Point-of-Care Guides

Acute Diverticulitis: Identifying Patients Unlikely to Have Complications

 

Am Fam Physician. 2020 Oct 15;102(8):495-496.

Author disclosure: No relevant financial affiliations.

Clinical Question

Can a clinical prediction rule accurately identify patients at low risk of complicated acute diverticulitis, defined as diverticulitis accompanied by abscess or peritonitis?

Evidence Summary

Uncomplicated diverticulitis is defined as diverticulitis without abscess, fistula, perforation, or bleeding.1 Two randomized trials found that patients with uncomplicated diverticulitis do not benefit from antibiotics, and a systematic review concluded that most of these patients can be safely managed as outpatients.24 To avoid unnecessary radiation exposure and cost, it would be desirable to prioritize imaging and referral for patients at increased risk of complicated diverticulitis, with conservative outpatient management for patients at low risk of complications.

A systematic review identified 12 studies, including a total of 4,619 patients, that evaluated risk factors for complicated diverticulitis.5 The authors concluded that individual risk factors include increasing age, diffuse rather than localized abdominal pain, guarding or rebound pain, initial episode of diverticulitis, steroid use, fever, constipation, vomiting, elevated C-reactive protein (CRP) level, and elevated white blood cell (WBC) count. They proposed a clinical prediction rule based on the results of the meta-analysis but did not test it.

Another study identified 182 patients hospitalized for acute diverticulitis, of whom 24 (13%) had complicated diverticulitis defined as abscess or need for surgery.6 The mean CRP level was 10 mg per dL (100 mg per L) in patients with nonsevere diverticulitis and 25.6 mg per dL (256 mg per L) in those with complicated disease. Using a cutoff of 17 mg per dL (170 mg per L), 91% with nonsevere diverticulitis had a CRP level below that cutoff compared with only 12.5% of those with complicated disease (91% sensitive and 87.5% specific for the diagnosis of nonsevere diverticulitis).6 A second study of 99 consecutive patients, all of whom underwent computed tomography, found a sensitivity of 90.9% and specificity of 90.9% using a similar cutoff of 17.3 mg per dL (173 mg per L).7

Finally, Bolkenstein and colleagues developed and validated a simple clinical risk score (Table 1) to determine the likelihood of complicated diverticulitis, defined as the presence of abscess or peritonitis and requiring intervention.8 They used data from 950 patients with acute diverticulitis, randomly dividing the patients into a derivation group, which was used to develop the risk score through multivariate analysis, and a validation group; both groups included 475 patients. The overall prevalence of complicated diverticulitis was 19% in the validation group.

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TABLE 1.

Clinical Risk Score for Complicated Diverticulitis

Clinical variablePoints

Abdominal guarding

Absent

0

Present

4

White blood cell count; per μL (× 109 per L)

≤ 15,000 (15.0)

0

15,100 to 20,000 (15.1 to 20.0)

1

> 20,000 (20.0)

2

C-reactive protein; mg per dL (mg per L)

≤ 10 (100)

0

10.1 to 15 (101 to 150)

3

15.1 to 20 (151 to 200)

4

20.1 to 25 (201 to 250)

5

> 25 (250)

7

Total:

Total points

Risk of complicated diverticulitis (%)


0

4.2

1

6.8

2

10.7

3

16.6

4

24.7

5

35

6

47.1

7

59.5

8

70.7

9

79.9

10 to 13

> 85


Adapted with permission from Bolkenstein HE, van de Wall BJ, Consten ECJ, et al. Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis. Scand J Gastroenterol. 2018;53(10–11):1295.

TABLE 1.

Clinical Risk Score for Complicated Diverticulitis

Clinical variablePoints

Abdominal guarding

Absent

0

Present

4

White blood cell count; per μL (× 109 per L)

≤ 15,000 (15.0)

0

15,100 to 20,000 (15.1 to 20.0)

1

> 20,000 (20.0)

2

C-reactive protein; mg per dL (mg per L)

≤ 10 (100)

0

10.1 to 15 (101 to 150)

3

15.1 to 20 (151 to 200)

4

20.1 to 25 (201 to 250)

5

> 25 (250)

7

Total:

Total points

Risk of complicated diverticulitis (%)


0

4.2

1

6.8

2

10.7

3

16.6

4

24.7

5

35

6

47.1

7

59.5

8

70.7

9

79.9

10 to 13

> 85


Adapted with permission from Bolkenstein HE, van de Wall BJ, Consten ECJ, et al. Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis. Scand J Gastroenterol. 2018;53(10–11):1295.

The final risk score included the presence or absence of abdominal guarding, the WBC count, and the CRP level. For patients with a CRP level of 10 mg per dL or lower, WBC count of 15,000 per μL (15.0 × 109 per L) or lower, and no abdominal guarding, the risk of complicated diverticulitis decreased from 19% to 4.2%. One limitation of the study was retr

Address correspondence to Mark H. Ebell, MD, MS, at ebell@uga.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Ambrosetti P, Grossholz M, Becker C, et al. Computed tomography in acute left colonic diverticulitis. Br J Surg. 1997;84(4):532–534....

2. Daniels L, Ünlü Ç, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104(1):52–61.

3. Chabok A, Påhlman L, Hjern F, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99(4):532–539.

4. Jackson JD, Hammond T. Systematic review: outpatient management of acute uncomplicated diverticulitis. Int J Colorectal Dis. 2014;29(7):775–781.

5. Bolkenstein HE, van de Wall BJM, Consten ECJ, et al. Risk factors for complicated diverticulitis: systematic review and meta-analysis. Int J Colorectal Dis. 2017;32(10):1375–1383.

6. Kechagias A, Rautio T, Kechagias G, et al. The role of C-reactive protein in the prediction of the clinical severity of acute diverticulitis. Am Surg. 2014;80(4):391–395.

7. Kechagias A, Sofianidis A, Zografos G, et al. Index C-reactive protein predicts increased severity in acute sigmoid diverticulitis. Ther Clin Risk Manag. 2018;14:1847–1853.

8. Bolkenstein HE, van de Wall BJ, Consten ECJ, et al. Development and validation of a diagnostic prediction model distinguishing complicated from uncomplicated diverticulitis. Scand J Gastroenterol. 2018;53(10–11):1291–1297.

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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