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Structured Abstract
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.
Contents
Suggested citation:
Balk EM, Adam GP, Cao W, Danko K, Bhuma MR, Mehta S, Saldanha IJ, Beland MD, Shah N. Management of Colonic Diverticulitis. Comparative Effectiveness Review No. 233. (Prepared by the Brown Evidence-based Practice Center under Contract No. 290-2015-00002-I.) AHRQ Publication No. 20(21)-EHC025. Rockville, MD: Agency for Healthcare Research and Quality; October 2020. DOI: https://doi.org/10.23970/AHRQEPCCER233. Posted final reports are located on the Effective Health Care Program search page.
This report is based on research conducted by the Brown Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00002-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment: This work was based on an evidence report, Management of Colonic Diverticulitis, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ).
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