Differentiating Colorectal Carcinoma From Diverticulitis With Computerised Tomography: Does Every Patient Need Follow-Up Colonoscopy After an Episode of Acute Diverticulitis?

Sandeep Singh,Alice Giucca,Nick Browning,Haytham Sumrien,Anna Heylen,Upekha Alagoda,James Shuttleworth

doi:10.7759/cureus.12027

Abstract

PurposeTo correlate computerised tomography (CT) and endoscopic follow-up (FU) in differentiating presentations of acute diverticulitis (AD) and colorectal carcinoma (CRC).MethodsPatient’s discharge summaries between April 2018 and September 2019, stating AD under-diagnosis were retrieved. Admission details, CT reports, endoscopic findings and histopathology results were retrospectively collected from prospectively maintained data.ResultsIn our study period of 17 months, we identified 150 patients with an admission diagnosis of AD. In total, 134 patients had a CT confirmed diagnosis of AD; 61% had uncomplicated acute diverticulitis (UAD) and 39% complicated acute diverticulitis (CAD). The mean age of the patients was 64 years, and 59% were female. Of the 134, 15 patients were excluded, and 119 with AD were discharged with a plan to have FU endoscopy. Overall, 75% of the patients managed to undergo complete endoscopic investigation, 4% had incomplete endoscopy, and 21% failed to attend endoscopy. Follow-up (FU) endoscopic investigation found polyps in 20 patients; seven were reported as tubular adenomas with low-grade dysplasia and 10 as non-concerning hyperplastic or sessile polyps. One was inflammatory, and two were malignant. CT scans for two patients with malignant polyps were reported as CAD with suspicion of sigmoid cancer in one and right-sided perforated diverticulitis in the other. Both patients were female aged over 60 years.ConclusionsThis study demonstrates that a selective approach is more appropriate for endoscopic FU after an episode of AD. Risk stratification is required to allocate FU endoscopic investigation for patients at high risk for CRC.

Highlights

In the United Kingdom, 50% of the population of 50 years is affected by diverticulosis; the prevalence increases with age [1]
computerised tomography (CT) scans for two patients with malignant polyps were reported as complicated acute diverticulitis (CAD) with suspicion of sigmoid cancer in one and right-sided perforated diverticulitis in the other
This study demonstrates that a selective approach is more appropriate for endoscopic FU after an episode of acute diverticulitis (AD)

Summary

Introduction

In the United Kingdom, 50% of the population of 50 years is affected by diverticulosis; the prevalence increases with age [1] The majority of those affected remain asymptomatic, though a proportion suffers acute diverticulitis (AD) which is described as an inflammation of diverticula, secondary to faecalith obstruction with localised mucosal inflammation [2]. Despite clinical presentation and a suggestive CT, the occasional lack of specific symptoms, examination and radiological findings prevent diagnostic confirmation of AD. Radiological findings such as vascular engorgement or mesenteric root fluid have been shown to have high specificity but low sensitivity for sigmoid diverticulitis [6]. The Royal College of Surgeons (RCS) recommended in 2014 that all

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