Long-term Implications of Persistent Diverticulitis: A Retrospective Cohort Study of 915 Patients

BACKGROUND Persistent (or ongoing) diverticulitis is a well-recognized outcome after treatment for acute sigmoid diverticulitis; however, its definition, incidence, and risk factors, as well as its long-term implications, remain poorly described. OBJECTIVE The purpose of this study was to assess the incidence, risk factors, and long-term outcomes of persistent diverticulitis. DESIGN This was a retrospective cohort study. SETTINGS Two university-affiliated hospitals in Montreal, Quebec, Canada were included. PATIENTS The study was composed of consecutive patients managed nonoperatively for acute sigmoid diverticulitis. INTERVENTION Nonoperative management of acute sigmoid diverticulitis was involved. MAIN OUTCOME MEASURES Persistent diverticulitis, defined as inpatient or outpatient treatment for signs and symptoms of ongoing diverticulitis within the first 60 days after treatment of the index episode, was measured. RESULTS In total, 915 patients were discharged after an index episode of diverticulitis managed nonoperatively. Seventy-five patients (8.2%; 95% CI, 6.5%-10.2%) presented within 60 days with persistent diverticulitis. Factors associated with persistent diverticulitis were younger age (adjusted OR = 0.98 (95% CI, 0.96-0.99)), immunosuppression (adjusted OR = 2.02 (95% CI, 1.04-3.88)), and abscess (adjusted OR = 2.05 (95% CI, 1.03-3.92)). Among the 75 patients with persistent disease, 42 (56.0%) required hospital admission, 6 (8.0%) required percutaneous drainage, and 5 (6.7%) required resection. After a median follow-up of 39.0 months (range, 17.0-67.3 mo), the overall recurrence rate in the entire cohort was 31.3% (286/910). After excluding patients who were managed operatively for their persistent episode of diverticulitis, the cumulative incidence of recurrent diverticulitis (log-rank: p < 0.001) and sigmoid colectomy (log-rank: p < 0.001) were higher among patients who experienced persistent diverticulitis after the index episode. After adjustment for relevant patient and disease factors, persistent diverticulitis was associated with higher hazards of recurrence (adjusted HR = 1.94 (95% CI, 1.37-2.76) and colectomy (adjusted HR = 5.11 (95% CI, 2.96-8.83)). LIMITATIONS The study was limited by its observational study design and modest sample size. CONCLUSIONS Approximately 10% of patients experience persistent diverticulitis after treatment for an index episode of diverticulitis. Persistent diverticulitis is a poor prognostic factor for long-term outcomes, including recurrent diverticulitis and colectomy. See Video Abstract at http://links.lww.com/DCR/B593. REPERCUSIONES A LARGO PLAZO DE LA DIVERTICULITIS PERSISTENTE ESTUDIO DE UNA COHORTE RETROSPECTIVA DE PACIENTES ANTECEDENTES:La diverticulitis persistente (o continua) es un resultado bien conocido posterior al tratamiento de la diverticulitis aguda del sigmoides; sin embargo, la definicion, incidencia y factores de riesgo, asi como sus repercusiones a largo plazo siguen estando descritas de manera deficiente.OBJETIVO:Evaluar la incidencia, los factores de riesgo y los resultados a largo plazo de la diverticulitis persistente.DISENO:Estudio de una cohorte retrospectiva.AMBITO:Dos hospitales universitarios afiliados en Montreal, Quebec, Canada.PACIENTES:pacientes consecutivos tratados sin cirugia por diverticulitis aguda del sigmoides.INTERVENCION:Tratamiento no quirurgico de la diverticulitis aguda del sigmoides.PRINCIPALES RESULTADOS EVALUADOS:Diverticulitis persistente, definida como tratamiento hospitalario o ambulatorio por signos y sintomas de diverticulitis continua dentro de los primeros 60 dias posteriores al tratamiento del episodio indice.RESULTADOS:Un total de 915 pacientes fueron dados de alta posterior al episodio indice de diverticulitis tratados sin cirugia. Setenta y cinco pacientes (8,2%; IC del 95%: 6,5-10,2%) presentaron diverticulitis persistente dentro de los 60 dias. Los factores asociados con la diverticulitis persistente fueron una edad menor (aOR: 0,98, IC del 95%: 0,96-0,99), inmunosupresion (aOR: 2,02, IC del 95%: 1,04-3,88) y abscesos (aOR: 2,05, IC del 95%: 1,03-3,92). Entre los 75 pacientes con enfermedad persistente, 42 (56,0%) requirieron ingreso hospitalario, 6 (8,0%) drenaje percutaneo y 5 (6,7%) reseccion. Posterior a seguimiento medio de 39,0 (17,0-67,3) meses, la tasa global de recurrencia de toda la cohorte fue del 31,3% (286/910). Despues de excluir a los pacientes que fueron tratados quirurgicamente por su episodio persistente de diverticulitis, la incidencia acumulada de diverticulitis recurrente (rango logaritmico: p <0,001) y colectomia sigmoidea (rango logaritmico: p <0,001) fue mayor entre los pacientes que experimentaron diverticulitis persistente despues el episodio indice. Posterior al ajuste de factores importantes de la enfermedad y del paciente, la diverticulitis persistente se asocio con mayores riesgos de recurrencia (aHR: 1,94, IC 95% 1,37-2,76) y colectomia (aHR: 5,11, IC 95% 2,96-8,83).LIMITACIONES:Diseno de estudio observacional, un modesto tamano de muestra.CONCLUSIONES:Aproximadamente el 10% de los pacientes presentan diverticulitis persistente despues del tratamiento del episodio indice de diverticulitis. La diverticulitis persistente, en sus resultados a largo plazo, es un factor de mal pronostico, donse se inlcuye la diverticulitis recurente y colectomia. Consulte Video Resumen en http://links.lww.com/DCR/B593.