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Background: Naldemedine is an orally available peripherally acting μ-opioid receptor antagonist approved to treat opioid-induced constipation (OIC). It is contraindicated for patients with known or suspected gastrointestinal obstruction to protect against naldemedine-induced perforation. Here, we report a clinical case of suspected perforation of a diverticulum in the sigmoid colon associated with naldemedine. Case presentation: The patient was a 65-year-old man with a history of oral cancer who had been prescribed oxycodone (20 mg/day) for cancer pain. On day 0, the patient started naldemedine 0.2 mg once daily before bedtime for OIC. The dose of oxycodone was increased for pain control up to 60 mg/day. On day 35 of naldemedine treatment, the patient developed fever and abdominal pain, and his frequency of defecation had decreased. Initial laboratory results showed a C-reactive protein (CRP) level of 28.5 mg/dL and white blood cell (WBC) count of 13,500/µL. On day 37, the patient still had tenderness in his lower abdomen. Abdominal computed tomography revealed free air in the abdominal cavity suggesting an intestinal perforation. A Hartmann procedure was performed. Histopathological findings showed numerous diverticula in the sigmoid colon, some of which were perforated. Conclusions: These results suggest that the effects of OIC may have compressed the intestinal tract, which was followed by naldemedine-activation of peristalsis, which led to the onset of intestinal perforation. In patients with pre-existing diverticular disease, we should monitor for increased WBC counts and CRP levels after the initiation of treatment with naldemedine, and consider performing appropriate tests early in the event of abdominal complaints. [ABSTRACT FROM AUTHOR]

Background: Frailty has been associated with increased postoperative mortality and morbidity; however, the use of the modified frailty index (mFI-11) to assess patients undergoing surgery for diverticular disease has not been widely assessed. This paper aims to examine frailty, evaluated by mFI-11, to assess postoperative morbidity and mortality among patients undergoing operative intervention for colonic diverticular disease. Methods: We used data from the Healthcare Cost and Utilization Project National Inpatient Sample (October 1, 2015–December 31, 2019). ICD-10-CM codes were utilized to identify a cohort of adult patients with a primary admission diagnosis of diverticulitis. mFI-11 items were adapted to correspond with ICD-10-CM codes. Patients were stratified into robust (mFI < 0.27) and frail (mFI ≥ 0.27) groups. Primary outcomes were in-hospital postoperative morbidity and mortality. Secondary outcomes included system-specific postoperative complications, length of stay (LOS), total admission cost, and discharge disposition. Multivariable regression models were fit. Results: Of the 26,826 patients, there were 24,194 patients with mFI-11 < 0.27 (i.e., robust) and 2,632 patients with mFI-11 ≥ 0.27 (i.e., frail). Adjusted analysis showed significant increases in postoperative mortality (aOR 2.16, 95% CI 1.38–3.38, p = 0.001) and overall postoperative morbidity (aOR 1.84, 95% CI 1.65–2.06, p < 0.001). LOS was higher in the frail group (MD 1.78 days, 95% CI 1.46–2.11, p < 0.001) as well as total cost (MD $25,495.19, 95% CI $19,851.63-$31,138.75, p < 0.001). Conclusion: In the elective setting, a high mFI-11 (i.e., presence of the variables comprising the index) could alert clinicians to the possibility of implementing preoperative optimization strategies. In the emergent setting, a high mFI-11 may help guide prognostication for these vulnerable patients. [ABSTRACT FROM AUTHOR]

This article explores the research behind diverticular disease and its dietary management, with a focus on dietary fibre. Diverticula, saclike protrusions in the colonic wall, are extremely prevalent in older people living in Western countries and range from asymptomatic (diverticulosis) to moderately symptomatic (diverticular disease) to severely symptomatic (diverticulitis). Diet and lifestyle are implicated in the development of these conditions, as demonstrated by the vast increase in prevalence as countries become more industrialised and follow a Western dietary pattern. Dietary fibre is a particular nutrient of interest. Contrary to prior dogma, research suggests that individuals with diverticular disease should actually strive for a high fibre diet to reduce the risk of developing further diverticula and prevent progression to diverticulitis. The dietary management of the symptoms of diverticular disease is not well understood. Vigorous physical activity may reduce the risk of diverticulitis. Community nurses can help their patients to avoid harmful and unnecessary dietary restrictions by using the information in this article. [ABSTRACT FROM AUTHOR]

The patients are often elderly, presenting the symptoms, and fully recognizing the disease is difficult. It is sometimes confused with inflammatory bowel disease. Within the scope of this research, we aimed to elucidate the frequency of colon diverticulum in patients who underwent lower gastrointestinal endoscopy in our clinic. Demographic data and its relationship with the patient's height-weight-body mass index will also be evaluated. The medical files of 200 patients aged 18–90 years who underwent lower gastrointestinal system endoscopy in our institution have been retrospectively analyzed. The demographic details, age, gender, and results of endoscopy findings have been investigated with respect to detecting colon diverticulum. The presence of diverticula was observed in 7% of the patients (n=14), external hemorrhoids in 1% (n=2), internal hemorrhoids in 28% (n=56), and polyps in 21.5% (n=43). A statistically significant relationship was observed between the genders of the patients in terms of the presence of polyps (p<0.05). The distribution of clinical findings of the patients according to age and body mass index (BMI) did not reveal any statistically significant relationship. The prevalence of diverticulitis is increasing gradually with the aging population. We believe interval lower gastrointestinal system endoscopy remains a significant tool, especially after an acute attack, particularly after complicated diverticulitis, to rule out malignancy or advanced adenomata at the target site and the rest of the colon. [ABSTRACT FROM AUTHOR]

Introduction. Epidemiological data on diverticulitis in Colombia are limited. The objective of this article was to characterize a population that was admitted with acute diverticulitis to the San Vicente Fundación University Hospital, a reference center in the city of Medellín, Colombia, to analyze the presentation and behavior of the disease in the local population, with its own statistics, and outcomes of the disease in recent years. Methods. Retrospective descriptive observational study between January 2015 and December 2019. An exploratory uni-, bi- and multivariate study of risk factors for treatment failure and mortality was performed. Results. A total of 103 patients were included. The most frequent Hinchey classification was Ia (41.7%). It occurs mainly in women, mean age 65 years. Hinchey Ia diverticulitis is the most frequent and medical management is successful in 100% of cases; while in III and IV, 100% were managed surgically with success rates between 50 and 64%. The presence of peritoneal signs on physical examination, leukocyte count and CRP, ICU admission and mortality increased directly proportional with Hinchey stage. Conclusions. There is a directly proportional relationship between Hinchey staging with clinical and paraclinical signs of inflammatory response, need for surgical management, ICU stay and mortality. [ABSTRACT FROM AUTHOR]

The association is defined as two or more malformations with unclear relationships, which do not fit the criteria of a syndrome. This case report presents a rare finding of tubular colonic duplication in association with Mayer--Rokitansky--Küster--Hauser syndrome in an adolescent girl. The patient presented with gastrointestinal bleeding and abdominal pain, necessitating surgical intervention. The successful excision of the duplicated segment highlights the importance of prompt diagnosis and treatment in such cases. [ABSTRACT FROM AUTHOR]

Aim: Diverticular disease is one of the most common gastrointestinal disorders to date, with a notable rising trend in developing countries. However, the proportion of colonic diverticulosis and its associated factors among patients who have undergone colonoscopy remains controversial. This study aimed to determine the local data on the proportion of diverticular disease in the community, its complications, the association of diverticulosis with diabetes mellitus and hypertension, as well as demographic characteristics. Material and Methods: A retrospective review of medical records was performed among patients who had undergone colonoscopy between January and December 2019. Demographic and clinical characteristics, the presence of diabetes mellitus, hypertension, and diverticular disease and its complications were examined, and the association of diverticular disease and its complications with demographic and clinical characteristics were analyzed. Results: Out of 221 patients, 12.7% (n=28) of them had diverticular diseases with a slightly predominant right-sided occurrence (42.9%, n=12). There were significant associations with age (p=0.002), ethnicity (p=0.011), and hypertension (p=0.036), but not with gender and diabetes mellitus (p=0.261, and p=0.334, respectively). There was no significant association between hypertension and recurrence of complicated diverticulitis (p=0.741), septic complications (p=0.678), and diverticular bleeding (p=0.243). Diabetes mellitus was significantly associated with diverticular bleeding complications (p=0.001) but not with septic complications (p=0.418) and recurrence of complicated diverticulitis (p=0.629). Conclusion: This study showed almost a similar percentage of diverticulosis compared to previous local studies. Age, ethnicity, and hypertension were associated with the presence of diverticulosis, and diabetes mellitus was associated with diverticular bleeding. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease. Aim: To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis. Methods: This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis. Results: We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05). Conclusions: Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management. [ABSTRACT FROM AUTHOR]

• Following uncomplicated sigmoid diverticulitis, long-term quality of life does not substantially differ between patients having undergone antibiotic therapy and those having only received symptomatic treatment. • Following Hinchey I/II sigmoid diverticulitis, while prophylactic surgery generally seems to improve quality of life, it has little or no beneficial effect on a sub-group of patients with small-sized abscesses. • Following sigmoid diverticulitis, emergency surgery seems to have little or no impact on quality of life. However, colorectal anastomosis with or without a protective stoma improves quality of life after Hartmann's procedure. Diverticular disease, including diverticulitis, begins when the patient becomes symptomatic. Sigmoid diverticulitis corresponds to inflammation/infection of a diverticulum of the sigmoid colon. Among diverticulosis patients, 4.3% develop diverticulitis, a frequent pathology that can entail major functional disorders. Following sigmoid diverticulitis, few studies have assessed functional disorders and quality of life, a multidimensional concept comprising physical, psychological and mental dimensions, as well as social relations. The purpose of this work is to report current published data on the quality of life of patients having had sigmoid diverticulitis. Following uncomplicated sigmoid diverticulitis, long-term quality of life does not substantially differ between patients having undergone antibiotic therapy and those having only received symptomatic treatment. As for patients having experienced recurrent events, their quality of life seems improved by elective surgery. Following Hinchey I/II sigmoid diverticulitis, elective surgery seems to improve quality of life, notwithstanding a 10% risk of postoperative complications. Following sigmoid diverticulitis, while emergency surgery seems not to have greater impact on quality of life than elective surgery, the surgical technique employed in an emergency setting seems to have an impact, particularly with regard to the physical and mental components of quality of life. Assessment of quality of life is of fundamental importance in diverticular disease and should orient operative indications, particularly in an elective context. [ABSTRACT FROM AUTHOR]

A 75-year-old woman underwent sigmoid colon resection and transverse colostomy for perforation of the diverticulum of the sigmoid colon at 70 years of age at another hospital. She was referred to our hospital with complaints of abdominal discomfort 3 months prior to presentation. Abdominal computed tomography revealed a parastomal hernia (PSH). We performed laparoscopic repair using the Sugarbaker approach with a Symbotex Composite Mesh™ and laparoscopic adhesive intestinal repair. The patient's post-operative course was unremarkable, and she was transferred to the Department of Internal Medicine after 10 days. There was no recurrence 6 months after surgery. Tension-free surgery using a mesh has been reported to be effective in preventing the recurrence of PSH. We performed a laparoscopic modified Sugarbaker mesh method using the Symbotex Composite Mesh™ with collagen film to repair an abdominal hernia. [ABSTRACT FROM AUTHOR]

An inverted colonic diverticulum (ICD) is a rare yet benign feature of diverticular diseases, usually requiring no treatment. Nonetheless, for a junior endoscopist, the condition is sometimes difficult to differentiate from a colonic polyp. Aggressive biopsy or polypectomy of an ICD could result in colon perforation. Special features of an ICD include its sessilemorphology, a normal appearance similar to the surrounding mucosa, and Aurora rings around its base. It could be deformed or flattened with manipulations such as forceps probing, water jet spraying or air insufflation. In this report, we describe two cases of inverted colonic diverticulum and review the literature on the prevalence, diagnostic approaches, and management of the condition. Since the prevalence of diverticular diseases and polyps both increase with age, it may be more common to encounter ICDs and polyps during colonoscopy in the elderly. It is important to consider these two conditions before taking further steps into invasive treatment. [ABSTRACT FROM AUTHOR]

Pathology examination confirmed the diagnosis of a giant colonic diverticulum (GCD) with chronic inflammatory characteristics. Diagnosis of giant sigmoidal diverticulum was made gl The patient was scheduled for elective colorectal surgery and prepared with ERAS preoperative protocol. Abdominal contrast-enhanced CT revealed a smooth-walled, air-filled cavity with no septations measuring 196 × 87 × 129 mm, suggesting for a giant colonic diverticulum. [Extracted from the article]

Purpose: This study aimed to validate the World Society for Emergent Surgery (WSES) scale for the management of acute left-sided colonic diverticulitis (ALCD). Methods: An observational study based on a prospective database of patients with ultrasound (US) and computerized tomography (CT) confirmed ALCD was conducted at our center from April 2018 to May 2019. The primary outcome was the success rate of outpatient management. Secondary outcomes were the association between different WSES stages, clinical and analytical parameters, treatments modalities, and outcomes, and the accuracy of US for management decisions. Results: A total of 230 patients were included. Outpatient management was successful in 51/53 (96.23%) cases with ALCD stage 0 and 62/72 (86.11%) patients with stage 1A. There were no differences in age (p = 0.076) or the presence of pericolic air bubbles (p = 0.06) between patients who underwent admission or outpatient management. Clinical and analytical data, treatment decisions, and outcomes showed statistically significant differences between WSES stages. In 7/12 patients with stage 2A, percutaneous drainage or emergency surgery was required. All cases with stage 2B (distant air) underwent conservative management without the need for emergency or elective surgery. The accuracy of US WSES stages for management decisions, when compared with CT, was 96.96%. Conclusion: The WSES classification for ALCD seemed to be valid helping clinicians in the decision-making process to select between admission or outpatient management. Differences in clinical and analytical data, elected treatments, and outcomes were found between WSES stages. The US WSES stages showed high accuracy for management decisions. [ABSTRACT FROM AUTHOR]

Introduction: Diverticular disease is one of the most common gastrointestinal diseases that require hospital admission. This study aims to identify trends in prior hospital admissions for patients that ultimately require a Hartmann's procedure for complicated diverticulitis.Methods: The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged 18 years or older admitted with an ICD-9 code for colonic diverticulitis and end colostomy creation. Patients with prior hospital admissions were identified. The primary outcome was mortality after Hartmann's procedure. Secondary outcomes were prior hospital admission and previous percutaneous drain placement. Multivariable logistic regression was performed to control for confounding factors for each outcome and results were weighted for national estimates.Results: There were 90,162 patients admitted with complicated diverticulitis requiring end colostomy creation. Prior hospital admissions were found in 28.1% (n = 25,307) and 14.4% (n = 12,947) had a previous percutaneous drain placed during a prior admission. The overall mortality rate was 5.9% (n = 5314) after Hartman's procedure. The mortality rate for patients with prior hospital admissions was 8.7% (P < .001), and the mortality rate for patients with previous percutaneous drain placement was 4.3% (P < .001). After controlling for confounding factors including comorbidities, patients with prior admission had an increased risk of mortality (OR 1.48 [1.40-1.58], P < .001) and patients with previous percutaneous drain placement had a decreased risk of mortality (OR .66 [.60-.72], P < .001).Conclusions: Hospitalizations for complications of diverticulitis are a costly burden to our healthcare system. By identifying those patients at high risk for readmission and emergency surgery, perioperative outcomes may be improved. [ABSTRACT FROM AUTHOR]

Image-enhanced endoscopy (IEE) allows real-time high-contrast imaging of a targeted lesion without any special equipment. Among various IEE technologies, narrow-band imaging, in which a light of shorter wavelength is used, emphasizes the surface and blood vessel patterns on the mucosal surface. This technology has been widely used in endoscopic diagnosis in the gastrointestinal tract. Red dichromatic imaging (RDI) was recently developed; it utilizes lights of longer wavelengths (520–550, 595–610, and 620–640 nm), which have weak light scattering characteristics in contrast to narrow-band imaging. RDI was designed to enhance the visibility of deep-lying blood vessels and areas of bleeding, and it has been installed in the latest Olympus endoscopy system, EVIS X1, as an advanced version of the optical-digital method that was originally developed. Improving the visibility of deep blood vessels allows more accurate evaluation of esophageal varices and the degree of inflammation in ulcerative colitis. Easier identification of a bleeding source makes hemostasis quicker and easier to accomplish during endoscopic resection procedures such as endoscopic submucosal dissection and peroral endoscopic myotomy as well as during treatment of gastrointestinal bleeding from a peptide ulcer or colon diverticulum. The authors herein review the technological development and principles, review the existing literature on RDI, and discuss the utility and effectiveness of this unique IEE technology in gastrointestinal endoscopy. [ABSTRACT FROM AUTHOR]

BACKGROUND : Prior studies have shown the effectiveness of both endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Therefore, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. METHODS : We reviewed data for 1679 patients with CDH who were treated with EBL (n = 638) or clipping (n = 1041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J study). Logistic regression analysis was used to compare outcomes between the two treatments. RESULTS : In multivariate analysis, EBL was independently associated with reduced risk of early rebleeding (adjusted odds ratio [OR] 0.46; P < 0.001) and late rebleeding (adjusted OR 0.62; P < 0.001) compared with clipping. These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant differences were found between the treatments in the rates of initial hemostasis or mortality. Compared with clipping, EBL independently reduced the risk of needing interventional radiology (adjusted OR 0.37; P = 0.006) and prolonged length of hospital stay (adjusted OR 0.35; P < 0.001), but not need for surgery. Diverticulitis developed in one patient (0.16 %) following EBL and two patients (0.19 %) following clipping. Perforation occurred in two patients (0.31 %) following EBL and none following clipping. CONCLUSIONS : Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH, offering the advantages of lower early and late rebleeding rates, reduced need for interventional radiology, and shorter length of hospital stay. [ABSTRACT FROM AUTHOR]

Acute diverticulitis is a common condition in Western society with the potential for substantial patient morbidity. Depending on the severity, the patient's clinical presentation and treatment options vary considerably, leaving uncertainty about optimal management. Traditionally, surgery was recommended to prevent complications, persistent symptoms, and recurrent episodes. Improvements in the understanding of the disease's natural history, diagnostic imaging, and long-term outcomes have prompted changes to diagnosis and treatment guidelines. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 12-year-old boy with obesity presented with acute diffuse abdominal pain. Topics include laboratory results being unremarkable where computed tomography (CT) of the abdomen and pelvis performed for ruling out appendicitis; and hypertension, diabetes, hyperlipidemia, thyroid dysfunction, and NAFLD increasing the risk of developing hepatocellular carcinoma.

Background: Acute right-sided colonic diverticulitis (RCD) is a common disease in Asian populations for which the optimal treatment remains controversial. The aim of this study was to investigate management and evaluate long-term outcomes of treatment in patients with acute RCD.Methods: We retrospectively collected and analyzed clinical data for patients with acute RCD admitted to the Tongren Hospital, Shanghai Jiao Tong University School of Medicine from December 2015 to December 2020. The patients were divided into two groups, according to primary treatment strategy, which was either conservative treatment or surgical treatment.Results: A total of 162 consecutive patients with acute RCD were enrolled in the study. There was no significant difference in age, sex, history of abdominal surgery, medical co-morbidities, fever, previous history of RCD, treatment success rate and incidence of complications between the conservative and surgery groups. However, the recurrence rate in conservative groups was significantly higher than in surgery groups (16.53% vs 2.44%, P = 0.020). And more frequent bowel movements and previous history of RCD increased the risk of recurrence of acute RCD. Moreover, there was no significant difference in either treatment success rate or the overall recurrence rate between the patients with uncomplicated diverticulitis and patients with complicated diverticulitis.Conclusions: Surgical treatment is also safe and effective for acute RCD. Surgical treatment should mainly be considered for patients with acute RCD with recurrence risk factors (more frequent bowel movements and previous history of RCD) or with complicated acute RCD. [ABSTRACT FROM AUTHOR]

Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated and uncomplicated left-sided colonic diverticulitis. This guideline is based on the current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.Methods: The ACP Clinical Guidelines Committee (CGC) based these recommendations on a systematic review on the role of colonoscopy after acute left-sided colonic diverticulitis and pharmacologic, nonpharmacologic, and elective surgical interventions after initial treatment. The systematic review evaluated outcomes rated by the CGC as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.Recommendation1: ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation; low-certainty evidence).Recommendation2: ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence).Recommendation3: ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences. [ABSTRACT FROM AUTHOR]

Description: The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the diagnosis and management of acute left-sided colonic diverticulitis in adults. This guideline is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.Methods: The ACP Clinical Guidelines Committee (CGC) developed this guideline based on a systematic review on the use of computed tomography (CT) for the diagnosis of acute left-sided colonic diverticulitis and on management via hospitalization, antibiotic use, and interventional percutaneous abscess drainage. The systematic review evaluated outcomes that the CGC rated as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology.Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with suspected or known acute left-sided colonic diverticulitis.Recommendation1: ACP suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis (conditional recommendation; low-certainty evidence).Recommendation2: ACP suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting (conditional recommendation; low-certainty evidence).Recommendation3: ACP suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics (conditional recommendation; low-certainty evidence). [ABSTRACT FROM AUTHOR]

BACKGROUND: We aimed to present cecum pathologies which are the cause of acute abdomen. METHODS: Between January 2015 and June 2019, patients that were operated with the diagnosis of acute abdomen and patients with the primary cecum pathologies were evaluated retrospectively. RESULTS: There were eight patients, five males and three females. The mean age was 7.2±2.9 years. Complaints were abdominal pain and vomiting in all patients. Physical examination was consistent with acute abdomen. In the imaging studies, the preliminary diagnosis was considered as two patients had acute appendicitis, two had invagination (one due to Meckel diverticulum and one with mesenteric cyst), two had ileus, one had perforated appendicitis, and one had cecum diverticulum. In surgery, five patients had cecum mass, one had cecum diverticulitis, one had cecum volvulus, and one had inflamed necrotic cecum. All patients underwent cecum resection and ileocolonic anastomosis. Histopathologic examination was resulted as Burkitt's lymphoma in three patients, cecum diverticulum in two, duplication of cecum in one, tuberculosis of cecum in one, and gangrenous necrosis due to volvulus in one patient. The mean follow-up period was 25 months (2 months--4 years). Follow-up was uneventful. CONCLUSION: Primary cecum pathologies are very rare. This leads to lack of standardization in treatment planning. Considering the patients with malignancy in the series, ileocolonic anastomosis with cecum resection is an adequate and appropriate treatment option in children with primary cecum pathology. [ABSTRACT FROM AUTHOR]

Introduction: Diverticular disease is defined as the presence of an asymptomatic diverticulum in the colon, and an infected diverticulum is called diverticulitis. Among patients with diverticular disease, 10-25% experience diverticulitis at some stage in their lives. This study aimed to evaluate the neutrophil-to-lymphocyte ratio (NLR) determined by dividing the neutrophil value by the lymphocyte value by comparing the stages of the patients according to the Hinchey classification who presented to the emergency department and were diagnosed with acute diverticulitis and to make a decision whether the patient should be treated by hospitalization or in the outpatient clinic. Methods: Patients who were admitted to the İstanbul Training and Research Hospital, between 2015 and 2019 and were diagnosed with acute diverticulitis by abdominal computed tomography were included in the study. Patients aged ≤18 years, pregnant patients, and patients with Crohn's disease, ulcerative colitis, colorectal, and/or anal cancer were excluded from the study. Results: Age, white blood cell count, hemoglobin, hematocrit, platelet, monocyte, granulocyte, neutrophil, NLR, C-reactive protein, and procalcitonin values were compared according to their stage. The neutrophil and NLR values were lower in patients with stage 1 than in those with stages 3 and 4. Moreover, the neutrophil and NLR values were lower in stage 2 than in stage 3. Conclusion: In our study, patients with acute diverticulum with higher NLR levels are more likely to develop complications. The combined use of NLR with physical examination, imaging, and other laboratory tests facilitates the diagnosis of complicated acute diverticulitis. However, further studies should be performed to confirm the utility of the NLR value in clinical practice. [ABSTRACT FROM AUTHOR]

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy. [ABSTRACT FROM AUTHOR]

Copyright of Acibadem Saglik Bilimleri Dergisi is the property of Acibadem University Medical School and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: The difference in outcome between right (RCD) and left colonic diverticulitis (LCD) is not well established. The aim of this study was to analyse the presentation and surgical outcome of RCD versus left-sided disease following emergency surgery.Method: We conducted a retrospective review of patients presenting with acute diverticulitis over a 10-year period from 2004 to 2014 to a tertiary unit. Patient demographics, Hinchey classification, need for emergency surgery, perioperative outcome and recurrence were evaluated.Results: In total 360 patients presented with acute diverticulitis, 218 (61%) were right-sided and 142 (39%) were left-sided. The mean age (57 yrs vs 68 yrs) and median length of stay (4 days vs 5 days) were significantly less in RCD (p < 0.001). The need for emergency surgery was similar between RCD and LCD (30.7% vs 23.2%, p = 0.12). Sixty-seven (31%) patients with RCD required emergency surgery, 42 (62.7%) of these were based on a presumptive diagnosis of appendicitis and underwent laparoscopic appendicectomy only. Operative morbidity (10.4% vs 51.5%, p < 0.001) and mortality were significantly higher in LCD (1.5% v 15.2%, p = 0.007). Subgroup analysis of non-appendicectomy, RCD patients, showed LCD were more likely to require surgery (11.5% vs 23.2%, p = 0.003). There was no difference in recurrence (p = 0.6).Conclusion: Right colonic diverticulitis patients are younger and disease course is more benign compared to LCD. Presentation can be confused with appendicitis without proper imaging. In the rare cases where emergency surgery is required, RCD is associated with a lower operative morbidity and mortality compared to left-sided disease. [ABSTRACT FROM AUTHOR]

Aim: This study assessed the results of conservative and surgical treatment of right colon diverticulitis. Right colon diverticula contain all layers of the colon and are called true diverticula. Perforation of these diverticula is observed less frequently due to their full thickness. Materials and Methods: 150 patients treated for colonic diverticulitis between 2015-2020 were retrospectively screened. Following exclusions, a total of 26 patients data were assessed. The patients were divided into two groups as conservative or surgical treatment. The outcomes for these two groups were compared and analyzed. Results: Most patients in the sample were female (n=18, 69%). The average age was 47 (22-83). Data from the conservative treatment group (n=17, 65%) and the surgical treatment group (n=9, 35%) were examined. Comorbidity, recurrence, and white blood cell count were all greater following conservative treatment (p> 0.05). In the surgical group, two (22% of the group) patients developed wound infections. Patients with fever at admission were in the surgical group (p <0.01). All patients in the conservative group had a Hinchey classifcation of 1a, while those in the surgical group were Hinchey 1a, 1b, and 3 (p <0.05). The median hospital stay was higher for the surgical group (p <0.05). No mortality was observed. Conclusion: Right colon diverticulitis has low complications and it can be treated conservatively. The differential diagnosis of right- sided colonic diverticulitis should be kept in mind when relevant symptoms present to prevent unnecessary surgeries. Surgical treatment is inevitable in instances of recurrent diverticulitis, generalized peritonitis, and suspected malignancy. [ABSTRACT FROM AUTHOR]

Background and Aim: Colonic diverticular bleeding is a common cause of acute lower gastrointestinal bleeding. Endoscopic hemostasis is generally selected as the first‐line treatment; however, a considerable number of patients experience early rebleeding after endoscopic treatment. We investigated the risk factors for early rebleeding after endoscopic treatment. Methods: We retrospectively evaluated the data of 142 consecutive patients who underwent endoscopic treatment (endoscopic clipping or endoscopic band ligation) for colonic diverticular bleeding with stigmata of recent hemorrhage between April 2012 and April 2020. Multivariate logistic regression analysis was conducted to evaluate the statistical relationship between patient characteristics and the incidence of early rebleeding occurring within 30 days after endoscopic treatment. Results: Of 142 patients, early rebleeding was detected in 34 (23.9%) patients. According to univariate analysis, platelet count of <10 × 104/μL, bleeding from the left‐sided colon, and endoscopic clipping usage were associated with early rebleeding (P < 0.05). The subsequent multivariate logistic regression analysis identified bleeding from the left‐sided colon (odds ratio [OR], 4.16; 95% confidence interval [CI], 1.73–10.0; P = 0.001) and endoscopic clipping usage (OR, 2.92; 95% CI, 1.21–7.00; P = 0.017) as the independent risk factors for early rebleeding. Conclusions: Bleeding from the left‐sided colon and endoscopic clipping usage were the risk factors for early rebleeding after endoscopic treatment. Using endoscopic band ligation was associated with a decreased risk for early rebleeding compared with the use of endoscopic clipping, indicating that endoscopic band ligation was a preferable endoscopic modality to prevent early recurrent bleeding. [ABSTRACT FROM AUTHOR]

Background: We hypothesized that a laparoscopic approach to sigmoidectomy for perforated diverticulitis is associated with less morbidity and mortality.Methods: The NSQIP database was used to investigate adult patients who underwent emergent colectomy with end colostomy for perforated diverticulitis. A multivariate analysis using logistic regression was used to compare outcomes of patients by surgical approach.Results: We found a total of 2937 adult patients who underwent emergent colectomy for perforated diverticulitis during 2012-2017. The rate of minimally invasive surgery (MIS) was 11.4% with 38.6% conversion rate to open. The 30-day mortality and morbidity rates were 8.8% and 65.8%, respectively. Following adjustment using a multivariate analysis, the open approach was associated with higher morbidity (67.2% vs 56.8%, AOR: 1.70, P < .01) and mean hospitalization length of patients (13 days vs 10 days, P < .01) compared to the MIS approach. Respiratory complications of ventilator dependency (14.3% vs 6%, AOR: 2.95, P < .01) and unplanned intubation (7.4% vs 2.4%, AOR: 2.14, P = .03) were significantly higher in the open approach. However, patients who underwent the open approach were older (age >70; 33.5% vs 24%, P < .01) with more comorbid conditions such as COPD (10.8% vs 7.2%, P = .04) and CHF (9% vs 3.1%, P < .0).Conclusion: The MIS approach to emergent partial colectomy for perforated diverticulitis is associated with decreased morbidity and hospitalization length of patients. Utilization of the MIS approach for partial colectomy for perforated diverticulitis is 11.4% with a conversion rate of 38.6%. Efforts should be directed toward increasing the utilization of laparoscopic approaches for the surgical treatment of perforated diverticulitis. [ABSTRACT FROM AUTHOR]

Objective: We aimed to determine the frequency, morphological features, differential diagnosis, possible adverse events of inverted colonic diverticulum (ICD), which may be misdiagnosed as polyps. Methods: In all, 810 patients who underwent a colonoscopy between April 2016 and November 2019 were included in the study, and their data were evaluated retrospectively. Colonoscopic procedures were performed at a single center by the same endoscopist. Results: Among all the 810 patients, the prevalence of diverticulum was 29.58% (121/409) in men and 25.19% (n = 101/401) in women, respectively. ICD was observed in 1.73% (n = 14) of all patients, including 11 (78.57%) men (aged 63.2 ± 12.95 years [range 47–90 years]) and three women (60.3 ± 4.04 years [range 58–65 years]). Most (63.16% [12/19]) ICD lesions were localized in the sigmoid colon. And the diagnosis was confirmed by eversion using biopsy forceps in 78.95% of them. One patient developed perforation after polypectomy with hot biopsy forceps and was treated by surgical operation. Conclusions: ICD is a common lesion that may lead to serious adverse events if misdiagnosed as polyps. Differential diagnosis of ICD is crucial during the colonoscopy. [ABSTRACT FROM AUTHOR]

Background Colon interposition is one of the traditional procedures for esophageal reconstruction following corrosive injury. While the colonic conduit has the potential to restore swallowing function in patients, yet the long term complications are not well documented. we, herby, present a case of colon diverticulum in the neck 17 years after bypass surgery. Methods a 22 years old female patient presented with a one year history of gradually progressive grade I dysphagia following a colon bypass surgery performed for esophageal reconstruction for corrosive stricture at the age of 5 years old. Clinical assessment revealed the presence of a swelling on the left side of her neck which increased in size upon swallowing. The patient reported that applying pressure on the swelling was associated with sensation of passage of the food bolus. Endoscopic and Radiological assessment confirmed the presence of a neck diverticulum at the site of the anastomosis. Results Neck exploration was performed. The diverticulum was dissected from the surrounding tissues with particular care to preserve the colon mesentery. The esophago-colic anastomosis was identified. It was found that this anastomosis was performed in an end to side fashion. The diverticulum appeared to be the enlarged side of the colon which was enlarged causing compression on the esophagus (1). This part was resected using a stapler after intraoperative endoscopic assessment (2,3). A second layer of interrupted sutures was performed over the stapled part (4). The postoperative course was uneventful and was associated with improved dysphagia. Conclusion Symptomatic colon diverticulum in the neck is a rare long term complication following colon bypass and esophago-colic anastomosis. Particular care should be made when performing it in an end to side fashion. End to end esophago-colic anastomosis could potentially prevent such complication. [ABSTRACT FROM AUTHOR]

Background: Colonic diverticulitis is one of the most common gastrointestinal pathologies and its prevalence increases with the aging of the population in Western countries. Approximately 15% of patients with Hinchey Ia acute diverticulitis present with concomitant isolated pericolic air bubbles that denote intestinal perforation and thus prompting a more "aggressive" treatment attitude, including emergency surgery, despite the absence of evidence-based indications. This study is trying to delineate whether this approach is justified or whether a conservative treatment would suffice for this group of patients.Materials and Methods: PubMed and Cochrane CENTRAL databases were systematically searched in order to identify all studies that reported the need for emergency surgery and for percutaneous drainage in patients presenting with Hinchey Ia colonic diverticulitis with extraluminal pericolic gas on CT imaging who were initially treated conservatively. The last database search was performed on November 29, 2019 and no language or study type restriction criteria were applied. The Newcastle-Ottawa scale was used to assess the risk of bias of selected studies.Results: Nine observational cohort studies with 411 patients reported the need for emergency surgery, with a pooled rate of 5.1%. Among these studies, four studies comprising 165 patients reported the need for percutaneous drainage separately with a pooled rate of 1.2%.Conclusion: Non-operative management of Hinchey Ia acute diverticulitis with isolated pericolic air is feasible and safe with a success rate of 94.9%. Abscess formation requiring percutaneous drainage is present in only 1.2% of patients, thus rendering the conservative initial treatment of these patients justified. Nevertheless, low quality of included studies indicates further research to validate the outcomes of this review. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Gastrointestinal stromal tumors (GISTs) generally form well-defined mass lesions. However, some cases of the flatly distributed and muscularis propria-replacing GISTs have been reported so far. We experienced an additional case of planar-type GIST of the sigmoid colon accompanied by a diverticulum with perforation. Case presentation: A 68-year-old Japanese male with sudden onset of abdominal pain was clinically diagnosed with gastrointestinal perforation, and an emergency abdominal operation was performed. A diverticulum with rupture was found in the sigmoid colon, but no apparent tumor was observed. Histological examination revealed bland spindle cells flatly proliferating and diffusely replacing the muscularis propria at the diverticular structure. The spindle cells were positive for KIT, DOG1, and CD34. Mutational analysis of the c-kit gene revealed that the lesion had a heterozygous deletion of 2 amino acids at codons 557 and 558 of exon 11. The mutation was not observed in the normal mucosa of the surrounding tissue. Conclusion: We diagnosed this case as an unusual planar-type GIST. Some similar cases have been reported in the sigmoid colon and other sites. We discuss the mechanism of development of the planar-type GISTs associated with the diverticulum. [ABSTRACT FROM AUTHOR]

Background: The impact of cirrhosis on outcomes of acute colonic diverticulitis (ACD) has been studied infrequently. We investigated the effect of cirrhosis on outcomes of surgical patients with ACD treated by either an open or laparoscopic approach.Methods: A cross-sectional study was performed using the Nationwide Inpatient Sample 2012 to 2014. Patients with ACD were stratified into compensated and decompensated cirrhosis for comparisons of demographic characteristics, hospital length of stay, complications, mortality, and cost. Groups were stratified according to surgical treatment: open colectomy and laparoscopic colectomy. A comparative effectiveness analysis of outcomes was performed between the 2 surgical treatments. Univariate comparisons between groups and multivariate regression analysis were performed to identify risk factors for mortality and specific complications.Results: Of 1,172,875 patients hospitalized with the diagnosis of ACD during the study period, 1,145 were cirrhotic. The majority were male (59%). There were 660 compensated cirrhotic patients and 485 decompensated cirrhotic patients and all underwent either open (n = 875) or laparoscopic colectomy (n = 270). Consistently, marked increases in mortality, hospital length of stay, and cost were observed in decompensated cirrhotic patients regardless of the type of treatment. Laparoscopic colectomy was accompanied by shorter hospital length of stay, lower costs, and significantly decreased mortality rate compared with open colectomy in compensated and decompensated cirrhotic patients.Conclusions: The presence of cirrhosis markedly impacts outcomes in patients with ACD, leading to prolonged hospitalization, higher cost, and increased complications and deaths. Laparoscopic colectomy is associated with better outcomes in patients requiring surgical management, including those with decompensated cirrhosis. [ABSTRACT FROM AUTHOR]

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world. [ABSTRACT FROM AUTHOR]

Background: Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach.Methods: The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat).Results: A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group.Conclusions: Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings. [ABSTRACT FROM AUTHOR]

Background: Right-sided colonic diverticulitis (RCD) is an Asian-centric disease. The optimal treatment for acute uncomplicated RCD remains a controversial area. This study aimed to compare the safety and efficacy of laparoscopic diverticulectomy (LD) with non-operative treatment (NT) in patients with uncomplicated RCD.Methods: A single-center, prospective, non-randomized controlled study ran from 2009 to 2017. Patients with first episode of uncomplicated RCD were divided into two treatment arms, LD or NT with bowel rest and broad-spectrum antibiotics, based on their choice. The primary outcome was recurrent diverticulitis during follow-up. Secondary outcomes were treatment success and complications.Results: A total of 155 patients were enrolled, with 81 in the NT arm and 74 in the LD arm. Mean follow-up was 49 months. The treatment success rate for the NT arm was 90.1% and for the LD arm, 86.5% (P = 0.480). There was no significant difference in the complication rate between the LD arm, 12.2% and the NT arm, 8.6% (P = 0.472). LD was better than NT in preventing recurrent diverticulitis. Nine patients in the NT arm and none in the LD arm had recurrence (P = 0.003). The number needed to treat to prevent recurrence was nine.Conclusion: Non-operative management with bowel rest and antibiotics for uncomplicated RCD is safe and effective. Alternatively, LD is also safe and effective, with the added benefit of preventing recurrences. While both treatments could be reasonably offered for uncomplicated RCD, LD is an appealing option when recurrence is a concern. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

After elective sigmoidectomy for diverticulitis, patients may experience persistent abdominal symptoms. This study aimed to determine the incidence and characteristics of persistent symptoms (PSs) and their risk factors in patients who had no reported recurrence after elective sigmoidectomy. Patients who underwent elective sigmoidectomy for diverticulitis from 2002 to 2016 at a tertiary academic colorectal surgery practice were included. After retrospective review of medical records, patients were contacted with a questionnaire to inquire about recurrence of diverticulitis and persistent abdominal symptoms since resection. Outcomes examined were prevalence of and risk factors for PSs after elective sigmoidectomy. Of 662 included patients, 346 completed the questionnaire and had no recurrent diverticulitis. PSs were reported by 43.9 per cent of the patients. The mean follow-up was 87 months. Female gender and preoperative diagnosis of irritable bowel syndrome were independent risk factors for PSs (Relative Risk 1.65, P < 0.001 and Relative Risk 1.41, P = 0.014). Previous IV antibiotics treatment was associated with PSs (P = 0.034) but not with a significant risk factor. As the follow-up interval increased, prevalence of PSs decreased (P = 0.006). More than 40 per cent of patients experienced persistent abdominal symptoms after sigmoidectomy for diverticulitis. Female patients and those with irritable bowel syndrome were at significantly increased risk. [ABSTRACT FROM AUTHOR]

Introduction: Duodenal diverticula are sacciform herniations of the intestinal wall, most commonly acquired and associated with old age. They are mostly located periampulary and although usually asymptomatic, can lead to complications in rare cases, such as obstructive jaundice, but also small bowel obstruction, bleeding or acute diverticulitis. Case Report: An 80-year-old female patient with a history of cardiovascular disease and biliary lithiasis presents with a reoccurrence of cholestatic syndrome. Her history begins in October 2023 when she first presented with abdominal discomfort and unexplained weight loss. At that point, there were signs of cholestasis (hyperbilirubinemia with increased direct bilirubin (BR) of 0,79 mg/dL, increased Alkaline Phosfatase(ALP) of 404 U/L and GammaGT (GGT) of 722 U/L). Cholangio-MRI was performed, revealing dilation of the common bile duct (CBD) of 15 mm and of the intrahepatic bile ducts (IHBD) along with a duodenal periampulary diverticulum of 27 mm in diameter. Unable to reveal any lithiasis or tumoral cause for the obstruction, ERCP was performed which was able to remove a gallstone of approximatively 10 mm in diameter. On second admission in February 2024, the patient had another episode of cholestasis this time with a total BR of 2,95mg/dL and direct BR of 2,2mg/dL and on CT: CBD=12mm in diameter, aerobilia, multiple hypodense hypocaptating nodular lesions (6mm) suggestive of abscesses (some of them with hydroaeric levels) in both hepatic lobes. The case was interpreted as acute cholagitis. Considering the history, an endoscopic ultrasound was performed which revealed the same initial diverticulum extending towards the hepatic hillum and compressing the CBD, which was the most plausible explanation. Further management included antibiotic therapy (Ceftriaxone and Metronidazole), hemocultures (negative) and surgical consultation (which evaluated the patient as unfit for surgical diverticulum resection). Discussions : Periampulary diverticula can predispose to obstructive jaundice either by direct obstruction of the CBD in the absence of lithiasis (a rare clinical entity known as Lemmel's syndrome) or by hindering normal biliary drainage and raising the likelihood for cholelithiasis. Due to the patient's age and limited information about the diverticulum, it is unclear which is the case. Additionally, considering the negative hemocultures (which can also rule out sepsis) and CBD compression, the hepatic abscesses are probably a result of repeated episodes of acute cholangitis. Conclusions: Although rarely symptomatic, duodenal periampulary diverticula can be a cause of gastrointestinal complications to be considered among the list of differential diagnoses. [ABSTRACT FROM AUTHOR]

A 55-year-old woman was admitted to hospital after presenting to the emergency department with erythema and moderate swelling, and tenderness above her left sternoclavicular joint (Figure 1A), which had started 3 days previously. (B) A contrast-enhanced computed tomography scan showed findings typical of diverticulitis, including a fluid-filled false diverticulum (arrow), bowel wall thickening, subcutaneous fat stranding and edema. A computed tomography (CT) scan of the neck showed soft-tissue swelling, thickening of the digestive tract wall and a fluid-filled, edematous outpouching of the digestive tract (Figure 1B). [Extracted from the article]

We then identified the bleeding diverticulum, but were unable to identify the bleeding vessels within the diverticulum because of the severe active bleeding (Fig. Although various endoscopic hemostasis techniques for colonic diverticular bleeding have recently been reported [1], identifying the bleeding diverticulum among other diverticula is difficult [2], and identifying the bleeding vessels within the diverticulum is even more difficult. [Extracted from the article]