Colonoscopy after the first episode of acute diverticulitis: challenging management paradigms

Diverticulitis does not increase the long-term risk of developing colon cancer: a systematic review and meta-analysis

PURPOSE

The aim of this review was to examine if diverticulitis increases the long-term risk (> 6 months) of developing colon cancer.

METHODS

A systematic search was conducted in PubMed, Embase, and Cochrane CENTRAL. Google Scholar was also searched. We included studies with human adults of 18 years of age and above. Studies that included only patients with diverticulitis as well as studies comparing groups with and without diverticulitis were included. The primary outcome was the incidence of colon cancer 6 months or more after an episode of diverticulitis.

RESULTS

Twelve records were included with 38,621 patients with diverticulitis. The crude rate of colon cancer among the prospectively followed populations with diverticulitis was by meta-analysis found to be 0.6% (95% CI 0.5-0.6%). The limitations of this review include heterogeneous reporting of outcomes across studies, specifically regarding population and outcome as well as variations in the design and reporting of the studies.

CONCLUSION

We found that the long-term risk of colon cancer after diverticulitis is not increased. The results of our review support current practice on follow-up after an episode of diverticulitis with short-term follow-up being the primary focus.

Yield of Post-Acute Diverticulitis Colonoscopy for Ruling Out Colorectal Cancer

BACKGROUND AND AIMS

Colonoscopy is recommended post-acute diverticulitis (AD) to exclude underlying adenocarcinoma (CRC). However, post-AD colonoscopy utility remains controversial. We aimed to examine yield of post-AD colonoscopy in our majority-Hispanic patient population.

METHODS

Patients undergoing post-AD colonoscopy between 11/1/2015-7/31/2021 were identified from a prospectively maintained endoscopic database. AD cases without computed tomography confirmation were excluded. Pertinent data, including complicated vs uncomplicated AD, fecal immunochemical test (FIT) result post-AD/pre-colonoscopy, and number/type/location of non-advanced adenomas, advanced adenomas, and CRC, were abstracted. Analyses were conducted using two-sample Wilcoxon rank-sum and Fisher's exact tests.

RESULTS

208 patients were included, of whom 62.0% had uncomplicated AD. Median age was 53, 54.3% were female, and 77.4% were Hispanic. Ninety non-advanced adenomas were detected in 45 patients (21.6%), in addition to advanced adenoma in eight patients (3.8%). Two patients (1.0%) had CRC, both of whom had complicated AD in the same location seen on imaging, and one of whom was FIT+ (the other had not undergone FIT). Patients with uncomplicated versus complicated AD had similarly low rates of advanced adenomas (4.7% vs. 2.5%, p=0.713). FIT data were available in 51 patients and positive in three (5.9%); non-advanced adenomas were found in all three FIT+ patients. No FIT- patient had an advanced adenoma or CRC.

CONCLUSION

Colonoscopy post-AD is generally low yield, with CRC being rare and found only in those with complicated AD. Colonoscopy post-complicated AD appears advisable, whereas less invasive testing (e.g. FIT) may be considered post-uncomplicated AD to inform the need for colonoscopy.

Evaluation and Management After Acute Left-Sided Colonic Diverticulitis : A Systematic Review

BACKGROUND

The value of interventions used after acute colonic diverticulitis is unclear.

PURPOSE

To evaluate postdiverticulitis colonoscopy and interventions to prevent recurrent diverticulitis.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.

STUDY SELECTION

Comparative studies of interventions of interest reporting critical or important outcomes, and larger single-group studies to evaluate prevalence of colonoscopy findings and harms.

DATA EXTRACTION

6 researchers extracted study data and risk of bias. The team assessed strength of evidence.

DATA SYNTHESIS

19 studies evaluated colonoscopy. Risk for prevalent colorectal cancer (CRC) compared with the general population is unclear. Based on low-strength evidence, long-term CRC diagnosis is similar with or without colonoscopy. High-strength evidence indicates that risk for prevalent CRC is higher among patients with complicated diverticulitis and colonoscopy complications are rare. Based on high-strength evidence, mesalamine does not reduce recurrence risk (6 randomized controlled trials [RCTs]). Evidence on other nonsurgical interventions is insufficient. For patients with prior complicated or smoldering or frequently recurrent diverticulitis, elective surgery is associated with reduced recurrence (3 studies; high strength). In 19 studies, serious surgical complications were uncommon.

LIMITATIONS

Few RCTs provided evidence. Heterogeneity of treatment effect was not adequately assessed.

CONCLUSION

It is unclear whether patients with recent acute diverticulitis are at increased risk for prevalent CRC, but those with complicated diverticulitis are at increased risk. Mesalamine is ineffective in preventing recurrence; other nonsurgical treatments have inadequate evidence. Elective surgery reduces recurrence in patients with prior complicated or smoldering or frequently recurrent diverticulitis, but it is unclear which of these patients may benefit most.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians

DESCRIPTION

The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated and uncomplicated left-sided colonic diverticulitis. This guideline is based on the current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.

METHODS

The ACP Clinical Guidelines Committee (CGC) based these recommendations on a systematic review on the role of colonoscopy after acute left-sided colonic diverticulitis and pharmacologic, nonpharmacologic, and elective surgical interventions after initial treatment. The systematic review evaluated outcomes rated by the CGC as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.

TARGET AUDIENCE AND PATIENT POPULATION

The target audience is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.

RECOMMENDATION 1

ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation; low-certainty evidence).

RECOMMENDATION 2

ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence).

RECOMMENDATION 3

ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences.

Routine colonoscopy may be needed for uncomplicated acute right colonic diverticulitis

Background

Routine colonoscopy is recommended to determine the coexistence of colon cancer after medical treatment for colon diverticulitis. However, in the case of uncomplicated diverticulitis diagnosed by computed tomography, the clinical relevance of routine follow-up colonoscopy has recently been debated. Yet, the role of follow-up colonoscopy for right colon diverticulitis, which tends to develop at a younger age than left colon diverticulitis, has not been specifically evaluated. Therefore, we aimed to evaluate the incidence of right colon cancer or colonic adenomatous polyps, detected by routine colonoscopy, after conservative management of acute uncomplicated right colon diverticulitis.

Methods

Patients with uncomplicated right colon diverticulitis (modified Hinchey stage Ia) diagnosed by computed tomography imaging, between 2011 and 2017, and who underwent follow-up colonoscopy surveillance after treatment were included. The primary outcome was the incidence of colon cancer, with the detection rate of adenoma being the secondary outcome. Information for analysis was retrieved retrospectively from patients’ medical records.

Results

The study group included 330 consecutive patients, with a mean age of 41.9 years, and 51.9% being men. For the primary outcome, the rate of colon cancer on follow-up colonoscopy was 0.3% (1/330 cases). The rate of adenoma detection was 20.9% (69/330 cases) and advanced adenoma (> 10 mm in diameter; or exhibiting a > 25% villous component or severe dysplasia), including colon cancer, was observed in 9 patients (2.7%).

Conclusions

In patients with acute uncomplicated right colonic diverticulitis, routine colonoscopy after conservative treatment may be necessary because although the colon cancer detection rate is low, it is possible to detect advanced colon adenoma.

Routine Colonoscopy After Acute Diverticulitis: is it Warranted?

PURPOSE

Recent evidence suggests routine colonoscopy after acute diverticulitis is not necessary but remains debatable. The aim of this study was to investigate the incidence of follow-up colonoscopic finding of adenoma, advanced neoplastic lesion, and adenocarcinoma after diverticulitis.

MATERIALS AND METHODS

A retrospective review of all cases of acute diverticulitis admitted from November 2015 to April 2018 was performed. Data collected included demographics, computed tomography (CT) findings, and findings of the follow-up colonoscopy within 12 months.

RESULTS

A total of 368 patients were admitted for acute diverticulitis. A total of 366 patients underwent CT scan for diagnosis. Of whom, 185 patients (50.5%) had a follow-up colonoscopy; 115 (31.4%) did not have a follow-up colonoscopy, and the remaining have had a recent colonoscopy. The overall incidence of adenomas was 25.9% (n=48) and advanced colonic neoplasia 1.62% (n=3) in patients who underwent follow-up colonoscopy.

CONCLUSIONS

The finding of advanced colonic neoplasia in follow-up colonoscopy after an acute episode of CT-proven diverticulitis is equivalent to, or less than, that of the population colorectal cancer screening program. Routine colonoscopy is not necessary unless there are other concerning symptoms/CT findings.

Systematic Review and Meta-analysis on Colorectal Cancer Findings on Colonic Evaluation After CT-Confirmed Acute Diverticulitis

BACKGROUND

CT findings of acute diverticulitis can overlap with features of malignancy, and current guidelines recommend colonic evaluation after acute diverticulitis. However, the benefits of routine colonic evaluation have been questioned.

OBJECTIVE

We review 30 studies, composed of 29,348 subjects, to evaluate the role of routine colonic evaluation after CT-proven acute diverticulitis.

DATA SOURCES

Medline, EMBASE, and the Cochrane Library were searched for articles published up to July 2018 to identify all relevant articles.

STUDY SELECTION

A combination of both Medical Subject Headings and non-Medical Subject Headings key terms using Boolean operators were used on Medline, including colonic neoplasms, colorectal cancer, colon cancer, colonic cancer, colonoscopy, and diverticulitis. Any randomized or nonrandomized, English-language article that specifically analyzed incidence of colorectal cancer after performing colonoscopy in patients with previous diverticulitis was included.

MAIN OUTCOME MEASURES

The desired outcome was to evaluate for incidence of colonic malignancy in cases of acute colonic diverticulitis. Subgroup analyses for incidence of malignancy in uncomplicated and complicated diverticulitis, and Asian population studies were also performed.

RESULTS

Findings of colonic malignancy occurred in 1.67% (95% CI, 1.24-2.14) of patients with CT-diagnosed diverticulitis. The risk of malignancy in cases with uncomplicated diverticulitis was 1.22% (95% CI, 0.63-1.97) as compared with 6.14% (95% CI, 3.20-9.82) in cases with complicated diverticulitis, with a relative risk of 5.033 (95% CI, 3.194-7.930; p < 0.001).

LIMITATIONS

Significant variability in design and methodology of the individual studies contributed to the heterogeneity of this study, but these were addressed by using the random-effects model analysis.

CONCLUSIONS

Colonic evaluation is worth considering for patients with diverticulitis because of the small but serious risk of underlying malignancy. The risk of malignancy is higher for patients of advanced age and with complicated diverticulitis.

Prevalence of colorectal cancer and advanced adenoma in patients with acute diverticulitis: implications for follow-up colonoscopy

BACKGROUND AND AIMS

Guidelines recommend colonoscopy after an episode of diverticulitis to exclude neoplasia but the effectiveness of testing is uncertain. Patients with complicated diverticulitis may be at higher risk for neoplasia, but most patients have uncomplicated disease. We examined the incidence of colorectal cancer (CRC) and advanced adenoma (AA) in patients with diverticulitis compared with patients undergoing screening colonoscopy.

METHODS

CT scans from January 1, 2008, to May 1, 2013, at the University of Pittsburgh Medical Center (UPMC) were reviewed to identify those with confirmed acute diverticulitis. Subsequent surgical, colonoscopy, and pathology reports were abstracted to identify those with a diagnosis of AA and CRC. The incidence of neoplasia was compared with that reported for screening colonoscopy from a meta-analysis (n = 68,324), and from colonoscopy examinations at UPMC between 2013 and 2015 (n = 28,573).

RESULTS

A total of 5167 abdominal/pelvic CT scan reports identified 978 patients with acute diverticulitis, among which 474 (48.5%) patients had undergone at least 1 colonoscopy or gastrointestinal surgery to April 2015. The CRC rate in patients with diverticulitis (13/474, 2.7%) was significantly higher (P < .0001) compared with both the meta-analysis (0.8%) and UPMC (0.3%). The AA rate (19/474, 4.0%) was similar to the rate in the meta-analysis (5.0%, P = .39) but significantly lower than at UPMC (7.7%, P = .003). The incidence of AA or CRC in complicated diverticulitis (10/141, 7.1%) did not differ significantly (P = .85) from the incidence of AA or CRC in uncomplicated diverticulitis (22/332, 6.6%).

CONCLUSIONS

CRC after diverticulitis was significantly higher than that observed at screening colonoscopy and was not limited to complicated disease. Colonoscopy is advisable after the diagnosis of diverticulitis.

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

Background

Routine colonoscopy was traditionally recommended after acute diverticulitis to exclude coexistent malignancy. Improved CT imaging may make routine colonoscopy less required over time but most guidelines still recommend it. The aim of this review was to assess the role of colonoscopy in patients with CT‐proven acute diverticulitis.

Methods

PubMed and Embase were searched for studies reporting the prevalence of advanced colorectal neoplasia (ACN) or colorectal carcinoma in patients who underwent colonoscopy within 1 year after CT‐proven left‐sided acute diverticulitis. The prevalence was pooled using a random‐effects model and, if possible, compared with that among asymptomatic controls.

Results

Seventeen studies with 3296 patients were included. The pooled prevalence of ACN was 6·9 (95 per cent c.i. 5·0 to 9·4) per cent and that of colorectal carcinoma was 2·1 (1·5 to 3·1) per cent. Only two studies reported a comparison with asymptomatic controls, showing comparable risks (risk ratio 1·80, 95 per cent c.i. 0·66 to 4·96). In subgroup analysis of patients with uncomplicated acute diverticulitis, the prevalence of colorectal carcinoma was only 0·5 (0·2 to 1·2) per cent.

Conclusion

Routine colonoscopy may be omitted in patients with uncomplicated diverticulitis if CT imaging is otherwise clear. Patients with complicated disease or ongoing symptoms should undergo colonoscopy.

Efficacy of colonoscopy after an episode of acute diverticulitis and risk of colorectal cancer

Background

Diverticular disease of the colon has a high global prevalence. The guidelines suggest performing a colonoscopy 4-6 weeks after the acute episode to exclude colorectal cancer (CRC). However, these recommendations are based on old studies, when computed tomography was not used to diagnose acute diverticulitis (AD). There are currently some studies showing that CRC incidence is low in uncomplicated AD (UAD). Therefore, we decided to perform this study to determine the CRC incidence after an AD episode and the diagnostic efficacy of colonoscopy in these patients.

Method

This was a retrospective cohort study that included patients with AD between July 2016 and December 2017.

Results

One hundred seventy-four patients had AD. Of these, 46 patients were excluded and we analyzed 128 patients, 72 (56.3%) women and 56 (43.7%) men. Ninety (70.3%) had UAD and 38 (29.7%) complicated AD (CAD). The colonoscopy showed lesions in 18 (14.06%), 5 (3.9%) being CRC. The patients with CRC had shown CAD and were >70 years old (P=0.0001 and P=0.002 respectively).

Conclusions

Routine colonoscopy in patients with UAD appears not have many benefits as a diagnostic tool. However, it has a higher efficacy if the patients have CAD and are >70 years old.

Should a colonoscopy be offered routinely to patients with CT proven acute diverticulitis? A retrospective cohort study and meta-analysis of best available evidence

BACKGROUND

The current guidelines suggest that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The usefulness of routine endoscopic evaluation of CT proven diverticulitis remains unknown.

AIM

To establish whether routine colonoscopy should be offered to patients after an episode of diverticulitis.

METHODS

We performed a retrospective study, comparing two groups: a diverticulitis group and a control group. The diverticulitis group consisted of patients undergoing a colonoscopy after an episode of diverticulitis. The control group consisted of asymptomatic patients undergoing a screening sigmoidoscopy. We also performed a systematic review and meta-analysis. We searched electronic data resources to identify all relevant studies. The primary outcome was the number of adenomas found, while the secondary outcomes were the number of cancers and polyps identified, and the adenoma risk.

RESULTS

68 and 1309 patients were included in the diverticulitis and control groups respectively. There was no difference in the risk of adenomas (5.9% vs 7.6%, P = 0.59), non-advanced adenomas (5.9% vs 6.9%, P = 0.75), advanced adenomas (0% vs 0.8%, P = 1), cancer (0% vs 0.15%, P = 1.00), and polyps (16.2% vs 14.2%, P = 0.65) between both groups. Meta-analysis of data from 4 retrospective observational studies, enrolling 4459 patients, showed no difference between the groups in terms of risk of adenomas (RD = -0.05, 95%CI: -0.11, 0.01, P = 0.10), non-advanced adenomas (RD = -0.02, 95%CI: -0.08, 0.04, P = 0.44), advanced adenomas (RD = -0.01, 95%CI: -0.04, 0.02, P = 0.36), cancer (RD = 0.01, 95%CI: -0.01, 0.03, P = 0.32), and polyps (RD = -0.05, 95%CI: -0.12, 0.02, P = 0.18).

CONCLUSION

Routine colonoscopy may not be appropriate in patients with acute diverticulitis. High quality prospective studies are required for more robust conclusions.

Risk of Colorectal Cancer in Patients With Acute Diverticulitis: A Systematic Review and Meta-analysis of Observational Studies

BACKGROUND & AIMS

We performed a systematic review and meta-analysis to assess the prevalence of colorectal cancer in patients with acute diverticulitis.

METHODS

We searched MEDLINE from inception through November 2nd, 2017 for studies reporting the prevalence of colorectal cancer in patients with diverticulitis, identified based on the protocol CRD42017083272. This systematic review was conducted in accordance to the MOOSE guidelines. Pooled prevalence values were obtained by random effects models and robustness was tested by leave-one out sensitivity analyses. Heterogeneity was assessed using the Q-test and quantified based on I2 value. The critical appraisal of included studies was performed using the Newcastle-Ottawa scale.

RESULTS

Our final analysis included 31 studies, comprising 50,445 patients. The pooled prevalence of colorectal cancer was 1.9% (95% CI, 1.5%-2.3%). Patients with complicated diverticulitis had a significantly higher risk for colorectal cancer (prevalence, 7.9%; 95% CI, 3.9%-15.3%) than patients with uncomplicated diverticulitis (prevalence, 1.3%; 95% CI, 0.1%-2%), corresponding to a pooled prevalence ratio of 6.7 (95% CI, 2.5-18.3). Subgroup analyses did not find significant difference in prevalence when separately pooling studies according to ranking on the Newcastle-Ottawa scale, geographical location or length of follow-up. Meta-regression did not find any association between age and colorectal cancer. Among patients who underwent endoscopy, the pooled prevalence of polyps was 22.7% (95% CI, 19.6%-26.0%), of advanced adenomas was 4.4% (95% CI, 3.4%-5.8%), of adenomas was 14.2% (95% CI, 11.7%-17.1%), and of hyperplastic polyps was 9.2% (95% CI, 7.6%-11.2%).

CONCLUSION

In a meta-analysis of observational studies of patients with acute diverticulitis, we found the pooled prevalence of colorectal cancer to be 1.9%. The risk of colorectal cancer was significantly higher in patients with complicated diverticulitis than in patients with uncomplicated diverticulitis.

Prevalence of colorectal cancer in acute uncomplicated diverticulitis and the role of the interval colonoscopy

PURPOSE

Although computed tomography (CT) is the imaging modality of choice for diagnosing colonic diverticulitis today, there remains a risk of colorectal cancer mimicking diverticulitis due to overlapping imaging features. Current practice guidelines recommend interval colonoscopy after diverticulitis to exclude occult malignancy. Some authors have suggested that this may be unnecessary in patients with uncomplicated diverticulitis. The aim of our study was to examine the prevalence of occult colorectal cancer in patients with CT-proven acute uncomplicated diverticulitis in an Asian population.

METHODS

This was a retrospective study of all patients admitted for CT-proven acute uncomplicated diverticulitis between 2007 and 2011 in a single institution. Colonoscopy and histopathology reports were reviewed for patients who underwent interval colonic evaluation. For patients who defaulted follow-up, national health records were reviewed for any subsequent diagnoses of colorectal cancer. The primary outcome was prevalence of colorectal cancer in the cohort. Secondary outcome was prevalence of advanced adenomas.

RESULTS

A total of 227 patients with acute uncomplicated diverticulitis were included in our study. One hundred and thirty-five patients (59.5%) underwent follow-up colonic evaluation. The overall prevalence of colorectal cancer was 1.8%, with half these patients presenting with acute colonic obstruction after defaulting follow-up evaluation. Of the patients, 1.5% who underwent colonoscopy had advanced adenomas.

CONCLUSION

Prevalence of colorectal cancer in patients with CT-proven acute uncomplicated diverticulitis may not be as low as previously suggested. We recommend that patients with acute uncomplicated diverticulitis continue to be offered interval colonoscopy until larger studies demonstrate the safety of omission.