Routine Colonoscopy after Acute Uncomplicated Diverticulitis - Challenging a Putative Indication

Abstract

Background and Aims: Most international guidelines recommend performing a routine colonoscopy after the conservative management of acute diverticulitis, mainly to rule out a colorectal malignancy; however, data to support these recommendations are scarce and conflicting. This study is aimed at determining the rate of advanced colonic neoplasia (ACN) found by colonoscopy, and hence the need for routine colonoscopy after CT-diagnosed acute diverticulitis. Methods: We retrospectively analyzed all patients hospitalized for acute diverticulitis between July 2008 and June 2013. Patients who underwent colonoscopy more than 1 year after the acute episode were excluded. Advanced adenoma (AA) was defined as an adenoma with: (i) ≥10 mm, (ii) ≥25% villous features, or (iii) high-grade dysplasia. ACN included cases of colorectal cancer (CRC) and AA. Results: Of the 364 selected patients, 252 (69%) underwent colonoscopy (51% women, median age 55 ± 11 years). Adenomatous polyps were evident in 14.7% patients; 5.1% had AA and 3.2% had CRC. Patients with complicated diverticulitis had a higher number of ACN compared to those with uncomplicated diverticulitis (20.9 vs. 5.7%, p = 0.003). On multivariate analysis, age ≥50 years (OR 8.12, 95% CI 2.463-45.112; p = 0.017) and abscess on CT (OR 3.15, 95% CI 1.586-11.586; p = 0.036) were identified as significant risk factors for ACN. Conclusions: Patients with diverticulitis complicated with abscess have a higher risk of ACN on follow-up colonoscopy. The prevalence of ACN in patients with uncomplicated diverticulitis is quite similar to the average-risk population, and therefore an episode of CT-diagnosed uncomplicated diverticulitis, per se, does not seem to be a recommendation for colonoscopy.

Acute Diverticulitis and Subsequent Colonoscopy: Instigating an Old Discussion

“…From the patients scoped after the acute episode, 4 patients (2.5%) had colorectal cancer (CRC) and any of them had a previous colonoscopy. Curiously, all patients in whom CRC was diagnosed had uncomplicated disease, which is the opposite of what was found in other studies in which the risk of advanced neoplasia was higher only in those with complicated disease [4,6,7]. In our study, no immediate or late complications related to the colonoscopy were reported.…”

“…In conclusion, we found a relative low prevalence of CRC in patients submitted to colonoscopy after an episode of acute diverticulitis, which is similar to what have been described by Andrade et al [4]. However, we found that the prevalence of precursor lesions such as adenomas is considerably large among patients with acute diverticulitis.…”

“…The issue of performing a colonoscopy after an episode of acute diverticulitis remains controversial and, according to the recently published American Gastroenterology Association guidelines on the Management of Acute Diverticulitis, the quantification of the yield, risks and timing of colonoscopy after an episode of acute diverticulitis should be a research priority [3]. It was with great interest that we read the paper from Andrade et al [4] entitled "Routine colonoscopy after uncomplicated acute diverticulitis -challenging a putative indication," in which the authors conclude that as the prevalence of advanced colonic neoplasia found on colonoscopy in patients with uncomplicated diverticulitis is quite similar to the average-risk population, an episode of CT-diagnosed uncomplicated diverticulitis does not seem to be a recommendation for colonoscopy. …”

Meta-analysis of the role of colonoscopy after an episode of left-sided acute diverticulitis

“…All studies were published after 2003. There were four prospective cohort studies and 13 retrospective cohort studies ( Table ). Four studies included only patients with left‐sided acute diverticulitis, and only the subgroup of patients with left‐sided diverticulitis from one Korean study was included in the present review.…”

Tumour Characteristics of Patients with Colorectal Cancer after Acute Uncomplicated Diverticulitis

“…They only suggest a colonoscopy when there are potential clues on CT findings that could lead to CRC, such as an increase in intestinal wall thickness more than 6 mm, abscess, obstruction or lymph node abnormalities. When a CT-confirmed diverticlutis is in the absence of other concering or intermediate findings, there is no benefit in a follow-up colonoscopy [23][24][25][26]. Recently, 3 meta-analyses were published concerning the risk of CRC after a radiologic confirmed diagnosis of acute diverticulitis.…”