Management of Colonic Diverticulitis [Internet]

Excerpt

Background: There remain uncertainties about the effectiveness and harms of various nonsurgical treatment options for acute diverticulitis, clinical consequences of diagnostic imaging, detection strategies for colorectal cancer (CRC) in patients with recent diverticulitis, and preventive options for long-term recurrence.

Methods: We searched Medline^®, the Cochrane databases, Embase^®, CINAHL^®, and ClinicalTrials.gov from 1990 through June 1, 2020. We included existing systematic reviews (SRs) of computed tomography (CT) test accuracy, randomized controlled trials, adequately adjusted nonrandomized comparative studies for all topics, and larger single-group studies that addressed specific questions.

Results: We included 77 primary studies and 2 SRs. With moderate strength of evidence (SoE), CT has high sensitivity (94%) and specificity (99%) to diagnose acute diverticulitis. There is low SoE that CT imaging leads to appropriate management decisions and that misdiagnoses on CT do not result in poor clinical outcomes. Incidental findings on CT may be common (low SoE), but their clinical significance is unclear. There is insufficient evidence about CT test accuracy to stage acute diverticulitis. For patients with uncomplicated acute diverticulitis, there is low SoE that initial outpatient or inpatient management have similar risks of recurrence or elective surgery, but insufficient evidence regarding risk of treatment failure and other outcomes. For patients with uncomplicated acute diverticulitis, there is low SoE that antibiotic treatment does not affect clinically important outcomes. There is insufficient evidence regarding percutaneous drainage to manage complicated acute diverticulitis. There is low SoE that patients with recent acute diverticulitis may be at increased risk of CRC compared with the general population, but that those who undergo colonoscopy soon after acute diverticulitis may ultimately have similar rates of CRC as those who do not. Patients 50 years and older may be at increased risk of CRC (moderate SoE) or premalignant lesions (low to high SoE) compared with younger patients. Colonoscopy after acute diverticulitis rarely results in complications or incomplete procedures (high SoE). The risk of recurrence is not reduced by 5-aminosalicylic acid (5-ASA) (high SoE). The evidence regarding other nonsurgical interventions to prevent recurrence is insufficient. In patients with prior complicated or smoldering/frequently recurrent (after uncomplicated) diverticulitis, elective surgery reduces the risk of diverticulitis recurrence (high SoE), but there is no evidence regarding which patients may benefit most from surgery.

Conclusion: Important questions about which interventions should be used for which patients remain either unanswered or answered with only low SoE. New high-quality research is needed.