Prognostic performance of the ‘DICA’ endoscopic classification and the ‘CODA’ score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study

Abstract

ObjectiveTo investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA).DesignA multicentre, prospective, international cohort study.Setting43 gastroenterology and endoscopy centres located in Europe and South America.Participants2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications.InterventionsA 3-year follow-up was performed.Main outcome measuresTo predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score).ResultsThe 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).ConclusionsDICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score.Trial registration numberNCT02758860.

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

“…The DICA score can predict the outcomes of the disease in terms of AD occurrence/recurrence and surgery. Indeed, after the first promising results coming from a retrospective study [ 43 ], a recent large (more than 2000 patients enrolled) prospective study confirmed that DICA classification plays a significant role in predicting the outcome of the disease since the severity of the DICA score was strictly linked to the risk of having an AD occurrence/recurrence, or to a surgical procedure due to DD complications [ 44 ]. Moreover, the authors found that the clinical evolution of the DICA classification, the CODA (Combined Overview on Diverticular Assessment), combines the DICA score with two clinical parameters; namely, age at baseline and severity of abdominal pain at baseline, showed a more substantial 3-year cumulative probability of diverticulitis and surgery [ 44 ].…”

“…Indeed, after the first promising results coming from a retrospective study [ 43 ], a recent large (more than 2000 patients enrolled) prospective study confirmed that DICA classification plays a significant role in predicting the outcome of the disease since the severity of the DICA score was strictly linked to the risk of having an AD occurrence/recurrence, or to a surgical procedure due to DD complications [ 44 ]. Moreover, the authors found that the clinical evolution of the DICA classification, the CODA (Combined Overview on Diverticular Assessment), combines the DICA score with two clinical parameters; namely, age at baseline and severity of abdominal pain at baseline, showed a more substantial 3-year cumulative probability of diverticulitis and surgery [ 44 ]. These results, together with an extensive validation process performed by experts [ 45 , 46 ] and in real life [ 47 ], confirm that DICA classification may significantly impact the therapeutic choice, and its development opens the way to further, more personalized therapeutic trials in these patients.…”

Polygenic Risk Prediction in Diverticulitis

“…Similarly, surgeons cannot predict which patients with acute diverticulitis will go on to suffer severe or recurrent disease. Clinical, radiologic, and endoscopic risk prediction tools have previously been proposed and prospectively studied [13][14][15][16] but have not been effectively adopted into clinical guidelines or common use. As a result of this lack of risk stratification, some patients with diverticulitis are overtreated with unnecessary surgery and others are undertreated, suffering recurrent episodes before a therapeutic operation.…”

Scoring systems for diverticular disease

“…The relatively rigid dictum/dogma that used to facilitate operative decision-making by essentially obviating the need to deviate from the algorithm has been replaced by a void as individual management may not always be evidence-based. Therefore, the work by Tursi and colleagues11 is indeed important in helping us to fill this void by potentially giving us some direction as to who with diverticular disease might need surgery. This very modern approach would be a welcome replacement to the now no longer practised age and number of episode-based criteria.…”

“…Tursi and coworkers11 are to be commended for having amassed 2198 patients who completed the study in 43 gastroenterology and endoscopy enters in Europe and South America. The diverticular inflammation and complication assessment (DICA) classification and the combined overview on diverticular assessment (CODA) are exceptionally intriguing.…”