EP.TU.809Challenges in management of acute diverticulitis within a district general hospital

Aim Incidence of perforated sigmoid diverticular disease is estimated at 3.4 to 4.5 per 100,000. Perforation may be the first manifestation of complicated diverticulitis with a range of 50% to 70%. We aim to review management of systemically unwell patients with acute diverticulitis in a district general hospital against the 2019 NICE guidelines. Methods 29 patients presenting septic with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed over a 6-month period. Results Mean time to antibiotics was 3.96 hours (range 0-23.11). Of the 7 with perforated diverticulitis severity classification included: Hinchey I – n = 1, 3.4%; Hinchey IIa – 5 (17.2%), and; Hinchey IIb – 1 (3.4%). Time to CT abdomen pelvis was 3.38 hours (range 0-16.4 hours). Two pericolic abscesses met NICE drainage criteria at 3.7 cm and 3.9 cm respectively. The 3.7 cm abscess was drained radiologically at 7 days post-admission and was re-admitted 6 days later requiring further radiological drainage. The patient with a 3.9 cm abscess received a Hartmann’s procedure and had multiple re-admissions requiring a hospital stay of 34 days. There was 0% mortality at 30 days. Conclusion Management of acute diverticulitis continues to present a unique challenge. For systemically unwell patients, timely administration of antibiotics within an hour of sepsis recognition is encouraged to optimise outcomes. Timely cross-sectional imaging is pivotal in disease classification and decision-making regarding acute management. Interventional drainage and surgical resection remain important therapeutic strategies for unwell patients with Hinchey grade II diverticulitis.

Incomplete Colonoscopy: Maximizing Completion Rates of Gastroenterologists

BACKGROUND Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear.OBJECTIVES: To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure.METHODS: All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul’s Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively.RESULTS: A total of 90 patients (29 males) with a mean (± SD) age of 58±13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture).CONCLUSION: Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.