Evidence-Based Answers

Follow-up colonoscopy may not be necessary after acute uncomplicated diverticulitis

Clinical Question:
Is it always necessary to perform a follow-up colonoscopy after acute diverticulitis to confirm the diagnosis and exclude malignancy?

Bottom Line:
: In this study, patients with acute uncomplicated diverticulitis were found to have a low rate of colon malignancy, similar to what is expected in the general population. Colon malignancy was, however, significantly increased among patients with acute complicated diverticulitis. (See the synopsis for a description of uncomplicated and complicated.) The authors conclude by recommending follow-up colonoscopy only for those patients with complicated diverticulitis. (LOE = 2a)

Reference:
Sharma P, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014;259(2):263-272  [PMID:24169174]

Study Design:
Systematic review

Funding:
Self-funded or unfunded

Setting:
Various (meta-analysis)

Synopsis:
Many guidelines currently recommend routine colonic evaluation after acute diverticulitis to confirm the diagnosis and exclude malignancy. These investigators searched multiple databases, including MEDLINE, EMBASE, CINAHL, the Cochrane Library, and bibliographies of significant articles without language restrictions for studies that evaluated outcomes in patients who received direct colonic evaluation after an episode of acute diverticulitis. Acceptable confirmation occurred by colonoscopy, flexible sigmoidoscopy, computed tomographic colonography, or contrast enema studies. Two individuals independently reviewed potential studies for inclusion criteria. Differences were resolved by consensus. The 11 studies that met inclusion criteria were further analyzed for independent reporting of uncomplicated diverticulitis (presence of colonic diverticular disease with localized wall thickening and/or stranding of pericolic fat) and complicated diverticulitis (presence of abscess, perforation, obstruction or fistula formation, protracted disease with symptoms, or associated mass lesion). All studies had computed tomography (CT) as the primary method of diagnosis of acute diverticulitis. Most studies performed additional colonic evaluation within 6 to 8 weeks of the index attack. From the total population of 3358 individuals with acute diverticulitis, 1970 patients underwent direct colonic evaluation. Of these 1970 patients, a colon malignancy was detected in 22 (1.1%). In a pooled population of 1497 patients with CT-determined uncomplicated diverticulitis, a colon malignancy was detected in only 5 patients (0.3%), which is similar to the expected rate of malignancy in the general asymptomatic adult population. However, colon malignancy was detected in 6 of the 79 patients with complicated diverticulitis (7.6%). A formal analysis found no evidence of significant heterogeneity among the individual studies.