The modified Hinchey classification is based on CT scan findings and is used to categorize diverticulitis, as well as help to guide appropriate. Objetivo: verificar que la clasificación radiológica de Neff modificada (mNeff) asociada a The Hinchey system is a surgical classification and as such it is not . Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of.
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The use of the modified Neff classification in the management of acute diverticulitis. Department of General Surgery. Hospital Universitari Parc Tauli. Acute diverticulitis AD is increasingly seen in Emergency services. The application of a reliable classification is vital for its safe and effective management.
To determine whether the combined hinfhey of the modified Neff radiological classification mNeff and clinical criteria systemic inflammatory response syndrome [SIRS] and comorbidity can ensure safe management of AD.
Prospective descriptive study in a population of patients diagnosed divetriculitis AD by computerized tomography CT. The protocol applied consisted in the application of the mNeff classification and clinical criteria of SIRS and comorbidity to guide the choice of outpatient treatment, admission, drainage or surgery. The study was carried out from February to February A total of episodes of AD were considered: Grade Ia 52, 8. Grade Ib 49, 8.
Review of current classifications for diverticular disease and a translation into clinical practice
Grade II 30, 5. Grade III 5, 0. Grade IV 34, 5. Of the 34 grade IV patients, 24 The mNeff classification is a safe, easy-to-apply classification based on CT findings. Together with clinical data and comorbidity data, it allows better management of AD. Its prevalence has risen in recent years due to the increase in the age of the general population and also due to dietary changes 1,2. As a result, Emergency Room ER consultations for this clasificaciin are becoming more frequent.
The presumptive diagnosis of AD can be made on the basis of a clinical history and physical examination.
Nuevas tendencias en el manejo de la diverticulitis y la enfermedad diverticular del colon
CT is useful for diagnosis, but above all is most useful to evaluate the degree of inflammation, for differential diagnosis vs ischemic colitis, inflammatory disease, tumor, and so onto assist treatment i. The ability to assess the severity of AD is important for therapeutic decision making.
Several classifications for AD are currently available. The Hinchey system is a surgical classification and as such it is not particularly useful, since nowadays very few ADs require surgery Multiple variations on the Hinchey system have been described based on radiological criteria: This classification allows a correct diagnosis of AD and stages it according to severity, from stage 0 localized pericolic abscess to stage IV pneumoperitoneum and diffuse peritonitis This modified version includes the sub-stage Ia, which can now be differentiated due to recent technological advances.
The degrees of radiological classification, together with clinical data, allow for a better management of this clinical entity Over time, management of AD has become more conservative both in the acute setting and in subsequent controls. Currently, the tendency is to manage uncomplicated AD at home.
Treatment for complicated AD varies from antibiotic use only to resective surgery of the inflamed area in case of peritonitis or pneumoperitoneum To be able to decide on the correct treatment, criteria are needed to create an action protocol for all AD cases once diagnosed.
Here we propose a protocol that can be implemented at any himchey with a radiology service and by any physician encountering this condition. In this study we describe our experience with the application of a management protocol for AD which uses the mNeff radiological classification in combination with clinical criteria of comorbidity and SIRS, in order to be able diberticulitis apply the most appropriate treatment in each case.
Prospective, observational study using a database including all consecutive patients attending our hospital’s ER who were diagnosed with AD after their visit.
Demographic data age, sexpresence or absence of comorbidities Table Iand presence of sepsis SIRS Table II were recorded, as well as the type of AD according to the radiological classification and its management in view of the clinical and radiological findings discharge, hospitalization, drainage, surgery, re-admission hinchfy re-examination.
Other factors unrelated to the application of the protocol were not considered. At our service, after radiological diagnosis, the type of AD is graded using the mNeff classification Table I. Clinical data are then assessed in order to define the appropriate management on a case-by-case basis. In accordance with the algorithm used at our center Fig. Patients who present grade 0, do not present SIRS or any of the comorbidity factors present in table IItolerate diet and have good pain control are discharged from the ER with antibiotic treatment and a residue-free diet, under a home health care scheme and seen at the outpatient service after two weeks.
If they present SIRS or any of the comorbidity factors mentioned above, they are admitted for control observation and treatment. Patients with type Ia AD receive antibiotic treatment and are kept under observation for 48 hours. Patients without comorbidities or SIRS who tolerate oral feeding and have no pain are discharged under a home health care scheme and seen at the outpatient service after two weeks.
From grade Ib upward, AD is considered to be complicated; patients are administered antibiotic treatment and are hospitalized. The grading determines the most suitable management. Grade Ib patients receive medical treatment. Grade IV patients require surgical treatment in most cases, but always depending on their hemodynamic and clinical status.
In this study, the program SPSS Quantitative variables were described using means and standard deviations or medians and ranges when the distribution was not normal. Categorical variables are described in absolute numbers and percentages. Between February and Februarycases of AD were diagnosed at our center women and men.
The median age was 60 years range years. All of them required hospitalization. Therefore, episodes were treated according to the management protocol Table III. The management of these patients is displayed in the flow chart Fig.
Of the AD stage 0, Of these, The other patients The main reason for consultation or admission was pain and oral intolerance at home. Of the patients initially considered for home hospitalization, required admission, due in most cases to difficult pain control and, to a lesser extent, to food intolerance while in the ER. Of the grade A patients, patients required admission as a result of comorbidity or SIRS 32oral intolerance or pain or after re-consultation at the ER Of the patients admitted, five 2.
Of the 52 AD stage Ia patients 8. The remaining 20 required admission for pain or oral intolerance. During the follow-up, eight of the eleven on home treatment Seven of the eleven patients completed home treatment, representing a success rate of Of all AD stage Ia patients, 45 were hospitalized.
Of clasoficacion 21 stage Ia patients The remaining patients evolved satisfactorily with antibiotic clasificcaion. Of the 49 stage Ib patients 8. Of the 30 stage II patients 5. Of the five stage III patients 0. Of the 34 stage IV patients 5. Drains were placed divertculitis three of the patients treated with antibiotics, with a good response.
The decision to insert an abdominal drain was taken in light of the radiological criteria of the size and accessibility of the abscess. None of the drains were associated with adverse effects. AD is an increasingly common entity whose management has evolved over time. Its treatment requires accurate diagnosis and clear staging criteria. This staging is the basis for the choice of a safe, effective and economical treatment in each particular clasuficacion The diagnosis of AD requires the performance of a radiological test, in this case CT.
In addition, it is able to assess the degree of inflammation produced, allows differential diagnosis, and may also predict the failure of conservative treatment or the need for drainage Once the diagnosis of AD has been made, and with all the data obtained with CT, we believe that it is important to be able to hincchey the condition in different degrees After reviewing classifications such as the Ambrosetti and the modified Hinchey systems 3,7,8we decided to use the mNeff classification 11,15 Table Ia radiology-based classification that distinguishes between six grades of AD and predicts its severity.
The mNeff emphasizes the staging of patients with low radiological involvement: In our study, of AD patients Of these, out of Our results are diverticuliis to those reported by other groups in Spain and abroad, such as Alonso et al. In the recent prospective randomized study by Biondo et al. The study concluded that outpatient treatment is safe and effective.
Although it used a different classification, like the mNeff system it also differentiated the uncomplicated AD group AD G0. Hindhey mNeff classification classifies patients requiring drainage within stages Ib and II. The management of stage IV AD also allows assessment of the need for surgery. Our protocol favors individualizing the indication of surgery.
In our study, ten out of 34 patients with calsificacion IV AD responded well to conservative treatment. We believe that the use of clinical criteria increases the dkverticulitis of a good response to conservative treatment. Perhaps when a larger number of patients have been assessed it will be possible to improve the mNeff classification and to define which groups of perforated or stage IV AD can be assigned to conservative treatment always assuming that the clinical criteria permit.
At all radiological stages, it is important to include clinical criteria in the assessment.