Investigation of the clinical features and recurrence patterns of acute right-sided colonic diverticulitis: A retrospective cohort study

Moon Young Oh, Rumi Shin, Seung Chul Heo, Han-Ki Lim, Min Jung Kim, Ji Won Park, Seung-Bum Ryoo, Seung-Yong Jeong, Kyu Joo Park, Moon Young Oh, Rumi Shin, Seung Chul Heo, Han-Ki Lim, Min Jung Kim, Ji Won Park, Seung-Bum Ryoo, Seung-Yong Jeong, Kyu Joo Park

Abstract

Background: Right-sided colonic diverticulitis (RCD) and left-sided colonic diverticulitis (LCD) are considered distinct diseases. However, separate guidelines for RCD do not exist. Since the establishment of RCD management would first require evaluation of disease characteristics and recurrence patterns, this study has aimed to investigate the differences in the clinical characteristics between RCD and LCD and the recurrence patterns of RCD.

Methods: Patients admitted for colonic diverticulitis between January 2012 and August 2020 were retrospectively reviewed. Clinical characteristics and recurrence rates in RCD and LCD patients, and predictors for recurrence and the recurrence patterns of RCD were analyzed.

Results: In total, 446 colonic diverticulitis patients (343 RCD, 103 LCD) were included in this study. RCD patients were more likely to be male, younger, taller, heavier, smoke, drink alcohol, have better physical performance scores, lower modified Hinchey stages and better initial laboratory findings. LCD patients were more likely to receive invasive treatments, have longer fasting and hospital days, higher mortality and cumulative recurrence rates (20.5% vs. 30.4%, P = 0.007). Recurrences in most RCD patients were of similar disease severity and received the same treatments for initial attacks, with rates of recurrence increasing after each recurrence. Predictors of the recurrence of RCD were complicated diverticulitis (hazard ratio[HR] 2.512, 95% confidence interval[CI] 0.127-5.599, p = 0.024) and percutaneous drainage (HR 6.549, 95% CI 1.535-27.930, p = 0.011).

Conclusion: RCD is less severe and has a lower recurrence rate than LCD, suggesting that RCD should be treated conservatively. Patients with complicated diseases and those requiring percutaneous drainage are more likely to experience a disease recurrence, suggesting nonsurgical management may be insufficient.

Keywords: CI, Confidence interval; CRP, C-reactive protein; Conservative treatment; HR, Hazard ratio; LCD, Left-sided colonic diverticulitis; Modified Hinchey classification; PCD, percutaneous drainage; Percutaneous drainage; RCD, Right-sided colonic diverticulitis; Recurrence; Right-sided colonic diverticulitis.

Conflict of interest statement

The authors declare no conflicts of interest.

© 2022 The Authors.

Figures

Fig. 1
Fig. 1
Kaplan-Meier analysis of the cumulative incidence of recurrence in patients with right-sided and left-sided diverticulitis. The cumulative recurrence rate of left-sided diverticulitis was significantly higher than that of right-sided diverticulitis (39.4% vs. 20.5%, p = 0.007 by log-rank test).
Fig. 2
Fig. 2
Recurrence patterns of right-sided colonic diverticulitis as a function of modified Hinchey stage. (a) Of the 25 patients with initially uncomplicated (modified Hinchey stage 0 and 1a) right-sided diverticulitis, 23 (92%) experienced recurrence as uncomplicated disease, whereas two (8%) experienced recurrence as complicated disease. (b) Of the eight patients with initially complicated (modified Hinchey stage 1b and 2) right-sided diverticulitis, three (37.5%) experienced recurrence as uncomplicated disease and five (62.5%) experienced recurrence as complicated disease.
Fig. 3
Fig. 3
Recurrence patterns of right-sided colonic diverticulitis by treatment. Recurrence rates increased after each recurrence, regardless of treatment. Recurrences occurred in 33.3–50.0% of patients after treatment with PCD interventions. In most cases, patients who experienced recurrences received the same treatment as at the initial episode.

References

    1. Masoomi H., Buchberg B.S., Magno C., Mills S.D., Stamos M.J. Trends in diverticulitis management in the United States from 2002 to 2007. Arch. Surg. 2011;146:400–406. doi: 10.1001/archsurg.2010.276.
    1. Mizuki A., Tatemichi M., Nakazawa A., Tsukada N., Nagata H., Kanai T. Changes in the clinical features and long-term outcomes of colonic diverticulitis in Japanese patients. Intern. Med. 2017;56:2971–2977. doi: 10.2169/internalmedicine.7710-16.
    1. Reddy V.B., Longo W.E. The burden of diverticular disease on patients and healthcare systems. Gastroenterol. Hepatol. 2013;9:21–27.
    1. Sandler R.S., Everhart J.E., Donowitz M., Adams E., Cronin K., Goodman C., Gemmen E., Shah S., Avdic A., Rubin R. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500–1511. doi: 10.1053/gast.2002.32978.
    1. Lahat A., Avidan B., Sakhnini E., Katz L., Fidder H.H., Meir S.B. Acute diverticulitis: a decade of prospective follow-up. J. Clin. Gastroenterol. 2013;47:415–419. doi: 10.1097/MCG.0b013e3182694dbb.
    1. Law W.L., Lo C.Y., Chu K.W. Emergency surgery for colonic diverticulitis: differences between right-sided and left-sided lesions. Int. J. Colorectal Dis. 2001;16:280–284. doi: 10.1007/s003840100339.
    1. Hajibandeh S., Smart N.J., Maw A. Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis. Colorectal Dis. 2020;22:1908–1923. doi: 10.1111/codi.15328.
    1. Lee K.Y., Lee J., Park Y.Y., Kim Y., Oh S.T. Difference in clinical features between right- and left-sided acute colonic diverticulitis. Sci. Rep. 2020;10:3754. doi: 10.1038/s41598-020-60397-5.
    1. Gilmore T., Jordan C., Edelstein E. Right-sided diverticulitis mimics appendicitis. J. Emerg. Med. 2013;44:29–32. doi: 10.1016/j.jemermed.2011.06.035.
    1. Feingold D., Steele S., Lee S., Kaiser A., Boushey R., Buie W.D., Rafferty J.F. Practice parameters for the treatment of sigmoid diverticulitis. Dis. Colon Rectum. 2014;57:284–294. doi: 10.1097/DCR.0000000000000075.
    1. Strate L.L., Morris A.M. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology. 2019;156:1282–1298. doi: 10.1053/j.gastro.2018.12.033.
    1. Patel S.V., Hendren S., Zaborowski A., Winter D. Evidence-based reviews in surgery long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: five-year follow-up results of a multicenter randomized controlled trial (DIRECT-Trial) Ann. Surg. 2020;272:284–287. doi: 10.1097/SLA.0000000000003920.
    1. Al Harakeh H., Paily A.J., Doughan S., Shaikh I. Recurrent acute diverticulitis: when to operate? Inflamm. Intest. Dis. 2018;3:91–99. doi: 10.1159/000494973.
    1. Mathew G., Agha R. For the STROCSS Group, STROCSS 2021: strengthening the Reporting of cohort, cross-sectional and case-control studies in Surgery. Int. J. Surg. 2021;96 Article 106165.
    1. Kaiser A.M., Jiang J.K., Lake J.P., Ault G., Artinyan A., Gonzalez-Ruiz C., Essani R., Beart R.W. The management of complicated diverticulitis and the role of computed tomography. Am. J. Gastroenterol. 2005;100:910–917. doi: 10.1111/j.1572-0241.2005.41154.x.
    1. Klarenbeek B.R., de Korte N., van der Peet D.L., Cuesta M.A. Review of current classifications for diverticular disease and a translation into clinical practice. Int. J. Colorectal Dis. 2012;27:207–214. doi: 10.1007/s00384-011-1314-5.
    1. Alonso S., Pera M., Pares D., Pascual M., Gil M.J., Courtier R., Grande L. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2010;12:278–282. doi: 10.1111/j.1463-1318.2009.02122.x.
    1. Etzioni D.A., Chiu V.Y., Cannom R.R., Burchette R.J., Haigh P.I., Abbas M.A. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis. Colon Rectum. 2010;53:861–865. doi: 10.1007/DCR.0b013e3181cdb243.
    1. Ha G.W., Lee M.R., Kim J.H. Efficacy of conservative management in patients with right colonic diverticulitis. ANZ J. Surg. 2017;87:467–470. doi: 10.1111/ans.13028.
    1. Tan K.K., Wong J., Sim R. Non-operative treatment of right-sided colonic diverticulitis has good long-term outcome: a review of 226 patients. Int. J. Colorectal Dis. 2013;28:849–854. doi: 10.1007/s00384-012-1595-3.
    1. Lee J.H., Ahn B.K., Lee K.H. Conservative treatment of uncomplicated right-sided diverticulitis: a systematic review and meta-analysis. Int. J. Colorectal Dis. 2021;36:1791–1799. doi: 10.1007/s00384-021-03913-x.
    1. Au S., Aly E.H. Treatment of uncomplicated acute diverticulitis without antibiotics: a systematic review and meta-analysis. Dis. Colon Rectum. 2019;62:1533–1547. doi: 10.1097/DCR.0000000000001330.
    1. Desai M., Fathallah J., Nutalapati V., Saligram S. Antibiotics versus No antibiotics for acute uncomplicated diverticulitis: a systematic review and meta-analysis. Dis. Colon Rectum. 2019;62:1005–1012. doi: 10.1097/DCR.0000000000001324.
    1. Tandon A., Fretwell V.L., Nunes Q.M., Rooney P.S. Antibiotics versus no antibiotics in the treatment of acute uncomplicated diverticulitis - a systematic review and meta-analysis. Colorectal Dis. 2018;20:179–188. doi: 10.1111/codi.14013.
    1. Oh H.K., Han E.C., Ha H.K., Choe E.K., Moon S.H., Ryoo S.B., Jeong S.Y., Park K.J. Surgical management of colonic diverticular disease: discrepancy between right- and left-sided diseases. World J. Gastroenterol. 2014;20:10115–10120. doi: 10.3748/wjg.v20.i29.10115.
    1. Margolin D.A. Timing of elective surgery for diverticular disease. Clin. Colon Rectal Surg. 2009;22:169–172. doi: 10.1055/s-0029-1236161.
    1. Salem L., Veenstra D.L., Sullivan S.D., Flum D.R. The timing of elective colectomy in diverticulitis: a decision analysis. J. Am. Coll. Surg. 2004;199:904–912. doi: 10.1016/j.jamcollsurg.2004.07.029.
    1. Rafferty J., Shellito P., Hyman N.H., Buie W.D. Practice parameters for sigmoid diverticulitis. Dis. Colon Rectum. 2006;49:939–944. doi: 10.1007/s10350-006-0578-2.
    1. Hupfeld L., Burcharth J., Pommergaard H.C., Rosenberg J. Risk factors for recurrence after acute colonic diverticulitis: a systematic review. Int. J. Colorectal Dis. 2017;32:611–622. doi: 10.1007/s00384-017-2766-z.
    1. Justin V., Uranues S., Rabl H., Fingerhut A. Quality of life in uncomplicated recurrent diverticulitis: surgical vs. conservative treatment. Sci. Rep. 2020;10 doi: 10.1038/s41598-020-67094-3.
    1. Kim M.R., Kye B.H., Kim H.J., Cho H.M., Oh S.T., Kim J.G. Treatment of right colonic diverticulitis: the role of nonoperative treatment. J. Korean. Soc. Coloproctol. 2010;26:402–406. doi: 10.3393/jksc.2010.26.6.402.
    1. Kim Y.C., Chung J.W., Baek H.J., Lee W.S., Kim D., Park Y.H., Yang J.Y., Lee W.K. Risk factors for recurrence of right colonic diverticulitis. Dig. Surg. 2019;36:509–513. doi: 10.1159/000494297.
    1. Park H.C., Kim B.S., Lee K., Kim M.J., Lee B.H. Risk factors for recurrence of right colonic uncomplicated diverticulitis after first attack. Int. J. Colorectal Dis. 2014;29:1217–1222. doi: 10.1007/s00384-014-1941-8.
    1. Park S.M., Kwon T.S., Kim D.J., Lee Y.S., Cheung D.Y., Oh S.T., Kim J.G., Lee I.K. Prediction and management of recurrent right colon diverticulitis. Int. J. Colorectal Dis. 2014;29:1355–1360. doi: 10.1007/s00384-014-1938-3.
    1. Manabe N., Haruma K., Nakajima A., Yamada M., Maruyama Y., Gushimiyagi M., Yamamoto T. Characteristics of colonic diverticulitis and factors associated with complications: a Japanese multicenter, retrospective, cross-sectional study. Dis. Colon Rectum. 2015;58:1174–1181. doi: 10.1097/DCR.0000000000000488.
    1. Chen Z., Zhang B., Wu D., Jin Y. Characteristics of predominantly right-sided colonic diverticulitis without need for colectomy. BMC Surg. 2020;20:202. doi: 10.1186/s12893-020-00863-z.
    1. Hajibandeh S., Hajibandeh S., Smart N.J., Maw A. Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis. Colorectal Dis. 2020;22:1908–1923. doi: 10.1111/codi.15328.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner