Critical Issues on Diverticular Disease

In this session diverse critical issues in diverticular disease were considered, including “In or outpatient management of uncomplicated diverticulitis?”, “Segmental colitis associated with diverticulosis: what is it?”and “Diverticular inflammation is a risk factor for colorectal cancer?”. The conclusions drawn are outlined in the statements but in summary, outpatient management is safe in selected patients, as long as correct diagnosis and stage are assured, and this can allow a cost effective treatment. Non-antibiotic management is also safe but should be confined as an outpatient treatment in carefully selected patients. Segmental colitis associated with diverticulosis (SCAD) is a defined pathological entity (only diagnosed on biopsy) characterized by an inflammatory bowel disease-like pathology, occurring principally in the sigmoid colon, with rectal and right colon sparing. The pathogenesis is unclear but may include a genetic predisposition, microbiome alteration and ischaemia. Treatment can last months, and depends on severity, options include antibiotics, 5 ASA and probiotics for mild cases. Severe disease needs systemic steroids or even anti TNFα treatment. Whether diverticular inflammation is a risk factor for colorectal cancer was debated and the conclusion that within the first eighteen months of diagnosis of diverticular disease associations with cancer are found, likely due to similar symptoms and misclassification of disease. After that time, diverticular disease does not increase the risk of colorectal cancer. Therefore, this is recommended to exclude cancer with imaging and colonoscopy after healing of the first episode of diverticulitis.

P514 Does faecal diversion induce clinical response for Crohn’s disease of the colorectum?

Background Fecal diversion is now selectively used in cases of medically refractory Crohn’s proctocolitis or advanced perianal disease. The aim of this study was to evaluate the rate of, and clinical factors, associated with the clinical response following faecal diversion in CD. Methods A retrospective chart review of adult CD patients undergoing an ileostomy for medically refractory distal disease (proctocolitis, perianal disease, segmental colitis, proctitis) between 2000 and 2019 at two inflammatory bowel disease centres was conducted. The primary outcome was the rate of clinical response; the secondary outcome was to assess factors associated with clinical response to faecal diversion. Results The study cohort of 98 patients had a median age of 40 (range, 19–84) years and included 50 females (51%). Median duration of disease was 15 (1–43) years. Indication for surgery was medically refractory proctocolitis and perianal disease (n = 48;49%), perianal disease alone (n = 34;35%), proctocolitis (n = 8;8%), segmental colitis (n = 5;5%), and proctitis alone (n = 3; 3%). Medications used before surgery included corticosteroids (n = 43;44%), immunomodulators (n = 33;34%) and biologics (n = 52;53%). Biologics used included adalimumab (n = 21), infliximab (n = 10, certolizumab (n = 8), vedolizumab (n = 8) and ustekinumab (n = 5). Only 16 (17%) patients were active smokers. Following ileostomy formation, 32 (33%) patients had a clinical response. The association between patient features and clinical response is shown in Table 1. Clinical response to fecal diversion was significantly decreased in the setting of proctocolitis with perianal disease (p = 0.005) and pre-diversion exposure to biologics (p = 0.04). Conclusion This largest report in the biologic era of faecal diversion for medically refractory CD proctocolitis or perianal disease showed that only 33% of patients achieved a clinical response. Both biologic uses before faecal diversion and diversion for proctocolitis with perianal disease were associated with a significantly lower clinical response.