonic investigation in the follow-up of diverticulitis. CTC detected diverticulosis with good accuracy while the detection accuracy of small polyps was poor. CTC is a viable alternative, especially in case of incomplete colonoscopy or in a situation with limited colonoscopy resources.

Keyword
colonic diverticulitis, CT- colonography, colonoscopy, accuracy, sensitivity, specificity
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-168281 (URN)10.3109/00365521.2013.809597 (DOI)000322850500012 ()
Available from: 2012-02-07 Created: 2012-02-07 Last updated: 2017-12-08Bibliographically approved

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