TY - JOUR
AU - Gervaz, P
AB - Abstract Background The natural history of sigmoid diverticulitis has been inferred from population-based or retrospective studies. This study assessed the risk of a recurrent attack following the first episode of uncomplicated diverticulitis. Methods Patients admitted between January 2007 and December 2011 with a first episode of uncomplicated sigmoid diverticulitis confirmed on computed tomography were enrolled in this prospective study. After successful medical management of the first episode, follow-up was conducted through yearly telephone interviews. Cox proportional hazards regression was performed to model the impact of various parameters on eventual recurrences and complications. Results During a median follow-up of 24 (range 3–63) months, 46 (16·4 per cent) of 280 patients experienced a second episode of diverticulitis. Six patients (2·1 per cent) subsequently developed complicated diverticulitis and four (1·4 per cent) underwent emergency surgery for peritonitis. In multivariable analysis, a raised serum level of C-reactive protein (over 240 mg/l) during the first attack was associated with early recurrence (hazard ratio 1·75, 95 per cent confidence interval 1·04 to 2·94; P = 0·035). Conclusion Uncomplicated sigmoid diverticulitis follows a benign course with few recurrences and little need for emergency surgery. Registration number: NCT01015378 (http://www.clinicaltrials.gov). Introduction Although sigmoid diverticulitis is common, there are no modern prospective data to elucidate the natural history. Original literature suggested a high risk of recurrence and subsequent complications1. However, recent series suggest that the natural history of sigmoid diverticulitis is more benign in the era of modern antibiotics2. Few series have looked at the true recurrence risk; the diagnosis was often based on clinical parameters without imaging by computed tomography (CT)3,4. This study was designed to assess the natural history of uncomplicated sigmoid diverticulitis diagnosed by CT. Methods Between January 2007 and December 2011, all patients with a first episode of uncomplicated diverticulitis, documented by CT and requiring admission to hospital, were included prospectively in the present study. Informed consent was obtained from all patients. The study was undertaken in accordance with ethical guidelines after being reviewed by the Ethics Committee for Clinical Research at this institution. This study was registered in ClinicalTrials.gov (registration number NCT01015378). Inclusion was based on a definition of simple diverticulitis that comprised clinical, biological, radiological and endoscopic criteria5: acute lower abdominal pain or discomfort; inflammatory syndrome (serum C-reactive protein (CRP) concentration over 50 mg/l or white blood cell count exceeding 11 × 109/l); signs of inflammation of the sigmoid and/or descending colon on CT; and endoscopic documentation of the presence of diverticula, while ruling out another associated condition. Exclusion criteria were: age younger than 18 or older than 85 years, malignancy, pericolic or pelvic abscess indicating complicated diverticulitis, an associated colorectal condition, and refusal to give informed consent. All patients were encouraged to undergo routine colonoscopy 8–12 weeks after the first attack. Follow-up was carried out at yearly intervals by telephone interview with the patient and/or physician. When the patient developed signs or symptoms that were unclear, the principal investigator reviewed the clinical and radiological data to clarify the situation and to rule out recurrent diverticulitis. The primary endpoint was the occurrence of a second episode of diverticulitis following complete resolution of the index episode. The minimum disease-free interval was defined as 3 months between episodes. Each new attack was documented by CT, and the previously described clinical, biological and radiological criteria were again required to make the diagnosis. Secondary endpoints were: severity of the recurrent episode (simple versus complicated), need for emergency surgery, and need for subsequent elective sigmoid resection. Complicated diverticulitis was defined according to the Hinchey classification6, or by the presence of a fistula or stenosis. Statistical analysis A time-to-event analysis was performed, the event considered being recurrence. Patients were censored at the time of the last call for follow-up. The survival function was estimated by the Kaplan–Meier method, with statistical testing by means of the log rank test. Univariable and multivariable analysis using Cox proportional hazards regression was carried out to test the effect of the following explanatory variables on recurrence: age, body mass index, leucocyte count, CRP level on admission with the first episode of diverticulitis, fever, free air on initial CT and intra-abdominal fluid on CT. For each model, the Cox proportional hazards and log-linearity assumptions were tested using Schoenfeld and cumulative Martingale residuals respectively. Hazard ratios are presented with 95 per cent confidence intervals. Two-sided P ≤ 0·050 was considered statistically significant. Data were analysed using R 2·13·2 software, package survival (R Foundation for Statistical Computing, Vienna, Austria; http://www.R-project.org). Results During the study period, 285 patients were admitted for a first episode of simple sigmoid diverticulitis documented by CT. Follow-up was complete for 280 patients (98·2 per cent), including 138 men and 142 women with a median age of 56 (range 24–85) years. Some 208 patients (74·3 per cent) underwent full colonoscopy. Patient characteristics are summarized in Table 1. After a median follow-up of 24 (range 3–63) months, the overall recurrence rate was 16·4 per cent. More than half of the recurrences occurred during the first year. In the group of 46 patients who developed a second attack of diverticulitis, only six recurrent episodes (2·1 per cent) were complicated; two patients with abscesses were managed with intravenous antibiotics plus CT-guided percutaneous drainage, and four (1·4 per cent) with Hinchey grade 3–4 peritonitis underwent emergency sigmoid resection with end colostomy. In the group of 40 patients who presented with an uncomplicated second attack, 23 (8·2 per cent of 280) underwent subsequent elective sigmoid colectomy. Table 1 Patient characteristics . No. of patients* (n = 280) . Age (years)† 59 (49–68) Body mass index (kg/m2)     < 25 102 (36·4)     25–35 105 (37·5)     > 35 73 (26·1) Leucocyte count (×109/l)† 11·3 (9·7–13·5) C-reactive protein (mg/l)† 135 (85–204)     > 240 44 (15·7) Fever (>37 °C) 49 (17·5) Free air on CT 23 (8·2) Intra-abdominal free fluid on CT 35 (12·5) . No. of patients* (n = 280) . Age (years)† 59 (49–68) Body mass index (kg/m2)     < 25 102 (36·4)     25–35 105 (37·5)     > 35 73 (26·1) Leucocyte count (×109/l)† 11·3 (9·7–13·5) C-reactive protein (mg/l)† 135 (85–204)     > 240 44 (15·7) Fever (>37 °C) 49 (17·5) Free air on CT 23 (8·2) Intra-abdominal free fluid on CT 35 (12·5) * With percentages in parentheses unless indicated otherwise; † values are median (interquartile range). CT, computed tomography. Open in new tab Table 1 Patient characteristics . No. of patients* (n = 280) . Age (years)† 59 (49–68) Body mass index (kg/m2)     < 25 102 (36·4)     25–35 105 (37·5)     > 35 73 (26·1) Leucocyte count (×109/l)† 11·3 (9·7–13·5) C-reactive protein (mg/l)† 135 (85–204)     > 240 44 (15·7) Fever (>37 °C) 49 (17·5) Free air on CT 23 (8·2) Intra-abdominal free fluid on CT 35 (12·5) . No. of patients* (n = 280) . Age (years)† 59 (49–68) Body mass index (kg/m2)     < 25 102 (36·4)     25–35 105 (37·5)     > 35 73 (26·1) Leucocyte count (×109/l)† 11·3 (9·7–13·5) C-reactive protein (mg/l)† 135 (85–204)     > 240 44 (15·7) Fever (>37 °C) 49 (17·5) Free air on CT 23 (8·2) Intra-abdominal free fluid on CT 35 (12·5) * With percentages in parentheses unless indicated otherwise; † values are median (interquartile range). CT, computed tomography. Open in new tab In univariable analysis, white blood cell count and serum CRP level showed a significant association with risk of recurrence, whereas age, body mass index, fever and presence of fluid within the peritoneal cavity did not (Table 2). The presence of free air on initial CT was of borderline significance (P = 0·055); this association is noteworthy, as patients with free air pockets on CT during the first episode of diverticulitis had 2·20 times the risk of recurrence compared with patients without pneumoperitoneum. Table 2 Results of univariable Cox proportional hazards analysis assessing the risk of recurrence . Hazard ratio . P . Age 0·99 (0·96, 1·01) 0·203 Body mass index 0·97 (0·91, 1·03) 0·330 Leucocyte count 1·11 (1·02, 1·20) 0·013 C-reactive protein 1·00 (1·00, 1·01) 0·010 Fever 1·06 (0·72, 1·56) 0·775 Free air on CT 2·20 (0·99, 4·90) 0·055 Intra-abdominal free fluid on CT 1·26 (0·59, 2·69) 0·559 . Hazard ratio . P . Age 0·99 (0·96, 1·01) 0·203 Body mass index 0·97 (0·91, 1·03) 0·330 Leucocyte count 1·11 (1·02, 1·20) 0·013 C-reactive protein 1·00 (1·00, 1·01) 0·010 Fever 1·06 (0·72, 1·56) 0·775 Free air on CT 2·20 (0·99, 4·90) 0·055 Intra-abdominal free fluid on CT 1·26 (0·59, 2·69) 0·559 Values in parentheses are 95 per cent confidence intervals. CT, computed tomography. Open in new tab Table 2 Results of univariable Cox proportional hazards analysis assessing the risk of recurrence . Hazard ratio . P . Age 0·99 (0·96, 1·01) 0·203 Body mass index 0·97 (0·91, 1·03) 0·330 Leucocyte count 1·11 (1·02, 1·20) 0·013 C-reactive protein 1·00 (1·00, 1·01) 0·010 Fever 1·06 (0·72, 1·56) 0·775 Free air on CT 2·20 (0·99, 4·90) 0·055 Intra-abdominal free fluid on CT 1·26 (0·59, 2·69) 0·559 . Hazard ratio . P . Age 0·99 (0·96, 1·01) 0·203 Body mass index 0·97 (0·91, 1·03) 0·330 Leucocyte count 1·11 (1·02, 1·20) 0·013 C-reactive protein 1·00 (1·00, 1·01) 0·010 Fever 1·06 (0·72, 1·56) 0·775 Free air on CT 2·20 (0·99, 4·90) 0·055 Intra-abdominal free fluid on CT 1·26 (0·59, 2·69) 0·559 Values in parentheses are 95 per cent confidence intervals. CT, computed tomography. Open in new tab As leucocytes and CRP were strongly correlated with each other, only CRP was retained for subsequent analysis. The effect of CRP at admission was examined over two intervals, one spanning the first 6 months after the initial episode of diverticulitis and the other the remaining period. This model showed that CRP at admission was a risk factor for recurrence only in the first 6 months. Thus, in multivariable analysis, the only risk factor for recurrence was a raised serum CRP level during the first episode (Table 3). Fig. 1 shows recurrence-free survival according to the CRP level; individuals with a CRP concentration greater than 240 mg/l had a 6-month recurrence risk of 22 per cent, compared with 8·2 per cent among individuals with a CRP level of 240 mg/l or less (P < 0·001). Table 3 Multivariable Cox proportional hazards model examining the relationship between serum C-reactive protein level on admission and the risk of early and late recurrent diverticulitis . Hazard ratio . P . Effect of CRP during first 6 months 1·75 (1·04, 2·94) 0·035 Effect of CRP after first 6 months 1·04 (0·69, 1·57) 0·854 . Hazard ratio . P . Effect of CRP during first 6 months 1·75 (1·04, 2·94) 0·035 Effect of CRP after first 6 months 1·04 (0·69, 1·57) 0·854 Values in parentheses are 95 per cent confidence intervals. CRP, C-reactive protein. Open in new tab Table 3 Multivariable Cox proportional hazards model examining the relationship between serum C-reactive protein level on admission and the risk of early and late recurrent diverticulitis . Hazard ratio . P . Effect of CRP during first 6 months 1·75 (1·04, 2·94) 0·035 Effect of CRP after first 6 months 1·04 (0·69, 1·57) 0·854 . Hazard ratio . P . Effect of CRP during first 6 months 1·75 (1·04, 2·94) 0·035 Effect of CRP after first 6 months 1·04 (0·69, 1·57) 0·854 Values in parentheses are 95 per cent confidence intervals. CRP, C-reactive protein. Open in new tab Fig. 1 Open in new tabDownload slide Kaplan–Meier analysis of recurrence according to serum C-reactive protein (CRP) level on admission. P < 0·001 (log rank test) Discussion In the present study, uncomplicated diverticulitis in the majority of patients followed a benign course without recurrence; recurrence was uncommon and very rarely complicated. Two previous studies analysed a large US administrative database and reported recurrence rates of 13 and 19 per cent respectively7,8, in accordance with the present findings. These results support the suggestion that a conservative policy for managing sigmoid diverticulitis is safe9,10. They also confirm that diverticulitis is not a progressive disease11. Young age has often been reported as a risk factor for recurrence after a first episode of simple diverticulitis, and two decades ago prophylactic sigmoid colectomy was still recommended in patients who had developed a first episode before the age of 50 years12,13. The present data do not support the hypothesis that sigmoid diverticulitis follows a more aggressive course in younger individuals. These results indicate that conservative management is valid for all age groups. The severity of inflammation (reflected by serum CRP level) was the only parameter that correlated with recurrence. Recent evidence suggests that CRP is the most sensitive serological marker in uncomplicated sigmoid diverticulitis, and that a concentration above 200 mg/l may be correlated with local complication14,15. The authors recently proposed that a CRP level exceeding 50 mg/l should be included in the diagnostic criteria for sigmoid diverticulitis16. In contrast, CT-related variables, such as the presence of fluid in the pelvis, did not emerge as predictors of recurrence. Notably, the presence of free air on CT was of borderline significance, and may emerge as a significant predictor of recurrence in a larger patient group. This study has demonstrated that the natural history of sigmoid diverticulitis is benign in more than 95 per cent of cases. It is concluded that complication rates related to prophylactic surgery for uncomplicated diverticulitis are higher than those related to the disease itself. Disclosure The authors declare no conflict of interest. References 1 Parks TG . 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Google Scholar Crossref Search ADS PubMed WorldCat 15 Tursi A , Elisei W, Brandimarte G, Giorgetti GM, Aiello F. Predictive value of serologic markers of degree of histological damage in acute uncomplicated colonic diverticulitis . J Clin Gastroenterol 2010 ; 44 : 702 – 706 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Gervaz P , Platon A, Widmer L, Ambrosetti P, Poletti PA. A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2 . Colorectal Dis 2012 ; 14 : 463 – 468 . Google Scholar Crossref Search ADS PubMed WorldCat © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd
TI - Assessment of recurrence and complications following uncomplicated diverticulitis
JO - British Journal of Surgery
DO - 10.1002/bjs.9119
DA - 2013-05-03
UR - https://www.deepdyve.com/lp/oxford-university-press/assessment-of-recurrence-and-complications-following-uncomplicated-UGwO60fk0I
SP - 976
EP - 979
VL - 100
IS - 7
DP - DeepDyve
ER -