Acute Diverticulitis: Clinical and Laboratory Features
Acute Diverticulitis: Clinical and Laboratory Features
Background Computed tomography (CT) demonstrates diverticulitis severity.
Aim To assess demographic, clinical and leucocyte features in association with severity.
Methods We reviewed medical records of 741 emergency department cases and in-patients with diverticulitis. CT findings were: (i) nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe (abscess and/or extra-luminal gas and/or contrast).
Results Patients with severe vs. nondiagnostic/moderate findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P = .002), fever (52.2% vs. 27.0%, P < .0001), leucocytosis (81.5% vs. 55.2%, P < .0001), neutrophilia (86.2% vs. 59.0%, P < .0001), 'bandemia' (18.5% vs. 5.5%, P < .0001) and the triad of abdominal pain, fever and leucocytosis (46.7% vs. 19.9%, P < .0001) respectively. Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P < .0001). The former group (odds ratio [95% CI]) included females less often (0.45 [0.26–0.76]) and had less lower abdominal pain only (0.54 [0.29–0.99]) and more constipation (2.32 [1.27–4.23]), fever (2.13 [1.27–3.57]) and leucocytosis (2.67 [1.43–4.99]).
Conclusions Less than 50% of severe cases have the clinical/laboratory triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who lack fever and leucocytosis have severe diverticulitis. Male gender, pain not limited to the lower abdomen, constipation, fever and leucocytosis are independently associated with severe diverticulitis.
Colonic diverticulosis affects up to 65% of Western populations by age 80. In the US, acute diverticulitis (AD) accounts for a majority of the 1.5 million days of in-patient (IP) care annually for diverticular disease, and hospitalisation is increasing. Even more patients are treated without hospitalisation.
Acute diverticulitis is often diagnosed on history and physical examination, but clinical evaluation can be inaccurate. The American College of Radiology and the American Society of Colon and Rectal Surgeons recommend computed tomography (CT) as the preferred imaging procedure to diagnose AD and its complications, and Ambrosetti and modified Hinchey classifications of AD severity are based on CT findings. Although antibiotic therapy is standard, Swedish investigators have used CT to help identify patients who can be successfully treated without antibiotics. Measurement of abscess size can indicate whether antibiotic therapy alone or drainage is required, and CT findings can predict recurrence.
The use of CT in US emergency departments for the evaluation of acute abdominal pain increased more than twofold between 2001 and 2005, but detection rates of AD did not increase. In contrast to generally increasing CT use, some authors argue against any initial imaging in patients suspected to have AD without peritonitis and instead suggest reliance on clinical diagnosis. Furthermore, routine use of CT should be reconsidered in light of recent evidence concerning the potential for radiation exposure from CT to cause cancer.
Physicians often suspect AD in patients with the triad of abdominal pain, fever and leucocytosis, and a modified Hinchey classification depends on these features to diagnose mild clinical AD without confirmation by imaging or surgery. Abdominal tenderness is usually present. Obesity increases the risk of diverticular disease. In the past few years, physicians have used demographic, clinical and laboratory features to more accurately diagnose AD, but there are few data on these factors in relation to disease severity, which is generally related to the severity of CT findings. Knowledge of such features that are associated with CT findings typical of severe AD could help physicians utilise this imaging procedure more judiciously and reduce cost and risk.
We studied patients in a large, integrated healthcare system who were diagnosed with AD after undergoing abdominopelvic CT and treated in an emergency department (ED) or after hospitalisation. We aimed to investigate their demographic and clinical features, including body mass index (BMI) and leucocyte counts and assess the association of these variables with CT results that ranged from nondiagnostic to those of severe AD.
Abstract and Introduction
Abstract
Background Computed tomography (CT) demonstrates diverticulitis severity.
Aim To assess demographic, clinical and leucocyte features in association with severity.
Methods We reviewed medical records of 741 emergency department cases and in-patients with diverticulitis. CT findings were: (i) nondiagnostic; (ii) moderate (peri-colic inflammation); and (iii) severe (abscess and/or extra-luminal gas and/or contrast).
Results Patients with severe vs. nondiagnostic/moderate findings had fewer females (42.4% vs. 58.2%, P = .004), less lower abdominal pain only (74.7% vs. 83.7%, P = .042) and more constipation (24.4% vs. 12.5%, P = .002), fever (52.2% vs. 27.0%, P < .0001), leucocytosis (81.5% vs. 55.2%, P < .0001), neutrophilia (86.2% vs. 59.0%, P < .0001), 'bandemia' (18.5% vs. 5.5%, P < .0001) and the triad of abdominal pain, fever and leucocytosis (46.7% vs. 19.9%, P < .0001) respectively. Severe vs. nondiagnostic/moderate findings occurred in 4.8% vs. 95.2% without fever or leucocytosis, 7.0% vs. 93.0% with fever, 12.3% vs. 87.7% with leucocytosis and 25.1% vs. 74.9% with fever and leucocytosis respectively (P < .0001). The former group (odds ratio [95% CI]) included females less often (0.45 [0.26–0.76]) and had less lower abdominal pain only (0.54 [0.29–0.99]) and more constipation (2.32 [1.27–4.23]), fever (2.13 [1.27–3.57]) and leucocytosis (2.67 [1.43–4.99]).
Conclusions Less than 50% of severe cases have the clinical/laboratory triad of abdominal pain, fever and leucocytosis, but only 1 of 20 with pain who lack fever and leucocytosis have severe diverticulitis. Male gender, pain not limited to the lower abdomen, constipation, fever and leucocytosis are independently associated with severe diverticulitis.
Introduction
Colonic diverticulosis affects up to 65% of Western populations by age 80. In the US, acute diverticulitis (AD) accounts for a majority of the 1.5 million days of in-patient (IP) care annually for diverticular disease, and hospitalisation is increasing. Even more patients are treated without hospitalisation.
Acute diverticulitis is often diagnosed on history and physical examination, but clinical evaluation can be inaccurate. The American College of Radiology and the American Society of Colon and Rectal Surgeons recommend computed tomography (CT) as the preferred imaging procedure to diagnose AD and its complications, and Ambrosetti and modified Hinchey classifications of AD severity are based on CT findings. Although antibiotic therapy is standard, Swedish investigators have used CT to help identify patients who can be successfully treated without antibiotics. Measurement of abscess size can indicate whether antibiotic therapy alone or drainage is required, and CT findings can predict recurrence.
The use of CT in US emergency departments for the evaluation of acute abdominal pain increased more than twofold between 2001 and 2005, but detection rates of AD did not increase. In contrast to generally increasing CT use, some authors argue against any initial imaging in patients suspected to have AD without peritonitis and instead suggest reliance on clinical diagnosis. Furthermore, routine use of CT should be reconsidered in light of recent evidence concerning the potential for radiation exposure from CT to cause cancer.
Physicians often suspect AD in patients with the triad of abdominal pain, fever and leucocytosis, and a modified Hinchey classification depends on these features to diagnose mild clinical AD without confirmation by imaging or surgery. Abdominal tenderness is usually present. Obesity increases the risk of diverticular disease. In the past few years, physicians have used demographic, clinical and laboratory features to more accurately diagnose AD, but there are few data on these factors in relation to disease severity, which is generally related to the severity of CT findings. Knowledge of such features that are associated with CT findings typical of severe AD could help physicians utilise this imaging procedure more judiciously and reduce cost and risk.
We studied patients in a large, integrated healthcare system who were diagnosed with AD after undergoing abdominopelvic CT and treated in an emergency department (ED) or after hospitalisation. We aimed to investigate their demographic and clinical features, including body mass index (BMI) and leucocyte counts and assess the association of these variables with CT results that ranged from nondiagnostic to those of severe AD.
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