doi:10.1111/codi.12449
Original article
Application of a modified Neff classification to patients with uncomplicated diverticulitis L. Mora Lopez*, S. Serra Pla*, X. Serra-Aracil*, E. Ballesteros† and S. Navarro‡ *Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), †Radiodiagnosis Service, Hospital Universitari Parc Tauli (Sabadell) and ‡Chief of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), Sabadell, Spain Received 20 January 2013; accepted 7 April 2013; Accepted Article online 8 October 2013
Abstract Aim Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management. Method All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients.
Introduction Clinically acute diverticulitis (AD) can be catogorized as uncomplicated when the inflammation is localized or as complicated when the inflammation is accompanied by the appearance of a gross perforation, abscess, peritonitis, fistula or stricture [1–3]. Imaging tests are used to confirm the diagnosis of AD [1,4]. Currently, CT is the gold-standard diagnostic option [1,4,5]. Although doubts have been raised about the need for CT in all patients with suspicion of Correspondence to: Laura Mora Lopez, MD, Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli, Parc Tauli s/n, Sabadell (Barcelona) Spain. E-mail: [email protected]
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Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded. Results Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25–90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixtyfour (94%) successfully completed the outpatient treatment protocol; four patients were readmitted. Conclusion Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme. Keywords Acute diverticulitis, Neff’s classification, outpatient What does this paper add to the literature? It describes a modified classification for diverticulitis that allows accurate selection of patients for stage-specific treatment.
uncomplicated AD [6], many authors recommend it as the diagnostic test of choice as it may identify patients at risk of complications that may cause conservative treatment to fail [7–10]. The Hinchey classification has traditionally been used to catogorize diverticulitis severity [11]. However, Hinchey’s predominantly surgical classification (Table 1) may not provide the level of detail necessary to indicate the presence, location and severity of the disease to guide subsequent patient management. Alternative clasifications to that of Hinchey have been described but in general we consider them to be impractical [12–15]. In this study we propose a new classification, based on that of Neff [16], which is based principally on radiological findings obtained with CT. The Neff
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Management of patients with AD after selection using Neff
Table 1 Hinchey classificaton. Hinchey stage Stage Stage Stage Stage
I: localized abscess paracolic II pelvic abscess III: purulent peritonitis IV: feculent peritonitis
classification consists of five stages, ranging from radiological diagnosis of uncomplicated AD (Stage 0) to pneumoperitoneum with abundant free liquid (Stage IV). Our modification adds a substage – Ia – in which a localized peri-colic pneumoperitoneum without abscess is observed (Table 2, Fig. 1). The aims of this study were therefore to describe and apply a modified Neff (mNeff) classification of AD based on CT findings and to assess the use of this classification for assigning patients to an outpatient treatment programme for uncomplicated AD.
Method All patients consulting the Emergency Service at our 800-bed university hospital with clinical signs of suspected AD (abdominal pain located in the left iliac fossa, fever, peritoneal irritation and/or leucocytosis) were included in the study. All patients underwent abdominal CT, reported by the duty radiologist to confirm the diagnosis. The mNeff classification (Table 2) was applied to divide patients according to the type of AD. The groups were uncomplicated, locally complicated, pelvic abscess or distant abscess. All patients were administered antibiotics suitable for treatment of Gramnegative bacilli and anaerobes (according to a protocol
Table 2 Modified version of the Neff classification (mNeff). mNeff system Stage 0: uncomplicated diverticulitis. Diverticula, thickening of the wall, increased density of the pericolic fat Stage I: locally complicated diverticulitis Stage Ia: localized pneumoperitoneum in the form of air bubbles Stage Ib: abscess (< 4 cm) Stage II: complicated diverticulitis with pelvic abscess. Abscess > 4 cm in pelvis Stage III: complicated diverticulitis with distant abscess. Abscess in abdominal cavity (outside pelvis) Stage IV: complicated diverticulitis with other distant complications. Abundant pneumoperitoneum and/or intraabdominal free liquid
Figure 1 Locally complicated diverticulitis. Localized pneumoperitoneum in the form of air bubbles is indicated with an arrow.
drawn up in agreement with the Infectious Disease Service at our centre, following recommendations[3]), at doses intended to favour compliance and also taking economic factors into account. Patients with uncomplicated AD (Stage 0) were managed as outpatients unless they had one of the comorbidity factors or one of the systemic inflammatory response syndrome (SIRS) criteria [17] specified in Table 3. Patients with previous episodes of AD were also excluded. Stage 0 patients were administered their first dose of amoxicillin/clavulanic acid (1 g) intravenously. If the patient was comfortable enough and able to tolerate liquids they were transferred to a home-care programme and treated with amoxicillin/clavulanic acid
Table 3 Exclusion criteria for outpatient treatment. Comorbidity and risk factors Previous episodes Diabetes mellitus Alcoholism Heart disease Liver disease Neoplastic disease Inflammatory intestinal disease Previous hospitalization (in the last 30 days) Age > 80 years Lack of family support SIRS criteria Temperature < 36°C or > 38°C Heart rate > 909′ Breathing rate > 209′or pCO2 < 32 Haemogram: > 12 000 leucocytes, < 4000 leucocytes or > 10% bands SIRS, systemic inflammatory response syndrome.
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875/125 mg/8 h (orally) for 10 days (or with ciprofluoxacin 500 mg/12 h orally and metronidazole 500 mg/8 h orally if the patient was allergic to amoxicillin/clavulanic acid). A liquid diet and analgesics were recommended for 48 h; subsequently, the patients were asked to consume a low-residue diet. Stage Ia patients were admitted for 48 h and treated with intravenous ceftriaxone 1 g/12 h and metronidazole 500 mg/8 h. After 48 h a peripheral catheter line was inserted and the patient was discharged to the outpatient programme. Treatment was continued with intravenous ceftriaxone 2 g/24 h and oral metronidazole 500 mg/8 h, as an outpatient for ten days if they did not present with any of the exclusion criteria (Table 3). All Stage 0 and Stage Ia patients were controlled by the nonhospital care service. The nonhospital care service removed the peripherally inserted central catheter (PICC) at the end of treatment. Stage Ib, II, III or IV patients, or patients with exclusion criteria to outpatient treatment, were hospitalized, treated with intravenous antibiotics (ceftriaxone 1 g/12 h intravenously and metronidazole 500 mg/ 8 h intravenously) for 7–10 days, kept nil by mouth and received analgesia. More aggressive measures were added, if necessary, during evolution, such as anti-emetics, intravenous fluid and electrolyte replacement, percutaneous drainage or surgery. Patients in both groups treated as outpatients (i.e. Stages 0 and Ia) were reviewed in the surgical outpatient clinic after 2 weeks. In addition to the clinical examination, patients completed a survey regarding their satisfaction with the care received. One month after diagnosis, all patients underwent colon CT or fibrocolonoscopy (FCS) [18] to confirm the diagnosis of AD and/or to detect other concomitant pathologies [19,20]. The protocol was approved by our hospital’s Ethical and Research Committee.
receive outpatient treatment. Of the 81 rejected, 35 presented SIRS (seven with temperature > 38° and 14 with leucocytosis > 12 000) or comorbidity (14 patients); 24 presented second episodes of AD; 14 had poor initial evolution and poor pain control; and eight had AD in an unusual location (the right colon (n = 3), the transverse colon (n = 2), the splenic flexure (n = 2) and the jejunum (n = 1)). These 81 patients were admitted to hospital: three required drainage of collections appearing during follow up and five were readmitted to the specialized ward: three were managed conservatively, one required surgery (Hartmann’s procedure) and the fifth required radiological drainage. The rest responded favourably to 7–10 days of intravenous antibiotic treatment and were then discharged. The 68 patients who met the selection criteria were assigned to the home-care programme. Only four (5.9%) returned to the Emergency Service, all for poor pain control after which readmission was uneventful, with progressive control of pain and tolerance of food. Sixty-four (94%) patients followed the outpatient programme without incident (Fig. 2). Of the 21 patients with acute AD of Stage Ia, seven had exclusion criteria. All of the remaining 14 were discharged after 48 h and assigned to outpatient treatment (intravenous ceftriaxone with metronidazole 500 mg/8 h orally for 10 days) with good subsequent evolution. Of the other patients admitted with AD of different stages (Ib, II, III and IV), three required percutaneous drainage and 19 required surgery (only 9.3% of all patients with acute AD). Subgroup analysis showed that 23 patients were > 80 years of age: 13 were Stage 0, five were Stage II and five were Stage IV. Seventeen patients gave a good response to conservative treatment, whereas three required percutaneous drainage (one Stage II and two Stage IV patients) and three required surgery (one Stage Ib, one Stage II and one Stage IV patient).
Results Between February 2010 and January 2013, 205 patients were diagnosed with AD at our centre. One-hundred and twenty-five were male and 80 were female, and their mean age was 59 years (range, 25–90 years). Of the 205 patients, 127 (62%) were Stage 0, 21 (10%) were Stage Ia, 17 (8%) were Stage Ib, 19 (9%) were Stage II, two (1%) were Stage III and 19 (10%) were Stage IV, according to the mNeff classification. There were 149 patients (128 mNeff Stage 0 and 21 mNeff Stage Ia) who were candidates for outpatient treatment on the basis of radiological criteria. After applying the clinical selection criteria (comorbidity and SIRS), only 68 patients could be assigned to
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Discussion The management of AD has become increasingly conservative. The Hinchey classification has traditionally been used to assess severity but is only useful for the minority of patients who undergo surgery. Classifications such as those given by Kaiser [12], Kohler [13], Sher [14] and Wasvary [15] merely add small details to the Hinchey system based on the diagnosis by CT. Ambrosetti’s classification of AD [9] is widely used but it only distinguishes between mild and severe cases: cases presenting thickening of the colon wall and rarefaction of the pericolic fat are defined as mild, and those presenting with collections, extraluminal air and/or ex-
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traluminal contrast are defined as severe. The new nonsurgical classification of AD we describe can be applied to most cases of diverticulitis diagnosed at hospital emergency services. We believe that a CT scan is necessary in all patients with suspected diverticulitis in order to confirm the diagnosis. In spite of its cost and high level of radiation, we feel that its use is justified by its ability to identify patients who can be safely assigned to receive home-care treatment and also because it allows early diagnosis of complicated cases requiring percutaneous drainage or surgery. We believed that the optimal classification system for AD would be radiology based because abdominal CT is the gold standard in the diagnosis of AD and radiological findings correlate adequately with the prognosis of each type of the condition [8,9]. We used the Neff classification, incorporating a substage – Ia – to distinguish diverticulitis with localized pneumoperitoneum, as described above. We believe that our mNeff system improves on the Hinchey classification by including
Stages 0 and 1a, which the results of our study demonstrate are the most prevalent stage at which AD presents. The Hinchey classification classifies abscesses according to location rather than to size. The mNeff system distinguishes between abscesses < 4 cm in diameter (which can be treated conservatively) and those with a diameter of ≥ 4 cm (which will require drainage). Hinchey Stages III and IV are included in mNeff Stage IV, which also includes the presence of abundant pneumoperitoneum. This mNeff classification is easy to use and can be applied by all health staff involved in the diagnosis and treatment of patients with AD, provided that their unit has access to emergency abdominal CT. We believe that the main improvement of the mNeff classification over other classifications, based on CT findings, is the introduction of Stage Ia (localized pneumoperitoneum). This allows the creation of a subgroup of patients who are likely to have a favourable prognosis and who can be included in the mild AD group and managed accordingly.
205 patients diagnosed with AD 57 patients Stage Ib or more (17 Stage Ib, 19 Stage II, 2 Stage III and 19 Stage IV)
149 patients Stage 0 or Ia (128 Stage 0; 21 Stage Ia)
81 patients with exclusion criteria (comorbidities, prior episodes, pain, etc.) 74 Stage 0; 7 Stage Ia
68 with uncomplicated AD; discharged from hospital on outpatient programme 54 Stage 0; 14 Stage Ia
4 patients returned to emergency service for poor pain control at home (Stage 0)
64 patients followed outpatient program without incident ( 50 Stage 0; 14 Stage Ia) Figure 2 Flow chart diagram of the management of patients presenting with acute diverticulitis (AD).
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Once a patient with uncomplicated AD is able to accept oral antibiotic treatment [21], outpatient treatment may be a safe therapeutic alternative [10,22]. Many studies have been published on the home treatment for uncomplicated AD. The first was a prospective Japanese study [5], in which 68 of 70 patients with uncomplicated AD were treated successfully with oral antibiotics at home. Other authors have found similar results, including one 693-patient study which randomized two groups to intravenous in-hospital treatment vs oral treatment at home [23], albeit with a retrospective observational design. Our study had similar success with outpatient management of uncomplicated AD, with 94% of patients selected for the outpatient programme successfully managed without readmission. The present study has several limitations. The strict selection criteria for outpatient management reduced the number of patients who were tretaed according to the study protocol and this may have had an impact on our results. The large number of patients excluded weakens the study and limits the clinical application of this study to all patients with mNeff Stage 0 and Stage 1a. Whilst this study has shown that the mNeff classification can provide radiological criteria by which patients can be identified for outpatient management, the high number of patients excluded from outpatient management owing to medical comorbidity or SIRS exclusion criteria suggests that an objective clinical prognistic marker is also required to maximize the number of patients who can be managed without hospitalization. Several studies have attempted to identify a marker of this kind, although so far without success [24–27]. Another exclusion criterion was those patients who presented with a second episode of AD. Since completion of this pilot study we have begun a second study in which patients with a previous history of AD are also being managed in the outpatient setting, as we believe that there should be no difference in the evolution of the disease in this patient group. This study has shown that the majority of patients with AD present with uncomplicated clinical profiles that are difficult to classify using the Hinchey staging system. Our mNeff system allows a more accurate definition of cases of AD, especially the milder forms, and can be used to establish specific protocols of treatment for each of the stages. In uncomplicated AD, outpatient treatment may be a safe approach in selected patients.
Acknowledgements We thank all the members of the Radiodiagnosis Service for their help in applying the new classification; the members of the Surgery Service, especially Dr Hidalgo
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and Dr Canovas of the Emergency Service; Dr Sola and the Home care programme team for their participation in the new protocol; and the members of the Coloproctology Unit at the Surgery Service, Dr Alcantara, Dr Ayguavives, Dr Bombardo and Dr Caro for their participation in this study. We thank Michael Maudsley for help with the English.
Author contributions L. Mora Lopez, Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data. Drafting the article; S. Serra Pla, Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data. Drafting the article; X. Serra Aracil, Substantial contributions to conception and design. Revising the article critically for important intellectual content; E. Ballesteros, Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; S. Navvarro, Revising the article critically for important intellectual content.
References 1 Garcia-Domingo MI, Munoz-Duyos A. Infecciones quirurgicas –Diverticulitis. Guias clínicas de la Asociaci on Espa~ nola de Cirujanos. Cirugía colorrectal 2006; 11: 225– 37. Ediciones Aran S.A. 2 Schug-Pass C, Geers P, Hugel O. Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis 2010; 25: 751–9. Epub 2010 Feb 6. 3 Jacobs DO. Diverticulitis. N Engl J Med 2007; 357: 2057–66 4 Al-Sahaf O, Al-Azawi D, Fauzi MZ. Early discharge policy of patients with acute colonic diverticulitis following initial CT scan. Int J Colorectal Dis 2008; 23: 817–20. 5 Ridgway PF, Latif A, Shabbir J. Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis 2009; 11: 941–6. 6 Hogan A, Winter D. Management of acute diverticulitis: is less more? Dis Colon Rectum 2011; 54: 126–8. 7 Etzioni DA, Chiu VY, Cannom RR. Outpatient treatment of acute diverticulitis: rates and predictos of failure. Dis Colon Rectum 2010; 53: 861–5. 8 Poletti PA, Platon A, Rutschmann O. Acute left colonic diverticulitis. AJR 2004; 182: 1159–65. 9 Ambrosetti P, Grossholz M, Becker C. Computed tomography in acute left colonic diverticulitis. Br J Surg 1997; 84: 532–4. 10 Biondo S, Lopez Borao J, Millan M. Current Status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis 2011; 14: eI–eII
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11 Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12: 85–109. 12 Kaiser AM, Jiang JK, Lake JP. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroent 2005; 100: 910–7. 13 Kohler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The scientific committee of the european association for endoscopic surgery. Surg Endosc 1999; 13: 430–6. 14 Sher ME, Agachan F, Bortul M. Laparoscopic surgery for diverticulitis. Surg Endosc 1997; 11: 264–7. 15 Wasvary H, Turfah F, Kadro O. Same hospitalization resection for acute diverticulitis. Am Surg 1999; 65: 632–5; discussion 636 16 Neff CC, van Sonnenberg E. CT of diverticulitis: diagnosis and treatment. Radiol Clin North Am 1989; 27: 743–52. 17 Rangel-Frausto MS, Pittet D, Costigan M. The natural history of the systemic inflammatory response syndrome (SIRS) a prospective study. JAMA 1995; 273: 117–23. 18 Sabanli M, Balasingam A, Bailey W. Computed tomographic colonography in the diagnosis of colorectal cancer. Br J Surg 2010; 97: 1291–4. 19 Lahat A, Yanai H, Sakhnini E. Role of colonoscopy in patients with persistent acute diverticulitis. World J Gastroenterol 2008; 14: 2763–6. 20 Westwood DA, Eglinton TW, Frizelle FA. Routine colonoscopy following acute uncomplicated diverticulitis. Br J Surg 2011; 98: 1630–4.
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21 Ribas Y, Bombardo J, Aguilar F. Prospective Randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicilin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Colorectal Dis 2010; 25: 1363– 70. 22 Friend K, Mills AM. Is outpatient oral antibiotic therapy safe and effective for the treatment of acute uncomplicated diverticulitis? Ann Emerg Med 2011; 57: 600–2. 23 Martin Gil J, Serralta de Colsa D, Garcia Martin A. Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda. Gastroenterol Hepatol 2009; 32: 83–7. 24 Van de Wall BJM, Draaisma WA, van der Kaaij RT, Consten ECJ, Wiezer MJ, Broeders IAMJ. The value of inflammation markers and body temperature in aucte diverticulitis. Colorectal Dis 2013; 15: 621–6. 25 Kaser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA. Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. World J Surg 2010; 34: 2717–22 26 Lameris W, van Randen A, van Gulik THM et al. A clinical decision rule to establish the diagnosis fo acute diverticulitis at the emergency department. Dis Colon Rectum 2010; 53: 896–904 27 Tursi A, Elisei W, Brandimarte G, Giorgetti GM, Aiello F. Predictive value of serologic markers of degree of histologic damage in acute uncomplicated colonic diverticulitis. J Clin Gastroenterol 2010; 44: 702–6
Editor’s choice The management of sigmoid diverticulitis is clearly evolving towards a more conservative approach. It is remarkable that this change has not been driven by large RCTs but rather by audit driven surgical awareness of weighing operative risk and outcome against the long term risks of recurrent diverticulitis and associated diminished quality of life. New questions arise and whether it is safe to treat patients with uncomplicated sigmoid diverticulitis in an out-patient setting is one of them. The present article attempts to answer this question and in doing so also addresses the associated problem of identifying patients with uncomplicated diverticulitis. Using CT scanning in all patients the authors have modified the Neff score. Patients with
doi:10.1111/codi.12461
signs of microperforation, localised free air but no abscess or free fluid, have been classified 1a and deemed suitable for out-patient management. Patients with significant co-morbidity and recurrent diverticulitis were excluded leaving 1 in 3 patients for out-patient management which was successful in well over 90% of these cases. This paper is interesting because it offers us a modified way of classifying patients with uncomplicated diverticulitis as well as excellent data on outpatient management in a well-defined and stratified group of patients.
Alexander Engel Editor, Colorectal Disease
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Original article
Application of a modified Neff classification to patients with uncomplicated diverticulitis L. Mora Lopez*, S. Serra Pla*, X. Serra-Aracil*, E. Ballesteros† and S. Navarro‡ *Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), †Radiodiagnosis Service, Hospital Universitari Parc Tauli (Sabadell) and ‡Chief of General and Digestive Surgery Service, Hospital Universitari Parc Tauli (Sabadell), Sabadell, Spain Received 20 January 2013; accepted 7 April 2013; Accepted Article online 8 October 2013
Abstract Aim Severity of acute diverticulitis (AD) has traditionally been assessed using the Hinchey classification; however, this classification is predominantly a surgical one. The Neff classification provides an alternative classification based on CT findings. The aim of this study was to evaluate a modification of the Neff classification to select patients presenting with early-stage AD to receive outpatient management. Method All patients with AD, presenting to a single unit, were prospectively studied. All patients underwent emergency abdominal CT and were assigned a Neff stage, including a modification (mNeff) to Neff Stage I. The Neff stages used were: Stage 0, uncomplicated diverticulitis; Diverticula, thickening of the wall, increased density of the pericolic fat; Stage I, locally complicated (our modification included substages Ia (localized pneumoperitoneum in the form of air bubbles) and Ib (local abscess); Stage II, complicated with pelvic abscess; Stage III, complicated with distant abscess; and Stage IV, complicated with other distant complications. Patients who presented with Stage 0 or Stage Ia were selectively managed as outpatients.
Introduction Clinically acute diverticulitis (AD) can be catogorized as uncomplicated when the inflammation is localized or as complicated when the inflammation is accompanied by the appearance of a gross perforation, abscess, peritonitis, fistula or stricture [1–3]. Imaging tests are used to confirm the diagnosis of AD [1,4]. Currently, CT is the gold-standard diagnostic option [1,4,5]. Although doubts have been raised about the need for CT in all patients with suspicion of Correspondence to: Laura Mora Lopez, MD, Coloproctology Unit of General and Digestive Surgery Service, Hospital Universitari Parc Tauli, Parc Tauli s/n, Sabadell (Barcelona) Spain. E-mail: [email protected]
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Patients with comorbidity or the presence of the systemic inflammatory response syndrome (SIRS) were excluded. Results Between February 2010 and January 2013, 205 patients (mean age 59 years; age range 25–90 years) presented with AD. One-hundred and forty-nine met the radiological criteria for potential outpatient treatment. After applying the exclusion criteria, 68 were eventually assigned to an outpatient programme. Sixtyfour (94%) successfully completed the outpatient treatment protocol; four patients were readmitted. Conclusion Our mNeff classification allowed selected patients with AD to be successfully managed in an outpatient programme. Keywords Acute diverticulitis, Neff’s classification, outpatient What does this paper add to the literature? It describes a modified classification for diverticulitis that allows accurate selection of patients for stage-specific treatment.
uncomplicated AD [6], many authors recommend it as the diagnostic test of choice as it may identify patients at risk of complications that may cause conservative treatment to fail [7–10]. The Hinchey classification has traditionally been used to catogorize diverticulitis severity [11]. However, Hinchey’s predominantly surgical classification (Table 1) may not provide the level of detail necessary to indicate the presence, location and severity of the disease to guide subsequent patient management. Alternative clasifications to that of Hinchey have been described but in general we consider them to be impractical [12–15]. In this study we propose a new classification, based on that of Neff [16], which is based principally on radiological findings obtained with CT. The Neff
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Management of patients with AD after selection using Neff
Table 1 Hinchey classificaton. Hinchey stage Stage Stage Stage Stage
I: localized abscess paracolic II pelvic abscess III: purulent peritonitis IV: feculent peritonitis
classification consists of five stages, ranging from radiological diagnosis of uncomplicated AD (Stage 0) to pneumoperitoneum with abundant free liquid (Stage IV). Our modification adds a substage – Ia – in which a localized peri-colic pneumoperitoneum without abscess is observed (Table 2, Fig. 1). The aims of this study were therefore to describe and apply a modified Neff (mNeff) classification of AD based on CT findings and to assess the use of this classification for assigning patients to an outpatient treatment programme for uncomplicated AD.
Method All patients consulting the Emergency Service at our 800-bed university hospital with clinical signs of suspected AD (abdominal pain located in the left iliac fossa, fever, peritoneal irritation and/or leucocytosis) were included in the study. All patients underwent abdominal CT, reported by the duty radiologist to confirm the diagnosis. The mNeff classification (Table 2) was applied to divide patients according to the type of AD. The groups were uncomplicated, locally complicated, pelvic abscess or distant abscess. All patients were administered antibiotics suitable for treatment of Gramnegative bacilli and anaerobes (according to a protocol
Table 2 Modified version of the Neff classification (mNeff). mNeff system Stage 0: uncomplicated diverticulitis. Diverticula, thickening of the wall, increased density of the pericolic fat Stage I: locally complicated diverticulitis Stage Ia: localized pneumoperitoneum in the form of air bubbles Stage Ib: abscess (< 4 cm) Stage II: complicated diverticulitis with pelvic abscess. Abscess > 4 cm in pelvis Stage III: complicated diverticulitis with distant abscess. Abscess in abdominal cavity (outside pelvis) Stage IV: complicated diverticulitis with other distant complications. Abundant pneumoperitoneum and/or intraabdominal free liquid
Figure 1 Locally complicated diverticulitis. Localized pneumoperitoneum in the form of air bubbles is indicated with an arrow.
drawn up in agreement with the Infectious Disease Service at our centre, following recommendations[3]), at doses intended to favour compliance and also taking economic factors into account. Patients with uncomplicated AD (Stage 0) were managed as outpatients unless they had one of the comorbidity factors or one of the systemic inflammatory response syndrome (SIRS) criteria [17] specified in Table 3. Patients with previous episodes of AD were also excluded. Stage 0 patients were administered their first dose of amoxicillin/clavulanic acid (1 g) intravenously. If the patient was comfortable enough and able to tolerate liquids they were transferred to a home-care programme and treated with amoxicillin/clavulanic acid
Table 3 Exclusion criteria for outpatient treatment. Comorbidity and risk factors Previous episodes Diabetes mellitus Alcoholism Heart disease Liver disease Neoplastic disease Inflammatory intestinal disease Previous hospitalization (in the last 30 days) Age > 80 years Lack of family support SIRS criteria Temperature < 36°C or > 38°C Heart rate > 909′ Breathing rate > 209′or pCO2 < 32 Haemogram: > 12 000 leucocytes, < 4000 leucocytes or > 10% bands SIRS, systemic inflammatory response syndrome.
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875/125 mg/8 h (orally) for 10 days (or with ciprofluoxacin 500 mg/12 h orally and metronidazole 500 mg/8 h orally if the patient was allergic to amoxicillin/clavulanic acid). A liquid diet and analgesics were recommended for 48 h; subsequently, the patients were asked to consume a low-residue diet. Stage Ia patients were admitted for 48 h and treated with intravenous ceftriaxone 1 g/12 h and metronidazole 500 mg/8 h. After 48 h a peripheral catheter line was inserted and the patient was discharged to the outpatient programme. Treatment was continued with intravenous ceftriaxone 2 g/24 h and oral metronidazole 500 mg/8 h, as an outpatient for ten days if they did not present with any of the exclusion criteria (Table 3). All Stage 0 and Stage Ia patients were controlled by the nonhospital care service. The nonhospital care service removed the peripherally inserted central catheter (PICC) at the end of treatment. Stage Ib, II, III or IV patients, or patients with exclusion criteria to outpatient treatment, were hospitalized, treated with intravenous antibiotics (ceftriaxone 1 g/12 h intravenously and metronidazole 500 mg/ 8 h intravenously) for 7–10 days, kept nil by mouth and received analgesia. More aggressive measures were added, if necessary, during evolution, such as anti-emetics, intravenous fluid and electrolyte replacement, percutaneous drainage or surgery. Patients in both groups treated as outpatients (i.e. Stages 0 and Ia) were reviewed in the surgical outpatient clinic after 2 weeks. In addition to the clinical examination, patients completed a survey regarding their satisfaction with the care received. One month after diagnosis, all patients underwent colon CT or fibrocolonoscopy (FCS) [18] to confirm the diagnosis of AD and/or to detect other concomitant pathologies [19,20]. The protocol was approved by our hospital’s Ethical and Research Committee.
receive outpatient treatment. Of the 81 rejected, 35 presented SIRS (seven with temperature > 38° and 14 with leucocytosis > 12 000) or comorbidity (14 patients); 24 presented second episodes of AD; 14 had poor initial evolution and poor pain control; and eight had AD in an unusual location (the right colon (n = 3), the transverse colon (n = 2), the splenic flexure (n = 2) and the jejunum (n = 1)). These 81 patients were admitted to hospital: three required drainage of collections appearing during follow up and five were readmitted to the specialized ward: three were managed conservatively, one required surgery (Hartmann’s procedure) and the fifth required radiological drainage. The rest responded favourably to 7–10 days of intravenous antibiotic treatment and were then discharged. The 68 patients who met the selection criteria were assigned to the home-care programme. Only four (5.9%) returned to the Emergency Service, all for poor pain control after which readmission was uneventful, with progressive control of pain and tolerance of food. Sixty-four (94%) patients followed the outpatient programme without incident (Fig. 2). Of the 21 patients with acute AD of Stage Ia, seven had exclusion criteria. All of the remaining 14 were discharged after 48 h and assigned to outpatient treatment (intravenous ceftriaxone with metronidazole 500 mg/8 h orally for 10 days) with good subsequent evolution. Of the other patients admitted with AD of different stages (Ib, II, III and IV), three required percutaneous drainage and 19 required surgery (only 9.3% of all patients with acute AD). Subgroup analysis showed that 23 patients were > 80 years of age: 13 were Stage 0, five were Stage II and five were Stage IV. Seventeen patients gave a good response to conservative treatment, whereas three required percutaneous drainage (one Stage II and two Stage IV patients) and three required surgery (one Stage Ib, one Stage II and one Stage IV patient).
Results Between February 2010 and January 2013, 205 patients were diagnosed with AD at our centre. One-hundred and twenty-five were male and 80 were female, and their mean age was 59 years (range, 25–90 years). Of the 205 patients, 127 (62%) were Stage 0, 21 (10%) were Stage Ia, 17 (8%) were Stage Ib, 19 (9%) were Stage II, two (1%) were Stage III and 19 (10%) were Stage IV, according to the mNeff classification. There were 149 patients (128 mNeff Stage 0 and 21 mNeff Stage Ia) who were candidates for outpatient treatment on the basis of radiological criteria. After applying the clinical selection criteria (comorbidity and SIRS), only 68 patients could be assigned to
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Discussion The management of AD has become increasingly conservative. The Hinchey classification has traditionally been used to assess severity but is only useful for the minority of patients who undergo surgery. Classifications such as those given by Kaiser [12], Kohler [13], Sher [14] and Wasvary [15] merely add small details to the Hinchey system based on the diagnosis by CT. Ambrosetti’s classification of AD [9] is widely used but it only distinguishes between mild and severe cases: cases presenting thickening of the colon wall and rarefaction of the pericolic fat are defined as mild, and those presenting with collections, extraluminal air and/or ex-
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Management of patients with AD after selection using Neff
traluminal contrast are defined as severe. The new nonsurgical classification of AD we describe can be applied to most cases of diverticulitis diagnosed at hospital emergency services. We believe that a CT scan is necessary in all patients with suspected diverticulitis in order to confirm the diagnosis. In spite of its cost and high level of radiation, we feel that its use is justified by its ability to identify patients who can be safely assigned to receive home-care treatment and also because it allows early diagnosis of complicated cases requiring percutaneous drainage or surgery. We believed that the optimal classification system for AD would be radiology based because abdominal CT is the gold standard in the diagnosis of AD and radiological findings correlate adequately with the prognosis of each type of the condition [8,9]. We used the Neff classification, incorporating a substage – Ia – to distinguish diverticulitis with localized pneumoperitoneum, as described above. We believe that our mNeff system improves on the Hinchey classification by including
Stages 0 and 1a, which the results of our study demonstrate are the most prevalent stage at which AD presents. The Hinchey classification classifies abscesses according to location rather than to size. The mNeff system distinguishes between abscesses < 4 cm in diameter (which can be treated conservatively) and those with a diameter of ≥ 4 cm (which will require drainage). Hinchey Stages III and IV are included in mNeff Stage IV, which also includes the presence of abundant pneumoperitoneum. This mNeff classification is easy to use and can be applied by all health staff involved in the diagnosis and treatment of patients with AD, provided that their unit has access to emergency abdominal CT. We believe that the main improvement of the mNeff classification over other classifications, based on CT findings, is the introduction of Stage Ia (localized pneumoperitoneum). This allows the creation of a subgroup of patients who are likely to have a favourable prognosis and who can be included in the mild AD group and managed accordingly.
205 patients diagnosed with AD 57 patients Stage Ib or more (17 Stage Ib, 19 Stage II, 2 Stage III and 19 Stage IV)
149 patients Stage 0 or Ia (128 Stage 0; 21 Stage Ia)
81 patients with exclusion criteria (comorbidities, prior episodes, pain, etc.) 74 Stage 0; 7 Stage Ia
68 with uncomplicated AD; discharged from hospital on outpatient programme 54 Stage 0; 14 Stage Ia
4 patients returned to emergency service for poor pain control at home (Stage 0)
64 patients followed outpatient program without incident ( 50 Stage 0; 14 Stage Ia) Figure 2 Flow chart diagram of the management of patients presenting with acute diverticulitis (AD).
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Once a patient with uncomplicated AD is able to accept oral antibiotic treatment [21], outpatient treatment may be a safe therapeutic alternative [10,22]. Many studies have been published on the home treatment for uncomplicated AD. The first was a prospective Japanese study [5], in which 68 of 70 patients with uncomplicated AD were treated successfully with oral antibiotics at home. Other authors have found similar results, including one 693-patient study which randomized two groups to intravenous in-hospital treatment vs oral treatment at home [23], albeit with a retrospective observational design. Our study had similar success with outpatient management of uncomplicated AD, with 94% of patients selected for the outpatient programme successfully managed without readmission. The present study has several limitations. The strict selection criteria for outpatient management reduced the number of patients who were tretaed according to the study protocol and this may have had an impact on our results. The large number of patients excluded weakens the study and limits the clinical application of this study to all patients with mNeff Stage 0 and Stage 1a. Whilst this study has shown that the mNeff classification can provide radiological criteria by which patients can be identified for outpatient management, the high number of patients excluded from outpatient management owing to medical comorbidity or SIRS exclusion criteria suggests that an objective clinical prognistic marker is also required to maximize the number of patients who can be managed without hospitalization. Several studies have attempted to identify a marker of this kind, although so far without success [24–27]. Another exclusion criterion was those patients who presented with a second episode of AD. Since completion of this pilot study we have begun a second study in which patients with a previous history of AD are also being managed in the outpatient setting, as we believe that there should be no difference in the evolution of the disease in this patient group. This study has shown that the majority of patients with AD present with uncomplicated clinical profiles that are difficult to classify using the Hinchey staging system. Our mNeff system allows a more accurate definition of cases of AD, especially the milder forms, and can be used to establish specific protocols of treatment for each of the stages. In uncomplicated AD, outpatient treatment may be a safe approach in selected patients.
Acknowledgements We thank all the members of the Radiodiagnosis Service for their help in applying the new classification; the members of the Surgery Service, especially Dr Hidalgo
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and Dr Canovas of the Emergency Service; Dr Sola and the Home care programme team for their participation in the new protocol; and the members of the Coloproctology Unit at the Surgery Service, Dr Alcantara, Dr Ayguavives, Dr Bombardo and Dr Caro for their participation in this study. We thank Michael Maudsley for help with the English.
Author contributions L. Mora Lopez, Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data. Drafting the article; S. Serra Pla, Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data. Drafting the article; X. Serra Aracil, Substantial contributions to conception and design. Revising the article critically for important intellectual content; E. Ballesteros, Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; S. Navvarro, Revising the article critically for important intellectual content.
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21 Ribas Y, Bombardo J, Aguilar F. Prospective Randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicilin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Colorectal Dis 2010; 25: 1363– 70. 22 Friend K, Mills AM. Is outpatient oral antibiotic therapy safe and effective for the treatment of acute uncomplicated diverticulitis? Ann Emerg Med 2011; 57: 600–2. 23 Martin Gil J, Serralta de Colsa D, Garcia Martin A. Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda. Gastroenterol Hepatol 2009; 32: 83–7. 24 Van de Wall BJM, Draaisma WA, van der Kaaij RT, Consten ECJ, Wiezer MJ, Broeders IAMJ. The value of inflammation markers and body temperature in aucte diverticulitis. Colorectal Dis 2013; 15: 621–6. 25 Kaser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA. Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. World J Surg 2010; 34: 2717–22 26 Lameris W, van Randen A, van Gulik THM et al. A clinical decision rule to establish the diagnosis fo acute diverticulitis at the emergency department. Dis Colon Rectum 2010; 53: 896–904 27 Tursi A, Elisei W, Brandimarte G, Giorgetti GM, Aiello F. Predictive value of serologic markers of degree of histologic damage in acute uncomplicated colonic diverticulitis. J Clin Gastroenterol 2010; 44: 702–6
Editor’s choice The management of sigmoid diverticulitis is clearly evolving towards a more conservative approach. It is remarkable that this change has not been driven by large RCTs but rather by audit driven surgical awareness of weighing operative risk and outcome against the long term risks of recurrent diverticulitis and associated diminished quality of life. New questions arise and whether it is safe to treat patients with uncomplicated sigmoid diverticulitis in an out-patient setting is one of them. The present article attempts to answer this question and in doing so also addresses the associated problem of identifying patients with uncomplicated diverticulitis. Using CT scanning in all patients the authors have modified the Neff score. Patients with
doi:10.1111/codi.12461
signs of microperforation, localised free air but no abscess or free fluid, have been classified 1a and deemed suitable for out-patient management. Patients with significant co-morbidity and recurrent diverticulitis were excluded leaving 1 in 3 patients for out-patient management which was successful in well over 90% of these cases. This paper is interesting because it offers us a modified way of classifying patients with uncomplicated diverticulitis as well as excellent data on outpatient management in a well-defined and stratified group of patients.
Alexander Engel Editor, Colorectal Disease
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