Family History Is Associated With Recurrent Diverticulitis After an Episode of Diverticulitis Managed Nonoperatively

Abstract

BACKGROUND: To date, the impact of family history on diverticulitis outcomes has been poorly described. OBJECTIVE: This study aims to evaluate the association between family history and diverticulitis recurrence after an episode of diverticulitis managed nonoperatively. DESIGN: This is a retrospective cohort study with prospective telephone follow-up. SETTINGS: This study was conducted at 2 McGill University-affiliated tertiary care hospitals in Montreal, Canada. PATIENTS: All immunocompetent patients with CT-proven left-sided diverticulitis who were managed nonoperatively from 2007 to 2017 were included. INTERVENTION: A positive family history for diverticulitis, as assessed by a detailed telephone questionnaire, was obtained. MAIN OUTCOME MEASURES: The primary outcome was diverticulitis recurrence occurring >60 days after the index episode. Secondary outcomes included a complicated recurrence and >1 recurrence (ie, re-recurrence). RESULTS: Of the 879 patients identified in the database, 433 completed the telephone questionnaire (response rate: 48.9%). Among them, 173 (40.0%) had a positive family history of diverticulitis and 260 (60.0%) did not. Compared to patients with no family history, patients with family history had a younger median age (59.0 vs 62.0 years, p = 0.020) and a higher incidence of abscess (24.3% vs 3.5%, p < 0.001). After a median follow-up of 40.1 (17.4–65.3) months, patients with a positive family history had a higher cumulative incidence of recurrence (log-rank test: p < 0.001). On Cox regression, a positive family history remained associated with diverticulitis recurrence (HR, 3.74; 95% CI, 2.67–5.24). Among patients with a positive family history, >1 relative with a history of diverticulitis had a higher hazard of recurrence (HR, 2.93; 95% CI, 1.96–4.39) than patients with only 1 relative with a history of diverticulitis. Positive family history was also associated with the development of a complicated recurrence (HR, 8.30; 95% CI, 3.64–18.9) and >1 recurrence (HR, 2.03; 95% CI, 1.13–3.65). LIMITATIONS: This study has the potential for recall and nonresponse bias. CONCLUSION: Patients with a positive family history of diverticulitis are at higher risk for recurrent diverticulitis and complicated recurrences. See Video Abstract at http://links.lww.com/DCR/B215. LOS ANTECEDENTES FAMILIARES ESTÁN ASOCIADOS CON DIVERTICULITIS RECURRENTE, DESPUÉS DE UN EPISODIO DE DIVERTICULITIS MANEJADA SIN OPERACIÓN ANTECEDENTES: Hasta la fecha, el impacto de los antecedentes familiares en los resultados de la diverticulitis, ha sido mal descrito. OBJETIVO: Evaluar la asociación entre los antecedentes familiares y la recurrencia de diverticulitis después de un episodio de diverticulitis manejado de forma no operatoria. DISEÑO: Estudio de cohorte retrospectivo con seguimiento telefónico prospectivo. AJUSTES: Dos hospitales de atención terciaria afiliados a la Universidad McGill en Montreal, Canadá. PACIENTES: Todos los pacientes inmunocompetentes con diverticulitis izquierda comprobada por TAC, que fueron manejados sin cirugía desde 2007–2017. INTERVENCIÓN: Una historia familiar positiva para diverticulitis, según lo evaluado por un detallado cuestionario telefónico. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la recurrencia de diverticulitis ocurriendo > 60 días después del episodio índice. Resultados secundarios incluyeron una recurrencia complicada y >1 recurrencia (es decir, re-recurrencia). RESULTADOS: De los 879 pacientes identificados en la base de datos, 433 completaron el cuestionario telefónico (tasa de respuesta: 48,9%). Entre ellos, 173 (40.0%) tenían antecedentes familiares positivos de diverticulitis y 260 (60.0%) no tenían. Comparados con los pacientes sin antecedentes familiares, los pacientes con antecedentes familiares tenían una mediana de edad más joven (59.0 vs 62.0 años, p = 0.020) y una mayor incidencia de abscesos (24.3% vs 3.5%, p < 0.001). Después de una mediana de seguimiento de 40.1 (17.4–65.3) meses, los pacientes con antecedentes familiares positivos tuvieron una mayor incidencia acumulada de recurrencia (prueba de log-rank: p < 0.001). En la regresión de Cox, un historial familiar positivo, permaneció asociado con recurrencia de diverticulitis (HR, 3.74; IC 95%, 2.67–5.24). Entre los pacientes con antecedentes familiares positivos, >1 familiar con antecedentes de diverticulitis, tuvieron mayores riesgos de recurrencia (HR, 2.93; IC 95%, 1.96–4.39) en comparación de los pacientes con solo 1 familiar. La historia familiar positiva también se asoció con el desarrollo de una recurrencia complicada (HR, 8.30; IC 95%, 3.64–18.9) y >1 recurrencia (HR, 2.03; IC 95%, 1.13–3.65). LIMITACIONES: Potencial de recuerdo y sesgo de no respuesta. CONCLUSIÓN: Los pacientes con antecedentes familiares positivos de diverticulitis tienen un mayor riesgo para diverticulitis recurrente y recurrencias complicadas. Consulte Video Resumen http://links.lww.com/DCR/B215. (Traducción—Dr. Fidel Ruiz Healy)

The Association Between Family History and Diverticulitis Recurrence: A Population-Based Study

“…Alternatively, they might see the long-term sequelae of smoldering symptoms or complicated disease and seek surgical treatment to avoid the experience of a family member. Another possibility is that surgeons are more likely to recommend colectomy for those with a family history, either due to recent literature demonstrating an association between family history and recurrence 12,14 or perhaps because family history predisposes individuals to disease characteristics unmeasured in the present study, such as smoldering symptoms or outpatient recurrence. Because elective surgery substantially reduces the risk of recurrence, 39,40 it is also possible that the increased use of surgery among those with a family history played a significant role in decreasing recurrence.…”

“…In a US-based, single-center analysis, Hall et al demonstrated an increased risk of recurrent diverticulitis (HR 2.2; 95% CI 1.4–3.2) among individuals with a family history of diverticulitis as defined by retrospective medical record review. 12 In a study at 2 Canadian centers, Almalki et al 14 demonstrated that a patient-reported family history of diverticulitis was associated with recurrence (HR 3.74; 95% CI 2.67–5.24). Participants in both studies were more likely to experience recurrence (36% and 37%, respectively), which may be due to inclusion of outpatient diverticulitis episodes as recurrences.…”

Emerging evidence and recent controversies in diverticulitis: a 5-year review

“…Additional phenome-wide association studies were undertaken that showed genetic enrichment of mesenchymal stem cells and other connective cell and tissue types. Patients with a family history of diverticulitis have also been noted to be at higher risk for recurrent and complicated episodes, though the potential genetic underpinning of this finding has not been specifically investigated [ 17 ]. The milieu of pathophysiologic factors that may cause diverticulitis is summarized in Fig.…”

Genetic Risk Factors for Diverticular Disease—Emerging Evidence

“…Outside of these rare syndromes and families however, diverticulitis typically occurs sporadically in otherwise healthy patients. However, even among typical diverticulitis patients, family history is an independent risk factor for disease recurrence and diverticular complications 23 .…”