Does a 48-Hour Rule Predict Outcomes in Patients with Acute Sigmoid Diverticulitis?

Abstract

We read with interest the paper by Evans 1 in which the author demonstrated that a noticeable drop in leucocyte count and temperature over the first 48-h of medical management predicted early discharge on oral antibiotics. We recently undertook an audit of all patients with acute sigmoid diverticulitis, over a 4-month period, which supported these findings.Our audit reviewed all admissions to the surgical admissions unit of our district general Trust to improve surgical practice and thereby patient care, focussing on management and length of stay. Of all 33 patients admitted, none developed any complications or required surgical interventions. Further, neither intolerance of oral intake, nor opioid need, precluded discharge -despite this, however, mean length of stay was 3 days.It has been shown that 70-85% of episodes of sigmoid diverticulitis resolve with medical management, 1 and, further, Broderick-Villa et al.2 have shown that the risk of recurrent diverticulitis after initial non-operative management was significantly lower than previous reports. Therefore, this study has important implications for current surgical practice.There are currently no published guidelines in the UK, and other studies have shown, as has our audit, that there is no consensus between practitioners regarding management. 3Combining the results of Evans' study, current ASCRS guidelines 4 and our audit, we have written a local guideline to encourage best practice and a reduction in unnecessary inpatient stay. If admission is necessary, then decreasing inflammatory markers within 48-h is an indication for discharge, as complications appearing after this have now been shown to be unlikely.A 48-h rule should have a significant impact on length of stay of patients with acute sigmoid diverticulitis, with consequent benefits for the patient and substantial financial savings for our Trust.

A Comprehensive review of abdominal infections

“…Most patients with uncomplicated diverticulitis respond to conservative management. Two studies found that patients who did not respond to antibiotics within 48 hours were more likely to require prolonged hospital stays for IV antibiotics and/or surgical intervention[71,72]. …”

New and emerging treatments for the prevention of recurrent diverticulitis

“…However, admission to hospital with acute diverticulitis requiring intravenous antibiotics remains associated with good outcomes 17,18. After initiation of intravenous antibiotic therapy one should see an appropriate drop in white blood cell count and temperature 18,19. The vast majority of patients with uncomplicated diverticulitis will recover without incident.…”