Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of PhysiciansFREE
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Abstract
Description:
The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the role of colonoscopy for diagnostic evaluation of colorectal cancer (CRC) after a presumed diagnosis of acute left-sided colonic diverticulitis and on the role of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence after initial treatment of acute complicated and uncomplicated left-sided colonic diverticulitis. This guideline is based on the current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences.
Methods:
The ACP Clinical Guidelines Committee (CGC) based these recommendations on a systematic review on the role of colonoscopy after acute left-sided colonic diverticulitis and pharmacologic, nonpharmacologic, and elective surgical interventions after initial treatment. The systematic review evaluated outcomes rated by the CGC as critical or important. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.
Target Audience and Patient Population:
The target audience is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.
Recommendation 1:
ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation; low-certainty evidence).
Recommendation 2:
ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence).
Recommendation 3:
ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences.
Clinicians and patients face several decisions in planning appropriate evaluation and management after acute left-sided colonic diverticulitis. Acute diverticulitis episodes are usually uncomplicated (only causing localized inflammation), but complicated diverticulitis, defined as inflammation associated with an abscess, a phlegmon, a fistula, an obstruction, bleeding, or a perforation (1–5), occurs in about 12% of cases (6). Prevention of recurrence, which occurs in about 8% to 36% of patients at 1 to 10 years (2, 3, 6), is important. In addition, patients with complicated diverticulitis may have a higher prevalence of colorectal cancer (CRC) (4, 5) that presents as acute diverticulitis and is misdiagnosed on clinical examination and/or imaging studies (7, 8). The evidence for use of various pharmacologic, nonpharmacologic, and surgical interventions to prevent the recurrence of diverticulitis has evolved over time (9–13).
Guideline Focus and Target Population
The purpose of this American College of Physicians (ACP) guideline is to present recommendations on the role of colonoscopy for diagnostic evaluation after an episode of presumed acute left-sided colonic diverticulitis in patients who have not had a recent colonoscopy, and on the effectiveness of pharmacologic, nonpharmacologic, and elective surgical interventions to prevent recurrence of acute left-sided colonic diverticulitis. The Clinical Guidelines Committee (CGC) developed the recommendations, which are based on the best available evidence on benefits and harms, patient values and preferences, and consideration of costs. These recommendations are based on a systematic review conducted by the Brown Evidence-based Practice Center and funded by the Agency for Healthcare Research and Quality (14). The development of the updated accompanying systematic review was funded by ACP (14).
The target audience for this guideline is all clinicians, and the target patient population is adults with recent episodes of acute left-sided colonic diverticulitis.
Methods
Systematic Review of the Evidence
Details and methods for the supporting systematic review are included in the original report, the accompanying article (14), and the Appendix. The CGC identified the key questions, and several members participated on a technical expert panel convened by the Brown Evidence-based Practice Center, which comprised key informants and technical experts to inform the systematic review and assist in refining the scope and key questions.
The systematic review involved a search of MEDLINE (via PubMed), Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and CINAHL for randomized controlled trials (RCTs), nonrandomized comparative studies, single-group studies, and existing systematic reviews published in English from 1 January 1990 through 1 June 2020 (updated through 16 November 2020). The review included studies of adults with a history of acute complicated or uncomplicated left-sided colonic diverticulitis and excluded studies of patients with active or ongoing acute diverticulitis, right-sided diverticulitis, or a history of a related condition (such as complicated diverticulosis, symptomatic uncomplicated diverticular disease, Meckel diverticula [unless it was concurrent with acute diverticulitis], and noncolonic diverticulitis). The review excluded right-sided diverticulitis because it is much less prevalent in Western countries and has a different natural history and management options (15).
Main Outcomes
Committee members (clinicians and nonclinician public members) and the CGC Public Panel members were asked a priori to independently rate the importance of evaluated outcomes (Table 1). All critical and important outcomes were considered in the development of the recommendations.
Values and Preferences
ACP staff searched several databases (MEDLINE, PsycINFO, PubMed, Trip Database, and Google Scholar) through 24 February 2021 to identify studies on values and preferences regarding evaluation and treatment after acute left-sided colonic diverticulitis. The development of this guideline also included perspectives, values, and preferences of 2 CGC members who represent the public and a 7-member CGC Public Panel, who rated outcomes, provided input on their preferences among the intervention options via a direct-choice exercise, and provided comments on the guideline and recommendations.
Costs
ACP staff searched several databases (PubMed, MEDLINE, NHS Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database) through 31 January 2021 to identify English-language publications of economic studies (including cost–utility, cost-effectiveness, cost–benefit, cost–consequences, and comparative cost analyses) on the included evaluation and treatment strategies after acute left-sided colonic diverticulitis.
Evidence to Recommendations
This guideline was developed by the CGC according to ACP's guideline development process, details of which can be found in ACP's methods papers (16, 17). When developing the recommendations, the CGC used GRADE (Grading of Recommendations Assessment, Development and Evaluation) tables derived from the accompanying systematic review (14) and graded the recommendations using the GRADE method (18, 19) (Figure 1). The Supplement presents the GRADE evidence-to-decision tables illustrating the evidence framework supporting the recommendations.
Figure 1. Grading the certainty of evidence and strength of recommendations of ACP clinical guidelines using GRADE.
ACP = American College of Physicians; GRADE = Grading of Recommendations Assessment, Development and Evaluation.
Peer Review
The guideline underwent a peer review process through the journal and was posted online for comments from ACP Regents and ACP Governors, who represent internal medicine and its subspecialty physician members at the national and international levels. The CGC considered all comments before finalizing the guideline.
Summary of the Evidence
The accompanying systematic review (14) and the Supplement provide a detailed summary of findings, but the main points are highlighted here. Tables 2 and 3 summarize study population details.
Key Findings on Critical and Important Outcomes
Colonoscopy After Acute Left-Sided Colonic Diverticulitis
The systematic review identified 19 studies addressing the use of follow-up colonoscopy to assess the presence of colonic neoplasia after an episode of presumed acute left-sided colonic diverticulitis (Table 2) (13, 20–37). Two observational studies (20, 21) compared follow-up colonoscopy with no colonoscopy, 2 observational studies (22, 23) compared follow-up colonoscopy in patients with recent acute left-sided colonic diverticulitis versus healthy controls, 1 RCT compared early (in-hospital) colonoscopy with later colonoscopy (24), 1 observational study compared colonoscopy with flexible sigmoidoscopy (13), and 13 were noncomparative studies of patients who had colonoscopy (25–37). Studies included middle-aged adults with mostly acute uncomplicated left-sided colonic diverticulitis who did not have colonoscopy within 1 to 2 years before the acute episode.
Among critical outcomes, low-certainty evidence from comparative studies showed that CRC diagnosis at 1 or 2 years of follow-up may not differ between patients with acute left-sided colonic diverticulitis who did or did not have colonoscopy after an acute episode within about 2 to 12 months (20, 21) (odds ratio [OR], 1.77 [95% CI, 0.79 to 3.99]). The identified CRC cases and high-risk colonic neoplasia in the included studies occurred mostly in patients with complicated diverticulitis. Evidence was very uncertain (insufficient) to determine whether patients with recent acute uncomplicated left-sided colonic diverticulitis had a higher prevalence of CRC on colonoscopy at 6 months after the acute episode compared with age-matched healthy adults undergoing screening colonoscopy (22, 23). Low-certainty evidence showed that patients with acute left-sided colonic diverticulitis may have lower odds of prevalent high-risk colonic premalignant lesions (for advanced adenomas, ORs ranged from a crude OR of 0.39 to an adjusted OR of 0.62; for large adenomas, crude ORs ranged from 0.36 to 0.38) than matched controls with a family history of CRC or the general screening population (22, 23). However, 1 study showed differences between the comparison and control groups in age, colonic inspection times, and polyp removal (23). No studies compared the effect on CRC mortality of colonoscopy after acute left-sided colonic diverticulitis versus either no colonoscopy or healthy controls.
Supplement Table 1 summarizes findings on CRC, CRC death, and abnormal lesion rates on follow-up colonoscopy from 19 observational retrospective studies (25–37), 6 of which included patients with mainly uncomplicated diverticulitis (ranging from 70% to 82% of patients). Subgroup analyses from these observational studies showed with high certainty that patients with complicated diverticulitis had higher odds of prevalent CRC (OR, 5.65 [CI, 2.95 to 10.82]) (27–29, 31, 35, 37) and advanced colonic neoplasia (OR, 3.85 [CI, 2.11 to 7.03]) (28, 29, 31) than patients with uncomplicated diverticulitis. Moderate-certainty evidence suggested a probable positive association between complicated diverticulitis and prevalence of advanced adenomas (OR, 2.00 [CI, 0.90 to 4.51]) (29, 31, 37) compared with patients with uncomplicated diverticulitis.
Important outcomes, including colonoscopy complications or failed or incomplete colonoscopy, were rarely reported in primary studies. High-certainty evidence showed that among 1253 patients in 5 observational studies (13, 22, 24, 31, 35), very few had a complication, such as bleeding or perforation (0.2% [CI, 0.04% to 0.64%]) (Supplement Table 1). High-certainty evidence from observational studies showed that 3.7% (CI, 2.7% to 4.9%) of patients with acute left-sided colonic diverticulitis undergoing colonoscopy 6 weeks to 1 year after hospital discharge had a failed or incomplete colonoscopy (13, 24, 29, 37).
Pharmacologic and Nonpharmacologic Interventions to Prevent Recurrence of Acute Left-Sided Colonic Diverticulitis
Twelve studies evaluated pharmacologic and nonpharmacologic interventions to prevent recurrent diverticulitis (Table 3) (38–42, 63–67). Six RCTs in 4 publications (38–41) compared mesalamine (5-aminosalicylic acid) in various doses versus placebo in patients with acute uncomplicated left-sided colonic diverticulitis, and an additional single-group study reported harms in patients receiving 4.8 g of mesalamine per day (42). Evidence was very uncertain (insufficient) for other treatments to prevent recurrence (rifaximin, probiotics, combination of mesalamine and rifaximin, combination of mesalamine and probiotics, and burdock tea) (39, 63–68). No eligible studies evaluated nutritional therapies, including dietary advice. Other behavioral interventions aimed at weight normalization or increasing physical activity were beyond the review's scope.
All outcomes were rated as critical. High-certainty evidence showed that mesalamine results in no difference in risk for recurrence compared with placebo at 9 to 24 months of follow-up (absolute risk difference [ARD], 2.7% [CI, −1.6% to 7.5%]) (38–41), and low-certainty evidence showed that there may be no differences in symptom scores between mesalamine and placebo (39, 40). High-certainty evidence showed an increase in discontinuation of mesalamine due to adverse events (ARD, 7.1% [CI, 1.5% to 13.9%]) (39–41), although moderate-certainty evidence showed that mesalamine probably results in no difference (ARD, −0.6% [CI, −3.2% to 3.5%]) in urinary tract infections requiring antibiotics, and low-certainty evidence showed that mesalamine may result in no difference in risk for serious adverse events (which the studies did not define; rates ranged between 9% and 11% across mesalamine groups and were similar in the placebo groups; ARD, 1.1% [CI, −2.0% to 5.2%]) (38–42). The evidence was very uncertain (insufficient) about the effect of mesalamine on other specific adverse events and on surgery for recurrent acute diverticulitis (39).
Elective Surgical Interventions to Prevent Recurrence of Acute Left-Sided Colonic Diverticulitis
The systematic review identified 2 small RCTs reported in 4 articles (43–46) and 1 large nonrandomized controlled trial (47) comparing elective surgery (laparoscopic sigmoid colectomy or colectomy) with nonoperative management (also described as conservative management or observation) in adults with a history of acute complicated or uncomplicated left-sided colonic diverticulitis with either smoldering symptoms (persisting >3 months) or frequent recurring symptoms (≥3 episodes within 2 years). Studies included persons with frequently recurring diverticulitis, smoldering diverticulitis, and complicated diverticulitis (Table 3). In addition, 16 noncomparative studies reporting on adverse events after surgery were also considered (10, 48–62, 69). The frequency of specific complications was not consistently reported, but the evidence suggested that abscess was diagnosed in 42% to 58% of the enrolled participants. Participant ages were similar across studies, with participants in their mid 50s, and 28% to 63% were males.
All outcomes were rated as critical. High-certainty evidence showed that elective surgery reduces risk for recurrence at 3 or 5 years in patients with 3 or more episodes of acute left-sided colonic diverticulitis within 2 years (mean number of previous episodes, 3.1 to 4.1) and symptoms persisting for more than 3 months or with complicated diverticulitis compared with nonoperative management (ARD, −21.5% [CI, −27% to −11%]) (43, 44, 47). Evidence was very uncertain (insufficient) on the effect of elective surgery compared with conservative management on mortality (43, 44, 47), length of hospital stay (43, 47), total serious adverse events (10, 43, 44, 62), and quality of life (44–46) and to evaluate predictors of surgery-related adverse events (including age, uncomplicated vs. complicated diverticulitis, body mass index, and comorbidities) (52, 61, 62, 69). Evidence from noncomparative case series showed that 1% to 5% of patients had perioperative complications after elective surgery, including surgical site infections (1.4% [CI, 0.8% to 1.9%]) (moderate certainty), anastomotic leakage requiring procedure (4.3% [CI, 2.2% to 6.9%]), and reoperations (5.5% [CI, 3.1% to 8.5%]) (10, 43–62, 69) (Table 4).
Values and Preferences
No systematic reviews were identified that assessed the relative importance of outcomes or patient values and preferences of follow-up colonoscopy after resolved episodes of acute left-sided colonic diverticulitis or nonpharmacologic or pharmacologic treatments after acute left-sided colonic diverticulitis. One patient survey found that fewer respondents who had elective surgery regretted this treatment choice compared with respondents undergoing conservative management (observation) for acute colonic diverticulitis (16% vs. 38%) (70). The survey analyzed responses from 133 adult patients treated for uncomplicated or complicated diverticulitis with conservative management or elective surgery between 2014 and 2019 and showed that shared decision making, well-formulated patient values, and feeling informed and supported were associated with lower risk for treatment choice regret and greater patient satisfaction. This association was independent of patient age, treatment type (elective surgery vs. observation), gender, and health status (70). However, the study had a high risk of response bias (14%), with different characteristics between the responders and nonresponders, potential recall bias, and no adjustment for allocation bias (70). Feedback from the CGC Public Panel showed a preference for follow-up colonoscopy after initial treatment of acute complicated left-sided colonic diverticulitis and an even stronger preference for management of postacute left-sided colonic diverticulitis without mesalamine. No trend was observed for preferences regarding management of complicated left-sided colonic diverticulitis with planned elective surgery versus conservative treatment or observation.
Costs
No studies were identified that reported on the cost-effectiveness of follow-up colonoscopy for detection of CRC after acute left-sided diverticulitis or nonpharmacologic or pharmacologic treatments after acute left-sided colonic diverticulitis. In addition, we did not identify any U.S. studies that examined the cost-effectiveness of elective surgery compared with nonsurgical intervention after an initial event of acute complicated diverticulitis or in any patients with uncomplicated diverticulitis. However, a 2019 European cost-effectiveness analysis provided indirect evidence for U.S. practice that elective surgery in patients with 3 or more episodes over a 2-year span had a 95% probability of being cost-effective compared with conservative management at 5 years of follow-up (with a threshold of €20 000 per quality-adjusted life-year) (46). Another 2002 modeling analysis used Medicare reimbursement rates to compare the costs and outcomes of performing surgery after 1, 2, or 3 (recurrent) uncomplicated colonic diverticulitis episodes in 60-year-old persons and concluded that performing elective surgery after the third recurrence is more cost-effective than after the first or second episode (71).
Multiple Chronic Conditions
Overall, eligible RCTs excluded patients with unstable comorbidities or immunosuppression and did not examine patient outcomes in subpopulations with major comorbidities.
Areas With Inconclusive Evidence
Evidence was inconclusive about the incremental net benefit of follow-up colonoscopy for detection of CRC after a resolved episode of acute uncomplicated left-sided colonic diverticulitis compared with routine CRC screening. Evidence was also inconclusive on whether follow-up colonoscopy after acute complicated diverticulitis improves CRC mortality.
More research is needed to evaluate which patients with frequent recurrent acute uncomplicated left-sided diverticulitis are most likely to benefit from surgery, as evidence was inconclusive to evaluate predictors of surgery-related adverse events (such as age, uncomplicated vs. complicated diverticulitis, body mass index, and comorbidities).
Areas With No Evidence
None of the studies that met inclusion criteria compared the effect of colonoscopy after a resolved episode of acute left-sided colonic diverticulitis versus usual routine screening and whether the latter leads to earlier detection of CRC, nor did the studies report on the effect of colonoscopy compared with no colonoscopy or usual routine screening on CRC incidence or mortality. Included studies also did not report on nutritional therapies, such as an increased-fiber diet, and did not report on the relative effect of elective surgery for patients with nonrecurrent uncomplicated diverticulitis or evidence regarding which patients may benefit most from surgery.
Recommendations
Figures 2 and 3 present visual summaries of the recommendations, evidence and rationales, and clinical considerations.
Recommendation 1: ACP suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy (conditional recommendation; low-certainty evidence).
Evidence from comparative studies is inconclusive about the incremental benefit of colonoscopy on clinical outcomes after a recent episode of presumed acute left-sided colonic diverticulitis. The CGC judged that colonoscopy is a reasonable option for patients with resolved complicated diverticulitis who have not had a recent colonoscopy. Colorectal cancer may rarely present with signs and symptoms similar to those of acute complicated diverticulitis and may have similar computed tomographic findings, with an estimated imaging overlap of 10% (72, 73). Therefore, patients diagnosed with acute left-sided colonic diverticulitis based on clinical examination and/or computed tomographic imaging may rarely have underlying CRC as a cause of their signs and symptoms and may be misdiagnosed without direct colonic visualization. The evaluated studies typically limited inclusion to patients without a colonoscopy within the previous 1 to 2 years. However, given the guidance on screening intervals for the general population; the known relatively indolent natural history of colonic neoplasms; and the fact that colonoscopy is associated with harms, burdens, and costs, extending the acceptable time from prior colonoscopic evaluation beyond 1 to 2 years is reasonable (74). In addition, CRC prevalence may not differ between those who do and those who do not undergo colonoscopy within 2 to 12 months after resolution of the acute episode. Finally, the identified CRC cases and high-risk colonic lesions in the included studies occurred mostly in patients with complicated diverticulitis. A subgroup analysis of patients having colonoscopy suggested that compared with patients with uncomplicated diverticulitis, those with complicated diverticulitis have a roughly 6-fold higher prevalence of CRC (overall prevalence, 1.6%), have an approximate 4-fold higher prevalence of advanced colonic neoplasia (overall prevalence, approximately 6%), and probably have a 2-fold higher prevalence of advanced adenomas (overall prevalence of cancer, 3.7%). Hence, this recommendation applies to patients with complicated disease in whom there is diagnostic uncertainty and when the intent of follow-up colonoscopy is to rule out CRC or advanced colonic neoplasia presenting as acute diverticulitis. The CGC did not explicitly consider the costs or cost-effectiveness of follow-up colonoscopy for this recommendation given the limited evidence on comparative effectiveness and the absence of cost-effectiveness studies.
Clinical Considerations
• This recommendation applies to patients with complicated diverticulitis in whom there is diagnostic uncertainty related to ruling out CRC or advanced colonic neoplasia presenting as acute diverticulitis. Clinicians should assess whether patients have had a recent high-quality direct visualization colonoscopy for any reason, such as screening for CRC, iron deficiency anemia, or intestinal bleeding (75, 76). High-quality colonoscopy is defined on the basis of the physician's experience, such as adequate adenoma detection rate, and examination-specific characteristics, such as examination from rectum to cecum, attention to complete polypectomy, and adequate bowel preparation to reliably detect lesions larger than 5 mm (75, 77).
• Having uncomplicated and/or recurrent diverticulitis episodes does not justify additional diagnostic colonoscopy evaluation in patients who are otherwise up-to-date on recommended CRC screening. Clinicians should confirm that patients are up-to-date with screening for CRC (74).
• Colonoscopy should not be performed until the acute phase of diverticulitis is resolved (minimum of 6 to 8 weeks after the complete resolution of acute symptoms) (76).
• Diagnostic colonoscopy for cancer assessment after an initial episode of suspected acute complicated diverticulitis may be most beneficial for patients with higher risk for CRC, including older patients and those with potential alarm symptoms for cancer (unintentional weight loss, change in bowel habits, bloody stool, and/or persistent abdominal pain), and malnutrition (low albumin level) (33, 78).
• Although the included studies reported rare complications from colonoscopy and few failed or incomplete colonoscopies, colonoscopy is an invasive procedure that involves bowel preparation, is typically done using moderate sedation, and is associated with risk for perforations and major bleeding (74).
Recommendation 2: ACP recommends against clinicians using mesalamine to prevent recurrent diverticulitis (strong recommendation; high-certainty evidence).
High-certainty evidence shows that mesalamine (dose range, 1.2 to 4.8 g/d) resulted in no difference in risk for recurrent diverticulitis compared with placebo, and low-certainty evidence showed that mesalamine may not improve symptoms. Evidence showed that mesalamine probably results in no difference in urinary tract infection requiring antibiotics (moderate certainty) or serious adverse events (low certainty) compared with placebo, but high-certainty evidence showed a higher risk for discontinuation due to adverse events. In addition, mesalamine therapy was associated with harms, such as epigastric pain, nausea, diarrhea, dizziness, rash, and renal and hepatic impairment (38, 79–81). Given that there are no demonstrated clinical benefits and there are known harms associated with mesalamine, the CGC did not consider costs or cost-effectiveness further. The CGC did not issue recommendations on other commonly considered pharmacologic and nonpharmacologic interventions because the evidence was either insufficient (rifaximin, probiotics, burdock tea) or unavailable (nutritional therapies, including dietary advice).
Recommendation 3: ACP suggests that clinicians discuss elective surgery to prevent recurrent diverticulitis after initial treatment in patients who have either uncomplicated diverticulitis that is persistent or recurs frequently or complicated diverticulitis (conditional recommendation; low-certainty evidence). The informed decision whether or not to undergo surgery should be personalized based on a discussion of potential benefits, harms, costs, and patient's preferences.
High-certainty evidence showed that recurrence rates are lower after elective surgery in patients with complicated or uncomplicated colonic diverticulitis with either smoldering symptoms (persisting >3 months) or frequent recurring symptoms (≥3 episodes within 2 years). However, any benefits of surgery must be balanced against potential harms. Low- to moderate-certainty evidence showed that 1.4% to 5.5% of patients have perioperative surgical complications (such as anastomotic leakage, sepsis, and myocardial infarction). Evidence was very uncertain (insufficient) about the effect of surgery on mortality, length of hospital stays, total serious adverse events, and quality of life and to evaluate predictors of surgery-related adverse events (age, uncomplicated vs. complicated diverticulitis, body mass index, and comorbidities), although a more recent RCT (82), published after the end search date, reported improvements in quality of life after surgery similar to those reported by the single study identified in this review.
Based on the direct evidence of decreased risk for recurrence as well as indirect evidence from a European cost-effectiveness analysis that concluded that elective surgery is cost-effective at 5 years of follow-up in patients with 3 or more episodes (45, 46), the CGC judged that elective surgery is likely cost-effective in patients with acute uncomplicated diverticulitis that persists or recurs frequently or with acute complicated left-sided colonic diverticulitis. Details regarding comparative effectiveness and safety of specific surgical procedures and the operative considerations are beyond the scope of this guideline.
Clinical Considerations
• This recommendation does not apply to patients with uncomplicated diverticulitis that is not persistent or frequently recurring.
• Clinicians should take a team-based approach to shared decision making with patients; discussions should include the primary care physician or internist, the gastroenterologist, and the surgeon.
Appendix: Detailed Methods
The Brown Evidence-based Practice Center conducted the supporting systematic review, which was funded by the Agency for Healthcare Research and Quality. Details of the ACP guideline development process can be found in ACP's methods papers (16, 17). Disclosure of interests and management of any conflicts can be found at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Key Questions (KQs) Addressed
• KQ 1: What are the benefits and harms of colonoscopy (or other colon imaging test) following an episode of acute left-sided colonic diverticulitis?
○ KQ 1a: What is the incidence of malignant and premalignant colon tumors found by colonoscopy, and what is the incidence of colon cancer mortality among patients undergoing screening?
○ KQ 1b: What are the procedure-related and other harms of colonoscopy or computed tomography colonography?
○ KQ 1c: What is the frequency of inadequate imaging due to intolerance or technical feasibility?
○ Do the benefits and harms vary by patient characteristics, course of illness, or other factors?
• KQ 2: What are the effects, comparative effects, and harms of pharmacologic interventions (for example, mesalamine), nonpharmacologic interventions (for example, medical nutrition therapy), and elective surgery to prevent recurrent diverticulitis?
○ Do the (comparative) effects and harms vary by patient characteristics, course of illness, or other factors?
Search Strategy
Reviewers searched several databases for studies and systematic reviews published in English from 1 January 1990 to 16 November 2020.
Quality Assessment
Reviewers assessed risk of bias using the Cochrane Risk of Bias (ROB) tool (83) for RCTs and a modified approach using elements from the ROBINS-I (Risk Of Bias In Non-randomised Studies – of Interventions) tool and the Cochrane ROB tool for nonrandomized controlled studies and single-group studies (84).
Populations Studied
KQ 1 (all): Adults with a history of (resolved) acute left-sided colonic diverticulitis.
KQ 2 (all): Adults with a history of (resolved) acute left-sided colonic diverticulitis.
Interventions Evaluated
KQ 1: Elective colonoscopy (full colon) or elective computed tomography colonography.
KQ 2: Any class, route, regimen, treatment duration, or initiation time, including pharmacologic treatments and nonpharmacologic interventions (for example, medical nutrition therapy); elective surgery (laparoscopic, open, robot-assisted, or any other type of colon surgery conducted as an elective [nonemergent] procedure).
Comparators
KQ 1: No comparator necessary or no colonoscopy or other colon imaging (complete or partial).
KQ 2: No intervention (placebo, defined usual care) or alternative pharmacologic or nonpharmacologic intervention (or regimen); no or deferred elective surgery.
Outcomes
KQ 1 (critical outcomes): Colonic premalignant lesions (for example, hyperplastic polyps and adenomas), colorectal cancer, colorectal cancer mortality, harms, adverse events, and adverse effects of colonoscopy (perforation).
KQ 1 (important outcomes): Harms, adverse events, and adverse effects of colonoscopy bleeding; tolerance, feasibility, and completion of procedure; technical adequacy.
KQ 2 (critical outcomes): Acute complicated diverticulitis; diverticulitis-related complications (fistula, stricture); harms, adverse events, or adverse effects of interventions; surgical complications; hospitalization for diverticulitis; recurrent diverticulitis; surgery for diverticulitis (including colostomy [avoidance of, except for elective surgery comparisons]).
KQ 2 (important outcomes): Diverticulitis-related complications (fistula, stricture); quality of life/functional outcomes.
Timing
KQ 1: Start of colorectal cancer screening after resolution of acute left-sided colonic disease.
KQ 2: No minimum duration of follow-up, hospitalization, unit stay, after hospitalization.
Setting
KQ 1: Outpatient.
KQ 2: Inpatient, emergency department (or equivalent), outpatient.
Target Audience
All clinicians.
Target Patient Population
Adult patients with a history of resolved acute left-sided colonic diverticulitis.
Public/Patient Involvement
The development of this guideline also included perspectives, values, and preferences of 2 nonphysician CGC members who represent the public and a 7-member CGC Public Panel.
Values and Preferences Search
ACP staff searched several databases (MEDLINE, PsycINFO, PubMed, Trip Database, and Google Scholar) through 24 February 2021 to identify studies on values and preferences regarding evaluation and treatment after acute left-sided colonic diverticulitis.
Cost Search
ACP staff searched several databases (PubMed, MEDLINE, NHS Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database) to identify English-language publications of cost–utility analyses, cost-effectiveness analyses, cost–benefit analyses, cost–consequences analyses, and comparative cost analyses using peer-reviewed filters for economic studies (www.cadth.ca/resources/finding-evidence/strings-attached-cadths-database-search-filters). Each eligible study was assessed for applicability, reporting quality, methodological limitations, and overall quality of evidence using consensus recommendations around economic evaluations in health care (85–92).
Peer Review
The supporting systematic review and guideline each underwent a peer review process through the journal. The guideline was posted online for comments from ACP Regents and ACP Governors, who represent internal medicine and its subspecialty physician members at the national and international level.
Supplemental Material
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Annals of Internal Medicine
Volume 175 • Number 3 • March 2022
Pages: 416 - 431
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Published online: 18 January 2022
Published in issue: March 2022
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© 2022 American College of Physicians.
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Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med.2022;175:416-431. [Epub 18 January 2022]. doi:10.7326/M21-2711
Colonoscopy for Diagnostic Evaluation and Interventions to Prevent Recurrence After Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med.2022;175:416-431. [Epub 18 January 2022]. doi:10.7326/M21-2711
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