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Effective Health Care Program

Management of Diverticulitis

Key Questions Draft
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Draft Key Questions

Key Question 1: What are the benefits and harms of CT imaging for the initial diagnosis of acute diverticulitis compared to other imaging modalities?

  1. Do the benefits and harms vary by patient characteristics or presentation of illness?

Key Question 2: What are the effectiveness/harms of antibiotics for the treatment of acute diverticulitis?

  1. What are the effectiveness/harms of antibiotics for the treatment of acute uncomplicated diverticulitis?
  2. What are the effectiveness/harms of antibiotics for the treatment of acute complicated diverticulitis?
  3. Do the effectiveness/harms vary by route of administration of antibiotic, type of antibiotic, duration of course of antibiotic?
  4. Do the effectiveness/harms vary by other patient characteristics or presentation of illness?

Key Question 3: What are the comparative effectiveness/harms of antibiotics for the treatment of acute diverticulitis?

  1. Do the comparative effectiveness/harms vary by patient characteristics or presentation of illness?

Key Question 4: What are the benefits and harms of distant colonoscopy following an episode of acute diverticulitis?

  1. Do the benefits and harms vary by patient characteristics or presentation/course of illness?

Key Question 5: What are the effectiveness and harms of pharmacological (e.g., mesalamine, etc.) and non-pharmacologic (e.g., dietary advice) interventions to prevent recurrent diverticulitis?

  1. Do the effectiveness and harms vary by patient characteristics or presentation/ course of illness?

Key Question 6: What are the comparative benefits and harms of the various treatments for recurrent diverticulitis?

  1. What are the comparative benefits/harms of the various treatments for recurrent uncomplicated diverticulitis?
  2. What are the comparative benefits/harms of the various treatments for recurrent complicated diverticulitis?
  3. Do the comparative benefits and harms vary by patient characteristics or presentation/course of illness?

Background

Colonic diverticulosis is a common condition in Western countries with prevalence rates that exponentially increases with age.1 Under the age of 30, only 1–2% of patients have diverticulosis but by 80 years of age the prevalence increases to 50-66%.2,3 About 10–25% of patients with diverticulosis will develop inflammation leading to a condition termed acute diverticulitis.4 Acute diverticulitis can be subdivided into uncomplicated and complicated categories. In their lifetime, approximately 15–20% of individuals with diverticulosis will develop acute complicated diverticulitis (ACD).5 As opposed to uncomplicated diverticulitis, ACD is characterized by the presence of phlegmon, abscess, or perforation.6 Recurrent episodes of ACD can lead to late complications such as stenosis or fistula.7

Recently, there has been a substantial increase in incidence rates of both complicated and uncomplicated diverticulitis as well as a considerable rise in number of hospital admissions. This has led to a significant cost burden of up to $2.4 billion annually in the United States attributable to diverticulitis complications alone.8,9

In recent years, several controversies have emerged with regards to the optimal management of acute diverticulitis.10 Whether antibiotics are truly necessary for treatment of acute uncomplicated diverticulitis has been recently questioned.11 Due to unfavorable mortality and complication rates for emergent surgery for ACD, physicians have opted to delay definitive surgical management by employing antibiotics and interventional radiology procedures such as percutaneous drainage of abscess in appropriate patients. Surgical approaches have also evolved from Hartmann's procedure to primary anastomosis with protective stoma or even laparoscopic lavage and drainage for diverticulitis complicated by perforations with purulent or feculent peritonitis.12 Other areas of controversy include selection of the optimal imaging modality to diagnose uncomplicated and complicated diverticulitis as well as appropriateness of performing distal colonoscopy following a resolved episode of diverticulitis to detect occult colonic malignancy.13,14 In addition, pharmacologic and non-pharmacologic measures such as 5-aminosalicylates and dietary modification, respectively, to prevent recurrent diverticulitis have been of recent interest for physicians.15,16

Draft Analytic Framework

Figure 1. Draft analytic framework for Key Question 1

Figure 1: This figure depicts key question 1 within the context of the PICOTS described in the previous section. In general, the figure illustrates how imaging modalities such as CT Scan, MRI, and other imaging modalities are used to manage adults with suspected diverticulitis. Use of imaging modalities lead to varying accuracies for diagnosing acute complicated and uncomplicated diverticulitis. Also, adverse events may occur after the imaging modality is used.

 

Figure 2. Draft analytic framework for Key Questions 2 & 3

Figure 2: This figure depicts key questions 2 and 3 within the context of the PICOTS described in the previous section. In general, the figure illustrates how interventions such as antibiotics delivered by various routes (including oral, parenteral, and other routes) or clear liquid diet only and no antibiotics may result in health outcomes such as resolution of diverticulitis, recurrent diverticulitis, avoidance of surgery, morbidity, and mortality. Also, adverse events may occur after the intervention is received.

 

Figure 3. Draft analytic framework for Key Question 4

Figure 3: This figure depicts key question 4 within the context of the PICOTS described in the previous section. In general, the figure illustrates how colonoscopy may be used in management of adults with resolved diverticulitis, which leads to detection of colorectal cancer or recurrent diverticulitis. Also, adverse events may occur after colonoscopy.

 

Figure 4. Draft analytic framework for Key Question 5

Figure 4: This figure depicts key question 5 within the context of the PICOTS described in the previous section. In general, the figure illustrates how drug interventions such as 5-aminosalicylates and non-drug interventions such as dietary modification may result in prevention of recurrent diverticulitis among adults with a history of diverticulitis. Also, adverse events may occur after the intervention is received.

 

Figure 5. Draft analytic framework for Key Question 6

Figure 5: This figure depicts key question 6 within the context of the PICOTS described in the previous section. In general, the figure illustrates how interventions such as laparoscopic lavage and drainage, percutaneous drainage (interventional radiology), surgical resection with primary anastomosis, Hartmann’s procedure, and antibiotics only may result in health outcomes such as resolution of diverticulitis, morbidity, and mortality among adults with recurrent (complicated or uncomplicated) diverticulitis. Also, adverse events may occur after the intervention is received.

 

Table 1. Key Questions and PICOTS

  KQ1: Diagnostic Imaging KQ2 & KQ3: Antibiotics KQ4: Follow-up Colonoscopy KQ5: Prevention of Recurrence KQ6: Surgical and Interventional Treatments
Population

Adults with suspected diverticulitis

Subgroups: age, ethnicity, gender, comorbidities, disease presentation

Adults with diverticulitis (uncomplicated or complicated)

Subgroups: age, ethnicity, gender, comorbidities, disease presentation

Adults with resolved episode of ACD

Subgroups: age, ethnicity, gender, comorbidities, disease presentation

Adults with history of diverticulitis

Subgroups: age, ethnicity, gender, comorbidities, disease presentation

Adults with recurrent diverticulitis (complicated or uncomplicated)

Subgroups: age, ethnicity, gender, comorbidities, disease presentation

Interventions CT scan Antibiotics (oral or parenteral) Colonoscopy Drug (ex. 5-amino salicylates, etc.) and non-drug (ex. dietary) interventions Percutaneous drainage (interventional radiology)

Laparoscopic lavage and drainage

Surgical resection with primary anastomosis

Hartmann’s procedure

Comparators MRI, ultrasound No antibiotics, clear liquid diet only, antibiotics by other route of administration, type of antibiotic, duration of course No colonoscopy No intervention No intervention, other active intervention

Comparisons of interest:

All ACD stages:

Intervention (surgery/laparoscopic lavage and drainage) vs. no intervention/antibiotics only

For peri-colic and pelvic abscesses (Hinchey stages I, II):

Percutaneous or laparoscopic drainage vs. surgery

For purulent and feculent peritonitis (Hinchey stages III, IV):

Laparoscopic lavage and drainage vs. surgery

For surgical approaches:

Primary anastomosis (with or without protective stoma) vs. Hartmann's procedure

Outcomes Diagnostic accuracy, adverse events Resolution of diverticulitis, recurrent diverticulitis, avoidance of surgery, morbidity, mortality, adverse events Occult colorectal cancer, recurrent diverticulitis, adverse events Recurrent diverticulitis, adverse events Resolution of diverticulitis, morbidity, mortality, adverse events
Timing All All Acute vs. convalescent All All
Setting Inpatient, outpatient Inpatient, outpatient Outpatient Outpatient Inpatient, Outpatient

Abbreviations: KQ=Key Questions; ACD=Acute Complicated Diverticulitis; MRI=Magnetic Resonance Imaging; CT=Computed Tomography

 

References

  1. Matrana MR, Margolin DA. Epidemiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg. 2009 Aug;22(3):141-6. doi: 10.1055/s-0029-1236157. PMID: 20676256.
  2. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J. 1969 Dec 13;4(5684):639-42.  PMID: 5359917.
  3. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut. 1969 May;10(5):336-44.  PMID: 5771665.
  4. Hobson KG, Roberts PL. Etiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg. 2004 Aug;17(3):147-53. doi: 10.1055/s-2004-832695. PMID: 20011269.
  5. Delvaux M. Diverticular disease of the colon in Europe: epidemiology, impact on citizen health and prevention. Aliment Pharmacol Ther. 2003 Nov;18 Suppl 3:71-4.  PMID: 14531745.
  6. Wilkins T, Embry K, George R. Diagnosis and management of acute diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-20.  PMID: 23668524.
  7. Vennix S, Morton DG, Hahnloser D, et al. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis. 2014 Nov;16(11):866-78. doi: 10.1111/codi.12659. PMID: 24801825.
  8. Jena MD, Marcello PW, Roberts PL, et al. Epidemiologic Analysis of Diverticulitis. Clin Colon Rectal Surg. 2016 Sep;29(3):258-63. doi: 10.1055/s-0036-1584503. PMID: 27582652.
  9. Strate LL, Modi R, Cohen E, et al. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol. 2012 Oct;107(10):1486-93. doi: 10.1038/ajg.2012.194. PMID: 22777341.
  10. Nally DM, Kavanagh DO. Current Controversies in the Management of Diverticulitis: A Review. Dig Surg. 2018 Apr 19doi: 10.1159/000488216. PMID: 29672283.
  11. Isacson D, Andreasson K, Nikberg M, et al. No antibiotics in acute uncomplicated diverticulitis: does it work? Scand J Gastroenterol. 2014 Dec;49(12):1441-6. doi: 10.3109/00365521.2014.968861. PMID: 25369865.
  12. Kim BC. Nonoperative management of acute complicated diverticulitis. Ann Coloproctol. 2014 Oct;30(5):206. doi: 10.3393/ac.2014.30.5.206. PMID: 25360424.
  13. Lohrmann C, Ghanem N, Pache G, et al. CT in acute perforated sigmoid diverticulitis. Eur J Radiol. 2005 Oct;56(1):78-83. doi: 10.1016/j.ejrad.2005.03.003. PMID: 16168267.
  14. Agarwal AK, Karanjawala BE, Maykel JA, et al. Routine colonic endoscopic evaluation following resolution of acute diverticulitis: is it necessary? World J Gastroenterol. 2014 Sep 21;20(35):12509-16. doi: 10.3748/wjg.v20.i35.12509. PMID: 25253951.
  15. Urushidani S, Kuriyama A, Matsumura M. 5-aminosalicylic acid agents for prevention of recurrent diverticulitis: A systematic review and meta-analysis. J Gastroenterol Hepatol. 2018 Jan;33(1):12-9. doi: 10.1111/jgh.13846. PMID: 28623877.
  16. Unlu C, Daniels L, Vrouenraets BC, et al. A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis. 2012 Apr;27(4):419-27. doi: 10.1007/s00384-011-1308-3. PMID: 21922199.