CT colonography versus colonoscopy in the follow-up of patients after diverticulitis - a prospective, comparative study

When to Perform a Colonoscopy in Diverticular Disease and Why: A Personalized Approach

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize “when” to safely perform a colonoscopy in the different DD settings and “why”.

CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study

Purpose

To perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD).

Methods

Fifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0–3 point scale for each variable.

Results

Of 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors.

Conclusion

DDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.

Computed tomography diagnosed first time diverticulitis and colorectal cancer

BACKGROUND

Computed tomography (CT) with intravenous contrast is the gold standard for diagnosing diverticulitis. Published results concerning follow-up colonoscopy after an episode of acute diverticulitis to rule out cancer are conflicting. This study aimed to evaluate the risk of underlying colonic malignancy in patients diagnosed with a first time diverticulitis with a state of the art CT investigation with intravenous contrast.

METHODS

Retrospective analysis of all patients with a first episode of diverticulitis diagnosed with CT at Danderyds Hospital, Stockholm, between January 1, 2015, and November 16, 2016. Data on modified Hinchey classification, age, sex, laboratory parameters, body mass index, and colonoscopy findings were recorded.

RESULTS

The study identified 518 patients with a CT-verified first time diverticulitis. Four hundred twenty-six (82%) of the 518 patients underwent follow-up colonoscopy and constitute our study cohort. CT showed that 402 patients had uncomplicated diverticulitis (modified Hinchey Ia), and 24 patients had complicated diverticulitis (modified Hinchey ≥Ib). Colonoscopy showed cancers in 2 (0.5%) of the 426 patients initially diagnosed as acute diverticulitis. In addition, 13 (3%) patients had advanced adenomas, and 121 (28%) patients had benign adenomas upon follow-up colonoscopy. Patients with CT-verified complicated diverticulitis (modified Hinchey ≥Ib) had a significantly higher risk for colon cancer compared with patients with an uncomplicated first time diverticulitis.

CONCLUSION

Our study supports routine follow-up colonoscopy after a first episode of CT-diagnosed complicated diverticulitis. In contrast, we do not find an increased risk for neoplasia in patients with uncomplicated diverticulitis.

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.

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.

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.

Management of Diverticular Hemorrhage: Catching That Culprit Diverticulum Red-Handed!

Background/Summary

Acute colonic diverticular hemorrhage (CDH) represents a significant challenge for gastroenterologists. There are some clinical problems in the diagnosis, treatment, and prevention of CDH. CDH is the most common cause of overt lower gastrointestinal bleeding in adults in Eastern and Western countries. Moreover, CDH imposes significant economic and clinical burdens on the health care system. Colonoscopy is recommended as a useful diagnostic tool for CDH after bowel preparation. Colonoscopy can be used to identify the culprit diverticulum and to provide endoscopic therapy. In most cases, however, the bleeding stops spontaneously. For this reason, it is still controversial whether urgent colonoscopy or elective colonoscopy is "preferable."

Key Messages

This review aims to highlight the various clinical problems (purge, timing of colonoscopy, CT angiography, and endoscopy) encountered in the attempt to identify and treat the culprit diverticulum red-handed.

High Probability of an Underlying Colorectal Cancer Among Patients Treated for Acute Diverticulitis. A Population-Based Cohort Follow-Up Study

INTRODUCTION

Patients treated conservatively for acute diverticulitis (AD) are recommended colonic assessment to rule out an underlying Colorectal cancer (CRC). This has been questioned in patients with a CT diagnosis of uncomplicated AD. We analyzed the frequency of CRC and compared the characteristics of the CRC patients with controls.

METHOD

A cohort of patients treated conservatively for AD during 2005-2011 was identified through an administrative database. Patients diagnosed with CRC within 1 year after the index admission and four randomly selected controls were identified. The patients' files were reviewed to verify the diagnosis and obtain information about the clinical characteristics and the management. A blinded review was performed of CT examinations. The expected number of CRC was calculated from age, sex, and period-specific incidence data. The characteristics of the CRC patients were compared with the controls in a nested case-control study.

RESULTS

890 patients (298 men and 592 women) were treated conservatively for AD. 12 patients were diagnosed with CRC within 1 year, and ten of them in the sigmoid, giving a Standardized Incidence Ratio of 20.0 (95 % CI 10.2-35.7, p<0.001) for sigmoidal cancer. All CRC patients were aged over 70 years. The cancer was missed in six CT scans at the primary reading and in five at the blinded review.

CONCLUSION

Patients conservatively treated for AD are at high risk for an underlying CRC, especially if older than 70 years, which motivates routine follow-up. A CT diagnosis of uncomplicated AD does not rule out CRC.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Diverticular Disease of the Colon: News From Imaging

Different scenarios embrace computed tomography imaging and diverticula, including asymptomatic (diverticulosis) and symptomatic patients (acute diverticulitis, follow-up of acute diverticulitis, chronic diverticulitis). If the role of computed tomography is validated and widely supported by evidence in case of acute diverticulitis, this is not the case of patients in their follow-up for acute diverticulitis or with symptoms related to diverticula, but without acute inflammation. In these settings, computed tomography colonography is gaining consensus as the preferred radiologic test.

The Current Role of Radiologic and Endoscopic Imaging in the Diagnosis and Follow-Up of Colonic Diverticular Disease

OBJECTIVE

Colonic diverticular disease is among the most prevalent conditions in Western society and is a common cause for outpatient visits and hospitalizations. The role of imaging is in evolution, but it has proven useful in confirming clinically suspected disease, assessing severity and complications, and directing patient management.

CONCLUSION

This review focuses on the current role of radiologic and endoscopic imaging in distinct clinical scenarios of diverticular disease, with emphasis on diverticulitis and its follow-up.

Prognostic Value of the Diverticular Disease Severity Score Based on CT Colonography: Follow-up in Patients Recovering from Acute Diverticulitis

RATIONALE AND OBJECTIVES

To assess the prognostic value of a diverticular disease severity score (DDSS) based on computed tomography colonography (CTC) after acute diverticulitis (AD).

MATERIALS AND METHODS

Of 252 patients who had an AD episode, we finally selected 46 patients who underwent both conventional CT at the acute event and CTC after 9 ± 7 weeks. Of these 46 patients, 17 underwent elective surgery after CTC. Disease severity was assessed with a 0-4 modified Hinchey CT-based score and a 1-4 CTC-based DDSS. A phone survey was performed 27 months later (range 4-52) for the 29 patients not surgically treated.

RESULTS

Significant correlation was found between CTC-based DDSS and clinical follow-up (P = 0.022) or elective surgery (P = 0.007), but not between clinical follow-up and CT-based score, extraluminal gas, C-reactive protein serum level, age, gender, or first versus recurrent AD episode. CTC demonstrated relevant additional findings in five of 46 (11%) patients: two AD complications (enterocolic and enterotubal fistulae), two colon cancers, and one extracolonic (lung) cancer.

CONCLUSIONS

The CTC-based DDSS showed a prognostic value and correlated with the risk of undergoing surgery, and clinically relevant additional findings were found in more than 10% of patients. CTC could be the preferred test in patients recovering after AD.

Colonoscopy after CT-diagnosed acute diverticulitis: Is it really necessary?

BACKGROUND

Computed tomography (CT) scans are commonly used to diagnose acute diverticulitis, but there are overlapping features between diverticulitis and colorectal cancer (CRC) on imaging studies. Hence, colonoscopy is typically recommended after an episode of acute diverticulitis to rule out underlying malignancy. Currently, 64-slice multidetector CT scanners are capable of providing higher-resolution images and may be able to distinguish malignancy from diverticular inflammation. We aimed to determine the prevalence of CRC among patients with CT-diagnosed acute diverticulitis.

METHODS

We performed a retrospective study of patients with acute diverticulitis diagnosed on CT scan between December 2005 and December 2010 at St. Paul's Hospital, Vancouver, BC. Nonresidents were excluded. We reviewed CT scan reports that included the term "diverticulitis," reports of follow-up colonic evaluation within 1 year of diagnosis and pathology results. We queried the provincial cancer registry to ensure no cases of CRC were missed.

RESULTS

A total of 293 patients had acute diverticulitis diagnosed on CT scan, but 8 were nonresidents and were excluded. Of the 285 included in the analysis, the mean age was 59.4 ± 15.1 years, and 167 (58.6%) were men. Among the 114 patients who underwent follow-up evaluation, malignancy was diagnosed in 4 (3.5%). The overall prevalence of malignancy among patients with CT-diagnosed diverticulitis was 1.4%.

CONCLUSION

Routine endoscopic evaluation after an episode of diverticulitis diagnosed with high-resolution CT scan does not appear to be necessary. Selective approach in patients with protracted clinical course or those with mass lesion/obstruction on CT scan may be of benefit.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis: a comparative cohort study

BACKGROUND

Current guidelines recommend routine follow-up colonoscopy after acute diverticulitis to confirm the diagnosis and exclude malignancy. Its value, however, has recently been questioned because of contradictory study results. Our objective was to compare the colonoscopic detection rate of advanced colonic neoplasia (ACN), comprising colorectal cancer (CRC) and advanced adenoma (AA), in patients after a CT-proven primary episode of uncomplicated acute diverticulitis with average risk participants in a primary colonoscopy CRC screening program.

METHODS

A retrospective comparison was performed of prospectively collected data from cohorts derived from two multicenter randomized clinical trials executed in the Netherlands between 2009 and 2013. 401 uncomplicated diverticulitis patients and 1,426 CRC screening participants underwent colonic evaluation by colonoscopy. Main outcome was the diagnostic yield for ACN, calculated as number of diverticulitis patients and screening participants with ACN relative to their totals, with differences expressed as odds ratios (OR). The histopathology outcome of removed lesions during colonoscopy was used as definitive diagnosis.

RESULTS

AA detection was similar [5.5 vs. 8.7%; OR 0.62 (95% CI 0.38-1.01); P = 0.053]. CRC was detected in 1.2% (5/401) of diverticulitis patients versus 0.6% (9/1,426) of screening participants [OR 1.30 (95% CI 0.39-4.36); P = 0.673]. ACN was diagnosed in 6.7% (27/401) of diverticulitis patients versus 9.1% (130/1,426) of screening participants [OR 0.71 (95% CI 0.45-1.11); P = 0.134]. ORs were adjusted for age, family history of CRC, smoking, BMI, and cecal intubation rate.

CONCLUSIONS

ACN detection does not differ significantly between patients with recent uncomplicated diverticulitis and average risk screening participants. Routine follow-up colonoscopy after primary CT-proven uncomplicated left-sided acute diverticulitis can be omitted; these patients can participate in CRC screening programs. Follow-up colonoscopy may be beneficial when targeted at high-risk patients, but such an approach first needs prospective evaluation.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines

AIM

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient.

RESULTS

Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence.

CONCLUSION

Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis

OBJECTIVE

To determine the yield of colorectal cancer at routine colonic evaluation after radiologically proven acute diverticulitis.

BACKGROUND

Acute diverticulitis accounts for 152,000 hospitalizations in the United States alone. Current guidelines recommend routine colonic evaluation after acute diverticulitis to confirm the diagnosis and exclude malignancy. However, research suggests that the yield of colorectal cancer after computed tomography-proven uncomplicated diverticulitis may be low. In the era of widespread computed tomographic scanning for diverticulitis, routine colonic evaluation after diverticulitis may represent a nonessential burden on health care resources.

METHODS

The PubMed (MEDLINE), EMBASE, BIREME, CINAHL, and the Cochrane Library databases were searched. Original studies of colonic evaluation after proven acute diverticulitis were included. Meta-analysis of data from included studies was performed using a DerSimonian Laird random effect proportion analysis.

RESULTS

Eleven studies from 7 countries were included in the analysis. Out of a pooled population of 1970 patients, cancer was found in 22. The pooled proportional estimate of malignancy was 1.6% (95% confidence interval [CI], 0.9%-2.8%). Of the 1497 patients with uncomplicated diverticulitis, cancer was found in 5 (proportional estimate of risk 0.7%; CI, 0.3%-1.4%). Of the 79 patients with complicated disease, cancer was found in 6 (proportion estimate of risk 10.8%; CI, 5.2%-21.0%).

CONCLUSIONS

The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, routine colonoscopy may not be necessary. Patients with complicated diverticulitis still have a significant risk of colorectal cancer at subsequent colonic evaluation.

Colonoscopy following nonoperative management of uncomplicated diverticulitis may not be warranted

BACKGROUND

Following the nonoperative management of acute diverticulitis, guidelines recommend routine follow-up colonoscopy; however, evidence to support this recommendation are lacking.

OBJECTIVE

This study aims to determine the diagnostic yield of endoscopy for clinically significant neoplasia following the successful nonoperative management of acute diverticulitis.

DESIGN

This study is a retrospective review.

SETTING

This study was conducted in a large urban health region.

PATIENTS

Adult patients who were admitted with a diagnosis of acute diverticulitis confirmed by CT and who were successfully managed nonoperatively to hospital discharge were included. Patients who underwent colonoscopy within 2 years of presentation were excluded.

MAIN OUTCOME MEASURE

The primary outcome measured was the incidence of clinically significant neoplasia (invasive malignancy or advanced adenoma) on follow-up endoscopy within 1 year of admission.

RESULTS

Four hundred fifty-eight patients were selected for analysis, of which 249 patients (54%) underwent endoscopy within 1 year of admission. Seventy-seven (30.9%) patients were found to have polyps, 19 (7.6%) patients had advanced adenomas, and 4 (1.6%) patients had an invasive malignancy; 23 patients (9.2%) were found to have clinically significant neoplasia. On subgroup analysis, patients presenting with complicated diverticulitis (n = 74) had a significantly higher incidence of advanced adenoma (18.9% vs 5%, p = 0.001) and invasive malignancy (5.4% vs 0%, p = 0.007) in comparison with patients who presented with uncomplicated diverticulitis (n = 175). On multivariate analysis, patient age (OR 1.04 (1.01-1.08), p = 0.02) and the presence of abscess (OR 4.15 (1.68-10.3), p = 0.002) were identified as significant risk factors for clinically significant neoplasia.

LIMITATIONS

The use of retrospective data was a limitation of this study; 54% of selected patients underwent endoscopic follow-up.

CONCLUSIONS

The incidence of clinically significant neoplasia on endoscopic follow-up after the nonoperative management of acute diverticulitis is 9.2%. Those with complicated diverticulitis are at higher risk, whereas the incidence of clinically significant neoplasia in those with uncomplicated diverticulitis is equal to the incidence in average-risk individuals. Routine diagnostic colonoscopy following the nonoperative management of acute uncomplicated diverticulitis may not be warranted.

CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy

OBJECTIVE

The aim of this study was to assess CT-colonography (CTC) in the follow-up of diverticulitis regarding patient acceptance and diagnostic accuracy for diverticular disease, adenomas and cancer, with colonoscopy as a reference standard.

METHODS

A prospective comparative study where half of the patients underwent colonoscopy first, followed immediately by CTC. The other half had the examinations in the reverse order. Patient experiences and findings were registered after every examination, blinded to the examiner.

RESULTS

Of a total of 110 consecutive patients, 108 were included in the study, with a median age of 56 years (range 27-84). The success rate was 91% for colonoscopy and 86% for CTC. Examination time was 25 min for both methods. The mean time for CTC evaluation was 20 min. Eighty-three per cent of the patients received sedation during colonoscopy. Despite this, patients experienced colonoscopy as more painful (p < 0.001) and uncomfortable (p < 0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a good agreement (κ = 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (κ = 0.17). No cancer was found.

CONCLUSION

CTC was less painful and unpleasant and can be used for colonic investigation in the follow-up of diverticulitis. CTC detected diverticulosis with good accuracy while the detection accuracy of small polyps was poor. CTC is a viable alternative, especially in case of incomplete colonoscopy or in a situation with limited colonoscopy resources.

Sigmoid diverticulitis: US findings

Acute diverticulitis (AD) results from inflammation of a colonic diverticulum. It is the most common cause of acute left lower-quadrant pain in adults and represents a common reason for acute hospitalization, as it affects over half of the population over 65 years with a prevalence that increases with age. Although 85% of colonic diverticulitis will recover with a nonoperative treatment, some patients may have complications such as abscesses, fistulas, obstruction, and /or perforation at presentation. For these reasons, different classifications were introduced through times to help clinicians to develop a correct diagnosis and guide the treatment and for the same reasons imaging is used in most cases both to realise a differential diagnosis and to guide the therapeutic management. US and CT are both usefull in diagnosis of diverticolitis, and their sensibility and specificity are similar. However CT scanning is essential for investigating complicated diverticular disease especially where there are diffuse signs and clinical suspicion of secondary peritonitis; instead in most uncomplicated cases the experienced sonographer may quickly confirm a diagnosis guided by the clinical signs. US is to be recommended in premenopausal women, and in young people to reduce dose exposure.

Diverticular disease severity score based on CT colonography

OBJECTIVE

We propose a diverticular disease severity score (DDSS) based on CT colonography (CTC) findings.

METHODS

Seventy-nine patients (62 ± 14.5 years) underwent CTC after recovering from an episode of acute diverticulitis. Two independent readers classified each case using a four-point scale (DDSS), based on maximum sigmoid colon wall thickness (MSCWT) and minimum lumen diameter at CTC: 1 = MSCWT <3 mm, lumen diameter ≥15 mm; 2 = MSCWT 3-8 mm, lumen diameter ≥5 mm; 3 = MSCWT ≥8 mm, lumen diameter ≥5 mm; 4 = MSCWT ≥8 mm, lumen diameter <5 mm. Intra- and interobserver reproducibility was evaluated. Of 79 patients, 32 (40 %) underwent surgery after CTC; MSCWT was directly measured on the pathological specimen.

RESULTS

Intra- and interobserver reproducibility of DDSS were almost perfect (k = 0.90-0.84). DDSS significantly correlated with the probability of surgery (P = 0.001). After surgery, histopathology revealed acute/chronic diverticular inflammation only in 29 cases, and superimposed sigmoid cancer (n = 2) or Crohn's disease (n = 1) in 3 patients with a DDSS of 4. MSCWT at histopathology correlated with DDSS (P = 0.008).

CONCLUSION

DDSS is highly reproducible and correlates with pathological MSCWT. Nearly 1 in 3 patients with a DDSS of 4 had significant superimposed histopathology. CTC with DDSS can provide colorectal surgeons with valuable information.

KEY POINTS

• A diverticular disease severity score (DDSS) based on CT colonography is proposed. • This DDSS is based on sigmoid colon wall thickness and lumen diameter. • High scores may be associated with relevant coexisting lesions. • A CTC-based DDSS may influence therapeutic decision-making.

Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review

PURPOSE

To estimate the prevalence of underlying adenocarcinoma of the colon in patients in whom acute diverticulitis was diagnosed at computed tomography (CT) and to compare that to the prevalence of colon cancer in the general population.

MATERIALS AND METHODS

A comprehensive literature review was performed to find articles in which patients with CT diagnosis of acute diverticulitis underwent surgery, colonoscopy, or barium enema study within 24 weeks. Patients meeting these criteria were included for analysis. A pooled prevalence of cancer was calculated on the basis of a random effects model and compared qualitatively with the prevalence of cancer in the general population. The 95% confidence intervals around the prevalence of cancer in the study populations were determined.

RESULTS

Ten articles met the inclusion criteria. Data from these articles included only 771 patients who underwent surgery, colonoscopy, or barium enema study within 24 weeks of diagnosis. Fourteen patients were found to have colon cancer, for a prevalence of 2.1% (95% confidence interval: 1.2%, 3.2%). This compares to a calculated estimated prevalence of 0.68% among U.S. adults older than 55 years.

CONCLUSION

There are limited data to support the recommendation to perform colonoscopy after a diagnosis of acute diverticulitis.

Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease

BACKGROUND

Ulcerative colitis with diverticulosis (UCD), segmental colitis associated with diverticulosis (SCAD) and acute uncomplicated diverticulitis (AUD) may affect the same colonic regions, but the real incidence of these entities in clinical practice is unknown.

AIM

To assess the incidence and the endoscopic findings of UCD, SCAD and AUD.

METHODS

From January 2004 to June 2009, 8525 consecutive colonoscopies were performed. Diagnosis of the diseases was based on specific endoscopic and histological (UCD and SCAD), and on endoscopic and radiological (AUD) patterns.

RESULTS

Ulcerative colitis with diverticulosis was diagnosed in 25 patients (0.3%), SCAD was diagnosed in 129 patients (2%) and AUD was diagnosed in 130 patients (2%). In UCD, the inflammation in colonic area harbouring diverticula always affects the overall colonic mucosa in all cases, involving also diverticular orifices. The endoscopic characteristic of SCAD is that inflammation is mainly detected within the inter-diverticular mucosa without involvement of the diverticular orifices. In AUD, the inflammation affects primarily diverticular orifice and peri-diverticular mucosa.

CONCLUSIONS

In clinical practice, the incidence of mucosal inflammation in the presence of colonic diverticular disease is low and endoscopy is the mainstay of differential diagnosis.

CT colonography for synchronous colorectal lesions in patients with colorectal cancer: initial experience

AIM

To assess accuracy of CT colonography (CTC) in identifying synchronous lesions in patients with colorectal carcinoma.

METHODS

This study included 174 consecutive patients undergoing CTC as part of staging or primary investigation where a colorectal cancer was diagnosed between 2004 and 2007. Prone unenhanced and portal phase enhanced supine series with air or CO(2) distension were acquired using 4- or 16-slice CT (Toshiba) and read by 2D +/- 3D formats. Synchronous lesions were classified according to American College of Radiology's (ACR) polyp classification. Segmental gold standard was flexible sigmoidoscopy/colonoscopy within 1 year and/or histology of colonic resection supplemented by follow-up. Nine patients without gold standard were excluded. Sensitivity, specificity and accuracy were calculated on a per polyp, per patient and per segment basis and discrepancies analysed.

RESULTS

Direct comparable data were available for 764/990 colonic segments from 165 patients. Of 41 (C2-C4) synchronous lesions on "gold standard", 33 were correctly identified on virtual colonoscopy (VC), overall per polyp sensitivity was 80.5%, with detection rates of 20/24 C3 (83.3%) and 3/3 C4 (100%) with per patient and per segment specificity of 95.4% and 99.2%, respectively.

CONCLUSION

CTC is an accurate technique to assess for significant synchronous lesions in patients with colorectal cancer and is applicable for total pre-operative colonic visualisation.

Diverticulosis and acute diverticulitis

Colonic diverticulosis is a common, usually asymptomatic, entity of Western countries, with an incidence that increases with age. When these diverticula become infected and inflamed, patients can present with a wide variety of clinical manifestations. Management of acute, uncomplicated diverticulitis can often be treated successfully with antibiotics alone and the decision to proceed with more aggressive measures such as surgical intervention is made on a case-by-case basis. The treatment algorithm for diverticular disease continues to evolve as the pathophysiology, etiology, and natural history of the disease becomes better understood.

Colonography by CT, MRI and PET/CT combined with conventional colonoscopy in colorectal cancer screening and staging

Colorectal cancer (CRC) remains a leading cancer killer worldwide. But the disease is both curable and preventable at an early stage. Regular CRC cancer screening has been shown to reduce the risk of dying from CRC. However, the importance of large-scale screening is only now starting to be appreciated. This article reviews a variety of imaging procedures available for detecting ulcerative colitis (UC) and Crohn’s disease (CD), polyps and CRC in their early stage and also presents details on various screening options. Detecting, staging and re-staging of patients with CRC also require multimodality, multistep imaging approaches. Staging and re-staging with conventional colonoscopy (CC), computer tomography colonography (CTC), magnetic resonance colonography (MRC) and positron emission tomography/computer tomography colonography (PET/CTC) are of paramount importance in determining the most appropriate therapeutic method and in predicting the risk of tumor recurrence and overall prognosis. The advantages and limitations of these modalities are also discussed.