Point-of-Care Guides

Diverticulitis: Predicting Which Patients with Acute Abdominal Pain Have the Disease

 

Am Fam Physician. 2020 Sep 15;102(6):371-372.

Author disclosure: No relevant financial affiliations.

Clinical Question

Is it possible to determine which patients with acute abdominal pain are likely to have diverticulitis and therefore do not require imaging?

Evidence Summary

Each year in the United States, acute abdominal pain costs $10.2 billion and accounts for more than 12 million (9%) ambulatory emergency department visits.1,2 In 2014, diverticulitis accounted for 372,000 emergency department visits, led to 160,000 hospital admissions, and was associated with 674 in-hospital deaths.2 Computed tomography is sensitive (94%) and specific (99%) for diverticulitis.3 Because up to 85% of patients with diverticulitis are treated nonoperatively,4 use of a clinical prediction rule to determine the likelihood of acute diverticulitis would help reduce the number of emergency department visits for acute abdominal pain leading to computed tomography, reducing cost and radiation exposure.1

A Dutch research group created a clinical prediction rule for acute diverticulitis that includes three indicators: absence of vomiting, a C-reactive protein level greater than 5 mg per dL (50 mg per L), and tenderness limited to the left lower quadrant (Table 1).5 Presence of all three indicators had a sensitivity of 36% (95% CI, 26% to 47%), specificity of 98% (95% CI, 89% to 100%), positive predictive value of 97% (95% CI, 83% to 99%), and negative predictive value of 47% (95% CI, 37% to 57%) in those suspected of having diverticulitis (63% of the derivation cohort).5

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TABLE 1.

Three-Item Clinical Prediction Rule for Acute Diverticulitis

The presence of all three of the following indicators is considered a positive result

 Absence of vomiting

 C-reactive protein level > 5 mg per dL (50 mg per L)

 Tenderness limited to the left lower quadrant


Note: See Table 2 for the performance of this rule in two cohorts.

Information from reference 5.

TABLE 1.

Three-Item Clinical Prediction Rule for Acute Diverticulitis

The presence of all three of the following indicators is considered a positive result

 Absence of vomiting

 C-reactive protein level > 5 mg per dL (50 mg per L)

 Tenderness limited to the left lower quadrant


Note: See Table 2 for the performance of this rule in two cohorts.

Information from reference 5.

An external validation study of the three-item rule showed a specificity of 93% (95% CI, 88% to 96%) and positive predictive value of 81% (95% CI, 69% to 89%) among a cohort in which acute diverticulitis was suspected based on information recorded on imaging orders. The positive likelihood ratio for this group was 5.29 (95% CI, 2.89 to 9.68), and the negative likelihood ratio was 0.68 (95% CI, 0.59 to 0.78). It is important to note that diverticulitis was suspected, and its prevalence was high in the validation cohort.6 In a less select cohort in which the prevalence of diverticulitis is lower, the rule would not be as effective at discriminating who has diverticulitis and who does not.

Table 2 summarizes the performance of the three-item clinical prediction rule in the derivation and validation cohorts.6

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TABLE 2.

Performance of the Three-Item Clinical Prediction Rule for Acute Diverticulitis

Performance factorOriginal derivation cohort with a 63% prevalence of acute diverticulitis (95% CI)External validation cohort with a 43% prevalence of acute diverticulitis (95% CI)

Sensitivity

36% (26% to 47%)

37% (29% to 46%)

Specificity

98% (89% to 100%)

93% (88% to 96%)

Positive likelihood ratio

18 (2.36 to 137)

5.29 (2.89 to 9.68)

Negative likelihood ratio

0.65 (0.55 to 0.77)

0.68 (0.59 to 0.78)

Positive predictive value

97% (83% to 99%)

81% (69% to 89%)

Negative predictive value

47% (37% to 57%)

66% (60% to 72%)


Information from reference 6.

TABLE 2.

Performance of the Three-Item Clinical Prediction Rule for Acute Diverticulitis

Performance factorOriginal derivation cohort with a 63% prevalence of acute diverticulitis (95% CI)External validation cohort with a 43% prevalence of acute diverticulitis (95% CI)

Sensitivity

36% (26% to 47%)

37% (29% to 46%)

Specificity

Address correspondence to Aaron Saguil, MD, MPH, at aaron.saguil@usuhs.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Rui P, Kang K; National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. Accessed July 24, 2020. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf...

2. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018 [published correction appears in Gastroenterology. 2019;156(6):1936]. Gastroenterology. 2019;156(1):254–272.

3. Andeweg CS, Knobben L, Hendriks JCM, et al. How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. Ann Surg. 2011;253(5):940–946.

4. Mehta D, Saha A, Chawla L, et al. National landscape of unplanned 30-day readmission rates for acute non-hemorrhagic diverticulitis: insight from National Readmission Database [published online May 1, 2020]. Dig Dis Sci. Accessed July 24, 2020. https://link.springer.com/article/10.1007/s10620-020-06284-5

5. Laméris W, van Randen A, van Gulik TM, et al. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum. 2010;53(6):896–904.

6. Kiewiet JJS, Andeweg CS, Laurell H, et al. External validation of two tools for the clinical diagnosis of acute diverticulitis without imaging. Dig Liver Dis. 2014;46(2):119–124.

7. Gans SL, Pols MA, Stoker J; expert steering group. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg. 2015;32(1):23–31.

8. Mayumi T, Yoshida M, Tazuma S, et al. Practice guidelines for primary care of acute abdomen 2015. J Hepatobiliary Pancreat Sci. 2016;23(1):3–36.

9. American College of Radiology Appropriateness Criteria. Left lower quadrant pain-suspected diverticulitis. Revised 2018. Accessed May 10, 2020. https://acsearch.acr.org/docs/69356/Narrative

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision-making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, deputy editor for evidence-based medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.

 

 

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