Colonoscopy after Diverticulitis

Patients suffering from diverticulitis are at increased risk for colorectal cancer and should undergo colonoscopy to rule out colorectal cancer. The prevalence of colorectal cancer in this population was estimated to range between 1.9 and 2.3%. This prevalence is higher in patients with complicated diverticulitis (abscess, perforation) and ranges between 6.1% and 7.9%. Therefore, interval colonoscopy is strongly recommended after an episode of complicated diverticulitis. The prevalence of colorectal cancer is lower in patients with uncomplicated diverticulitis and approaches the prevalence from screened populations. In patients with uncomplicated diverticulitis, the indication for colonoscopy is still a matter of debate and should be done on a case-by-case basis.

EP.FRI.1020 The necessity of colonoscopy to rule out colorectal malignancy after computerised tomography proven diagnosis of acute diverticulitis

Introduction The current Royal College of Surgeons commissioning guideline on colonic diverticular disease suggests that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The necessity of routine endoscopic assessment of CT proven diverticulitis remains debatable. Aim To establish whether routine endoscopic assessment should be carried out for patients after an episode of acute diverticulitis. Method Data was collected retrospectively from all patients diagnosed with acute diverticulitis on CT and who subsequently had follow up endoscopic assessment from January to July 2019. Results Total number of patients were 64.Median age of the cohort was 58.Of all patients, 48 had diagnosis of uncomplicated diverticulitis whereas 16 patients had diagnosis of complicated diverticulitis on CT scan. All patients had follow up colonoscopy after an acute attack with following findings: 2 patients had no pathology, 56 patients had diagnosis of only diverticulosis, 4 patients had both diverticulosis and polyps and 2 patients had bowel cancer. All 4 cases of polyps had benign pathology and uncomplicated diverticulitis on CT scan. Two bowel cancer patients, one had complicated diverticulitis with thickening of proximal sigmoid and the other patient had abnormal sigmoid colon suggestive of malignancy on CT scan. Conclusion Recent meta-analysis showed no difference between diverticulitis and normal population group in terms of risk of bowel cancer. Routine colonoscopy may not be appropriate in patients with acute uncomplicated diverticulitis but endoscopic assessment after an episode of complicated diverticulitis is necessary.

EP.FRI.971 Is routine endoscopic evaluation of the colon necessary after an episode of acute diverticulitis?

Aim Currently standard practice is for patients diagnosed with diverticulitis to undergo endoscopic evaluation of the colon following the acute episode. The primary aim of endoscopy is to exclude underlying malignancy which may have been undetectable on initial CT scanning. We aim to determine if endoscopic evaluation of the colon is necessary for all patients. Methods All patients with CT proven diverticulitis were included between May 2017 and July 2018. Medical records, CT and endoscopy reports of 154 consecutive patients were retrospectively reviewed. Based on the CT reports, diverticulitis was classified as either uncomplicated (colonic wall thickening, pericolic fat stranding) or complicated (perforation, abscess, generalised free air and/or fluid). Results There were 154 patients included in the study. 59% percent were male. Median age at the time of diagnosis was 56 years old. There were 114 patients with uncomplicated and 40 patients with complicated diverticulitis. 79 patients (50 flexible sigmoidoscopy, 29 colonoscopy) with uncomplicated diverticulitis and 21 patients (15 flexible sigmoidoscopy, 6 colonoscopy) with complicated diverticulitis underwent endoscopy. Of the patients that underwent endoscopy, one patient (1.3%) with uncomplicated disease and one patient (4.8%) with complicated disease were found to have colorectal cancer (both rectal). Neither of these were associated with the diverticular segment. Conclusions Our data shows that routine endoscopic evaluation of the colon after an episode of acute diverticulitis may not be necessary in all cases. Patient numbers in this study are small therefore further work is required to draw conclusions which could influence future clinical practice.

1069 Diverticular Disease: An Audit of Adherence to NICE Guidelines

Introduction Diverticular disease is a common surgical problem ranging from diverticulosis to uncomplicated diverticulitis to complicated diverticulitis. The NICE Guidelines for diverticular disease recommended that antibiotics should only be given in patients who are systemically unwell, background of immunosuppression or have complicated diverticulitis. We aimed to access the compliance to these guidelines with regards to the use of antibiotics at our local institute. Method This was a retrospective audit reviewing the management of patients with Computed Tomography Scan findings of uncomplicated acute diverticulitis (Hinchey Ia) at the surgical emergency unit at Basildon University Hospital between August 2018 and May 2020. Data obtained included demographic data, presenting symptoms (fever, abdominal pain), haematological investigations (full blood count and c-reactive protein) and use of intravenous/oral antibiotics. Results Twenty patients were included, the M:F ratio was 1:1.9, the age range was between 36-80 years. 13 patients (65%) had left iliac fossa pain as part of their presenting symptom while only three (15%) had pyrexia. Seventeen patients(85%) had NEWS score between 0-1 with 60% of the patients presenting with elevated white blood cell count and 75% with c-reactive protein >5. All our patients were prescribed antibiotics. Conclusions There was no discrimination in the use of antibiotics/admission for uncomplicated diverticulitis as all patients had antibiotics and as such there is need for increased awareness about the guidelines among the surgical team and adherence to the protocol to prevent indiscriminate use of antibiotics.

161 Current Practice of Antibiotic Prescription in Acute Uncomplicated Diverticulitis

Aim To review the current antibiotic prescribing practice for patients with acute uncomplicated diverticulitis against the NICE guidelines November 2019, to avoid unnecessary/overuse of antibiotics. Method A retrospective review of patients presenting with lower abdominal pain between 1/11/2019 -31/1/2020. All patients with suspected diverticulitis were included. Patients who were subsequently diagnosed with complicated diverticulitis/alternate diagnosis were excluded from the analysis. Results 22/27 (81.5%) of the patients were admitted. 26 out of 27 (96.3%) patients with acute uncomplicated diverticulitis were administered antibiotics. Antibiotics were indicated as per NICE guidelines in 17 patients (62.97%) and not indicated in 9 patients (33.34%). Admission was not indicated in 20 patients (90.91%) according to NICE guidelines. Conclusions Our adherence to NICE guidelines is 66.67% in terms of antibiotic administration, however the drug and duration of antibiotic administration needs to be reviewed. NICE guidelines recommend that acute uncomplicated diverticulitis can be managed as an outpatient. Antibiotics should be administered only if patient is systemically unwell, is immunosupressed or has significant co morbidities

1382 Retrospective Audit to Assess Compliance to National Guidance for The Follow-Up of Acute Uncomplicated Diverticulitis and Adenoma Detection Rate at University Hospital Bristol

Aim Diverticulitis is a common cause for acute surgical admissions. UK guidance recommends uncomplicated diverticulitis is managed with antibiotics, and follow-up outpatient lower gastrointestinal (LGI) endoscopy (flexible sigmoidoscopy or colonoscopy) arranged 6-8 weeks after discharge. This audit aimed to assess compliance to national guidance and assess adenoma detection rate. Method Retrospective analysis of discharge summaries coded ‘diverticulitis’ from January 2017 – April 2020 at University Hospital Bristol(UHB). Results 426 patients presented with uncomplicated diverticulitis, mean age 60.5 years (22-92 years). 42% (179/426) of patients underwent LGI endoscopy as an inpatient or on discharge. Median time to outpatient endoscopy was 70 days (6-287 days). 23% (99/426) had LGI endoscopy within the 8-week target. Histology showed: 21% (37/179) polyp; 5% (9/179) tubular adenoma; and one patient had high grade dysplasia. The histology for the remaining 28 patients with polyps showed: hyperplasia; granulation tissue; inflammation; or samples were not sent for histology. No cases of malignancy were detected. Conclusions 58% of patients admitted with acute uncomplicated diverticulitis did not have a follow-up LGI endoscopy and only 23% had LGI endoscopy within the 8-week target. 21% had a polyp with a 5% rate of tubular adenoma and no cases of malignancy. UHB needs to improve compliance with national guidance for the arrangement of follow-up LGI endoscopy, however the absence of detection of malignancy raises the question of whether we need to re-consider its necessity for patients with uncomplicated diverticulitis.

Changing Paradigms in the Management of Acute Uncomplicated Diverticulitis

Left-sided colonic diverticulitis is a common condition with significant morbidity and health care costs in Western countries. Acute uncomplicated diverticulitis which is characterized by the absence of organ dysfunction, abscesses, fistula, or perforations accounts for around 80% of the cases. In the last decades, several traditional paradigms in the management of acute uncomplicated diverticulitis have been replaced by evidence-based routines. This review provides a comprehensive evidence-based and clinical-oriented overview of up-to-date diagnostics with computer tomography, non-antibiotic treatment, outpatient treatment, and surgical strategies as well as follow-up of patients with acute uncomplicated diverticulitis.

321 Role of Antibiotics in Acute uncomplicated diverticulitis, A Systematic Review and Meta-Analysis

Introduction Diverticular disease is a common health problem with a wide clinical spectrum. About 75% of the patients would have uncomplicated diverticulitis. Cornerstones of treatment are antibiotics, analgesia, and dietary advice. Recent evidence has shown that its treatment is controversial, questioning the use of antibiotics. Aim is to assess the role of antibiotics in the treatment of acute uncomplicated diverticulitis. Method This is a systematic review and Meta-analysis. Literature review of the available studies was conducted using search engines like Pubmed, Medline, Embase, Google Scholar, and Cochrane databases. Statistical analysis was conducted using RevMan5.4. Results Out of 1754 records 1324 were duplicates, 430 studies were screened. 395 were further excluded.35 full text articles were assessed and in the final review 10 studies were included. PRISMA guidelines were used. Pooled OR for recurrence = 0.92 (95% CI = 0.74 to 1.13). Pooled OR for Hospital stay= -0.66 (95% CI= -1.12 to -0.21). Pooled OR for complications = 1.06 (95% CI = 0.69 to 1.64). Pooled OR for treatment failure= 1.24 (95% CI = 0.90-1.69). Conclusions We conclude that from the available evidence antibiotics have no role in reducing recurrence, complications, treatment failure, and duration of hospital stay in acute uncomplicated diverticulitis.