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

Abstract

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.

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

“…Further, we reported the following prevalences for polyps: Polyp 22.7% (21 studies, 95%CI: 19.6%-16.0%), hyperplastic polyp 9.2% (13 studies, 95%CI: 7.6%-11.2%), adenoma 14.2% (15 studies, 95%CI: 11.8%-17.1%) and advanced adenoma 4.4% (8 studies, 95%CI: 3.4%-5.8%)[ 2 , 3 ]. We note that these prevalences are higher than the prevalence reported by Asaad et al[ 1 ] in patients suffering from diverticulitis.…”

“…We think that the opposing conclusions reached by Asaad et al[ 1 ] might be explained by limitations in their study design, as they have reported in their publication. First, we believe that the number of patients suffering from diverticulitis included by the authors over a three-year period in three centers is too small and that their study is insufficiently powered to show any difference with reference patients.…”

“…We thank Asaad et al[ 1 ] for their interesting publication in the field of colorectal cancer and diverticulitis, that we have read with great attention.…”

“…Asaad et al[ 1 ] concluded that “ routine endoscopy assessment of patients after an episode of CT proven acute diverticulitis may be unnecessary ”. The authors proposed endoscopy to be performed on a “ case-by-case basis ” and to reserve it to patients with complicated diverticulitis.…”

A selective approach for colonoscopy after acute diverticulitis

“…These findings are in line with the recommendations from the World Society of Emergency Surgery [2]. Currently, multidetector CT is widely used for the diagnosis of diverticulitis and its complications, with high sensitivity and specificity, leading to a better evaluation of the affected colonic segment and a selective approach to colonoscopy [3,4].…”