A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2

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1 Original article doi: /j x A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2 P. Gervaz*, A. Platon, L. Widmer, P. Ambrosetti* and P.-A. Poletti Departments of *Surgery and Radiology, Geneva University Hospital and Medical School, Genève, Switzerland Received 15 January 2011; accepted 11 March 2011; Accepted Article online 4 April 2011 Abstract Aim After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis. Method We reviewed the charts of 60 patients [median age 61 (range 31 90) years] who were admitted initially for a first episode of uncomplicated left colonic diverticulitis, and who were eventually readmitted for a second episode, both being documented by abdominal computed tomography (CT) scan. Results The median delay between the two episodes was 19 (3 97) months. Six (10%) patients developed a second complicated episode of diverticulitis [Hinchey II (n = 2), CT-guided percutaneous drainage; Hinchey III (n = 3), emergency Hartmann s operation; colovesical fistula (n = 1), elective sigmoid resection]. Fifty-four (90%) patients were admitted for a second episode of uncomplicated diverticulitis. In this group, the duration of hospital stay [11 (4 22) vs 10 (1 39) days, P = 0.28], serum levels of C-reactive protein [131 (31 350) vs 112 (22 333) mm, P = 0.62] and CT scan-based severity score [3 (1 6) vs 3 (0 7) points, P = 0.07] were similar between the two episodes. In 19 out of 54 (35%) patients with simple recurrent diverticulitis, although disease severity was similar, the disease topography differed and recurrence involved another segment of the left colon. Conclusion The majority of patients who develop recurrence do so in a similar mode and location. However, 10% develop complicated diverticulitis and in 35% of patients recurrent diverticulitis occurs at a different location. Keywords Diverticulitis, recurrence, complications, outcome, CT scan What is new in this paper? Recurrent episodes of sigmoid diverticulitis might involve different areas of the left colon and therefore represent morphologically distinct entities, even when they are clinically similar to the first episode. Introduction Sigmoid diverticular disease is common, but there are no modern prospectively collected data to elucidate its natural history [1]. Patients who have developed an initial episode of simple diverticulitis may remain indefinitely asymptomatic, but are at risk of recurrence. Outdated literature from the 1960s had suggested that sigmoid diverticulitis is a progressive disease, with recurrences developing in > 40% of patients, and that recurrent Podium presentation at the Annual Meeting of the American Society of Colon and Rectal Surgeons, Vancouver, 17 May Correspondence to: Pascal Gervaz MD, Department of Surgery, University Hospital Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève, Switzerland. pascal.gervaz@hcuge.ch diverticulitis is associated with complications in up to 60% of patients [2,3]. However, more recent series suggest that the natural history of sigmoid diverticulitis in the era of modern antibiotics, is more benign [4,5], and that current recommendations to proceed with elective sigmoid resection after two episodes of uncomplicated diverticulitis need to be re-evaluated [6]. Data from our institution [7] and others [8,9] indicate that after an initial episode of uncomplicated diverticulitis, recurrence rates range from 25 to 35% within 5 years. A couple of series have looked at the nature and severity of the recurrent episode. Although their conclusions suggested that recurrence occurs in a similar mode to the initial episode, these findings were mostly based upon clinical parameters only and up to 50% of patients Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14,

2 Sigmoid diverticulitis: episodes I and II P. Gervaz et al. did not have computed tomography (CT)-proven diverticulitis [10]. Since the 1990s, CT represents the best imaging modality to establish diagnosis, assess the severity, identify complications and define the precise location of sigmoid diverticulitis [11]. Thus, there is a lack of morphological and radiological information regarding the mode of development of recurrent diverticulitis. The aim of this study was to: (i) compare the clinical and radiological severity of the first two episodes of sigmoid diverticulitis in a population of patients who needed in-hospital admission and (ii) to characterize morphologically the precise location of both episodes, in order to determine whether recurrent diverticulitis might involve a different segment of the left colon. Method Between 2000 and 2010 the charts of all patients hospitalized twice with a diagnosis of diverticulitis at Geneva University Hospital were retrospectively reviewed. Patients were excluded from the study for the following reasons: presence of concomitant colon cancer or inflammatory bowel disease, diagnosis of complicated diverticulitis on the initial episode [abscess (Hinchey stage I and II) or fistula, diverticulitis not documented with CT scan or with a CT scan performed in another institution and missing data from chart] and patient refusal to participate in the research. CT scans were reviewed by two radiologists (AP and PAP) who assessed disease severity and location for both episodes. A diverticulitis severity score was established and based upon the following parameters: (i)colonic wall thickness (< 5 mm = 0 points, 6 to 10 mm = 1 point, > 1 cm = 2 points); (ii) mesenteric fat infiltration (poor = 0 points, moderate = 1 point, severe = 2 points); (iii) presence of free fluid within the pelvis (absence = 0 points, presence = 1 point); (iv) presence of free air (absence = 0 points, presence = 1 point); and (v) presence of an abscess (none = 0 points, presence = 1 point). The sum of each of the five parameter scores defined a CT scan-based severity score (range 0 7) for both episodes. In addition, the radiologists compared CT scans of both episodes to establish a precise localization of disease [descending colon proximal sigmoid middle (horizontal) sigmoid distal sigmoid]. The following clinical and biological parameters were collected for all patients and for each episode of diverticulitis: age at the time of diagnosis, delay between both episodes, serum C-reactive protein, leucocyte count, duration of hospital stay, need for CT scan-guided percutaneous drainage of abscess, emergency surgery and subsequent elective sigmoid resection. The study was conducted in accordance with the ethical recommendations from the Institutional Review Board for Clinical Research from Geneva University Hospital and Medical School. Definitions The Hinchey classification was used to define the septic complications of sigmoid diverticulitis [12]; stage 1 refers to the presence of a small (< 4 cm) abscess within the mesocolon, stage II is a larger extra-mesocolic collection in the pelvis, stage III is purulent peritonitis and stage IV is faecal peritonitis. Simple, uncomplicated diverticulitis was therefore defined as the absence of abscess, fistula or peritonitis. The term perforated diverticulitis was not used because, by definition, all episodes of diverticulitis require some degree of micro-perforation of a false diverticulum within the mesocolon or outside the mesocolon causing a small amount of free air within the abdominal cavity. Recurrent diverticulitis was defined as the occurrence of a second, distinct episode of acute inflammation 3 months at least after the initial episode. There were many patients who were readmitted within 2 8 weeks of discharge with continuing symptoms and mild colonic inflammation on CT scan. We considered that these patients had persistent diverticulitis not responding to initial antibiotherapy, but that this was not a true recurrence because there was no free, asymptomatic interval between the two acute episodes. Statistical analysis Statistical analyses were undertaken by means of the software package STATGRAPH 3.0Ò software for Windows (Statgraph Software Inc., San Diego, California, USA). Quantitative data were expressed as median (range). Groups comparisons were made using two-sided Fisher s exact test for categorical variables and the Wilcoxon match-paired or Mann Whitney U-test, when indicated, for continuous variables. P-values 0.05 were considered statistically significant. Results Sixty consecutive patients [median age 61(range 31 90) years at the time of first admission] were considered for analysis. There were 36 women and 24 men. The median delay between the two episodes was 19 (range 3 97) months. The clinical and radiological characteristics of patients and diverticulitis episodes are summarized in Table 1. During the study period 32 patients underwent elective sigmoid resection, three had an emergency 464 Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14,

P. Gervaz et al. Sigmoid diverticulitis: episodes I and II Table 1 Clinical and radiological characteristics of patients and diverticulitis episodes.

3 P. Gervaz et al. Sigmoid diverticulitis: episodes I and II Table 1 Clinical and radiological characteristics of patients and diverticulitis episodes. Parameter Episode 1 Episode 2* P Age, years (median, range) 61 (30 90) 62 (31 91) Hospital stay, days (median, range) 11 (4 22) 10 (1 24) 0.79 Leucocyte count (median, range) 11.5 ( ) 10.2 ( ) 0.11 C-reactive protein, mm (median, range) 137 (31 570) 112 (22 333) 0.57 CT scan severity score (median, range) 3 (1 6) 3 (0 7) 0.22 Diverticulitis location Descending colon 4 5 Proximal sigmoid Middle sigmoid Distal sigmoid 5 1 Simple diverticulitis Complicated diverticulitis 0 6 Hinchey I II 2 Hinchey III IV 3 Fistula 1 *Excluding values for six patients with complicated diverticulitis. Wilcoxon matched-pairs signed-ranks test. Hartmann s procedure, which was eventually reversed, while 25 patients did not need to have an operation. Case scenario 1: progressive disease severity at the same location Six (10%) patients developed a second complicated episode of diverticulitis. Of these, two elderly female patients presented with a Hinchey II abscess, which was successfully managed with CT-guided percutaneous drainage. Three male patients presented with Hinchey III diverticulitis requiring urgent laparotomy and a Hartmann s operation. Finally, another patient developed a colovesical fistula and underwent elective sigmoid resection. In every case, recurrence occurred in the same location as the initial episode, albeit with a large perforation, responsible for septic complications. In this small group, the mean delay between both episodes was 31 months (Fig. 1). Case scenario 2: same disease severity at the same location Fifty-four (90%) patients developed a second uncomplicated episode of diverticulitis. In this group, the clinical and radiological parameters of disease severity were similar between both episodes. Duration of hospital stay [11 (4 22) vs 10 (1 39) days, P = 0.28], serum levels of C-reactive protein [131 (31 350) vs 112 (22 333) mm, P = 0.62) and CT scan-based severity score [3 (1 6) vs 3 (a) (b) Figure 1 Case scenario 1: disease progression at the same location. (a) Episode 1, May 2007, simple diverticulitis (arrow). (b) Episode 2, September 2007, complicated diverticulitis with two abscess collections (arrows). The patient, a 35-year-old man, underwent emergency laparotomy and a Hartmann s operation for stage III diverticulitis. Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14,

Sigmoid diverticulitis: episodes I and II P. Gervaz et al. (a) (b) Figure 2 Case scenario 2: same disease severity at the same location.

07] were similar between the two episodes. Moreover, in 35 (65%) out of 54 patients diverticulitis occurred at the same location in the left colon.

Case scenario 3: same disease severity at a different location In 19 (35%) patients with recurrent uncomplicated diverticulitis there was a shift of disease location.

4 Sigmoid diverticulitis: episodes I and II P. Gervaz et al. (a) (b) Figure 2 Case scenario 2: same disease severity at the same location. (a) Episode 1, January 2001, simple diverticulitis in the horizontal part of the sigmoid (arrow). (b) Episode 2, August 2006, same severity in the same location (arrow). (0 7) points, P = 0.07] were similar between the two episodes. Moreover, in 35 (65%) out of 54 patients diverticulitis occurred at the same location in the left colon. Thus case senario 2 mirrors the clinical and topographical characteristics of the initial episode (Fig. 2). Case scenario 3: same disease severity at a different location In 19 (35%) patients with recurrent uncomplicated diverticulitis there was a shift of disease location. Variations in disease location were significant, with the areas of maximal inflammation differing in distance by 8 (range 3 18) cm. Recurrent diverticulitis occurred more proximally than the initial episode in 12 patients. In this scenario, the disease is not progressive in severity but seems to vary its location (Fig. 3). Discussion The data presented here indicate that a minority of patients with an initially simple episode of diverticulitis will develop eventual septic complications, such as abscesses, fistulas or peritonitis, and require emergency surgery. In > 50% of cases, disease progression follows a relatively benign course. Recurrences have the same severity and occur at the same location as the index episode. Many patients, however, experience a second episode that is clinically similar, but morphologically different, involving another segment of the left colon. Our series describes a specific population of patients with sigmoid diverticulitis, who were hospitalized twice with a CT scan-proven diagnosis. Thus, comparisons with other series are made difficult by differences in diagnostic criteria and imaging modalities; most series from the 1990s report experience with patients who did not have a (a) (b) Figure 3 Case scenario 3: same disease severity at a different location. (a) Episode 1, October 2002, simple diverticulitis in the proximal sigmoid colon (arrow). The horizontal loop of the sigmoid appeared normal at the time (asterisk). (b) Episode 2, January 2003, simple diverticulitis in another, more distal location (arrow). 466 Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14,

5 P. Gervaz et al. Sigmoid diverticulitis: episodes I and II CT scan at the time of diagnosis [13]. Nevertheless, we previously reported a 25 30% sigmoid diverticulitis recurrence rate at 5 years, which is in accordance with the general opinion that one-third of patients develop a second attack [14]. It is interesting to note that more recent series report higher (48%) recurrence rates [15]. The rate of subsequent episodes of complicated diverticulitis (10%) and emergency surgery (5%) appears, again, well in line with a large series from the US [16]. In summary, out of 100 patients who have been previously admitted for uncomplicated diverticulitis and who have successfully responded to conservative management: (i) will not recur; (ii) will develop a second, uncomplicated episode and (iii) 2 3 will progress towards severe septic complications. Having said that, it is tempting to conclude that uncomplicated sigmoid diverticulitis is a benign disease, characterized by slow progression and excellent outcome, justifying a conservative approach [17]. Actually, the absence of severity of the first episode does not completely protect patients from eventual septic complications. The data presented here indicate that diverticulitis may be ubiquitous, with a different topography at each episode: the same diverticulum is not necessarily responsible for every attack of diverticulitis, and this represents new and clinically relevant information for surgeons. Recurrent diverticulitis involving the distal descending colon or the colo-sigmoid junction warrants a proximally extended resection, which requires full mobilization of the splenic flexure in order to perform a tension-free anastomosis between the middle third of the descending colon and the upper rectum [18]. In summary, recurrent sigmoid diverticulitis, even when it is clinically similar, might represent morphologically a distinct entity. CT scan imaging of each diverticulitis episode is, therefore, a prerequisite for adequate disease location, making possible a resection encompassing all previously inflamed segment(s) of the distal colon. In this situation, a CT scan provides not only a map of the disease, but also helps the surgeon in better defining the territory to explore [19]. Our study has several limitations, the most obvious being that we considered only patients who needed inhospital management. A large percentage of patients with sigmoid diverticulitis have a more benign clinical course and can be successfully managed in an ambulatory setting: thus, the population herein described might represent a specific group of patients at risk for developing a more severe form of the disease. Another limitation of our study is related to the small number of patients, which may explain in part the absence of differences in the severity of both episodes. However, 90% of patients were treated in the same way for both episodes, with a similar outcome. Finally, the CT scan-based severity score used in this study was not validated. In conclusion, our data give confirmation that in the era of modern antibiotics, simple sigmoid diverticulitis usually follows a benign course. However, even when it remains clinically stable or slowly progressive, it can alter its location to involve different areas of the left colon. These variations in disease distribution are of paramount importance for the surgeon and highlight the role of CT in providing morphological information to define the extent of proximal resection. Finally, these morphological findings may also reflect changes in disease epidemiology. In a recent series, between 1998 and 2005, admission rates for diverticulitis increased by 82% among patients aged years [20]. It is an intriguing hypothesis that a new pattern of diverticulitis is emerging, which predominantly affects young male patients, follows an aggressive course and is more proximally located. Authors contributions PG and LW: acquisition and analysis of clinical data, and drafting the manuscript. AP and PAP: acquisition and analysis of radiological data. PA: design, interpretation of data, and revising manuscript. Transparency statement Funding support and financial relationships: none. References 1 Parks TG. Natural history of diverticular disease of the colon. Review of 521 cases. BMJ 1969; 4: Boles RS, Jordan SM. The clinical significance of diverticulosis. Gastroenterology 1958; 35: Colcock BP. Surgical management of complicated diverticulitis. N Engl J Med 1958; 259: Chapman J, Davies M, Wolff B et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005; 242: Makela JT, Kiviniemi HO, Laitinen ST. Spectrum of disease and outcome among patients with acute diverticulitis. Dig Surg 2010; 27: Salem L, Veenstra DL, Sullivan SD, Flum DR. The timing of elective colectomy in diverticulitis: a decision analysis. JAm Coll Surg 2004; 199: Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P, Soravia C. Long-term follow-up after first episode of sigmoid diverticulitis: is surgery mandatory? Dis Colon Rectum 2002; 45: Frileux P, Dubrez J, Burdy G et al. Sigmoid diverticulitis. Longitudinal analysis of 222 patients with a minimal followup of 5 years. Colorectal Dis 2010; 12: Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14,

6 Sigmoid diverticulitis: episodes I and II P. Gervaz et al. 9 Moreno AM, Wille-Jorgensen P. Long-term outcome in 445 patients after diagnosis of diverticular disease. Colorectal Dis 2007; 9: Eglinton T, Nguyen T, Raniga S, Dixon L, Dobbs B, Frizelle FA. Patterns of recurrence in patients with acute diverticulitis. Br J Surg 2010; 97: Ambrosetti P. Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg 2008; 12: Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12: Shaikh S, Krukowski ZH. Outcome of a conservative policy for managing acute sigmoid diverticulitis. Br J Surg 2007; 94: Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49: Klarenbeek BR, Samuels M, van der Wal MA, van der Peet Dl, Meijerink J, Cuesta MA. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010; 251: Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140: Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcome? Ann Surg 2006; 243: Gervaz P, Inan I, Perneger T, Schiffer E, Morel P. A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 2010; 252: Houellebecq M. (2010) The Map and the Territory. Flammarion, Paris. 20 Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Diverticulitis in the United States: : changing patterns of disease and treatment. Ann Surg 2009; 249: Colorectal Disease Ó 2011 The Association of Coloproctology of Great Britain and Ireland. 14,

Acute Diverticulitis. Andrew B. Peitzman, MD Mark M. Ravitch Professor of Surgery University of Pittsburgh

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