When to Perform a Colonoscopy in Diverticular Disease and Why: A Personalized Approach

Abstract

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize "when" to safely perform a colonoscopy in the different DD settings and "why".

Keywords: DICA classification; acute diverticulitis; colonoscopy; diverticular bleeding; diverticular disease; segmental colitis associated with diverticulosis.

Figure 1

A 68-year-old female underwent a colonoscopy due to bloody diarrhea. Endoscopic appearance shows hyperemia and erosions on the colonic folds and the interdiverticular mucosa, with complete sparing of the diverticula. These lesions can be classified as type B SCAD.

Figure 2

A 72-year-old inpatient female with acute diverticulitis complicated by stenosis underwent a colonoscopy due to persistent abdominal pain. A colonoscopy confirmed stenosis of the proximal descending colon (panel a), but histology was inconclusive. She underwent resection of the sigmoid and proximal descending colon (panel b), and histology was consistent with well-differentiated colonic adenocarcinoma.

Figure 3

Massive diverticulosis with the stiffness of the lumen. Until the development of the DICA classification, the significance of these colonic characteristics was unknown. Now, this endoscopic picture can be scored as DICA 2 (left-sided diverticulosis: 2 points; >15 diverticula per district: 1 point; rigidity of the colonic wall: 4 points; total: 7 points), having an increased risk of developing complications related to the disease.

Figure 4

Endoscopic appearance of the colon eight weeks after an episode of uncomplicated diverticulitis. No signs of inflammation may be detected, and the patient risks being mis-scored according to the DICA classification.

Figure 5

A 79-year-old man underwent colonoscopy due to massive rectal bleeding associated with severe anemia (hemoglobin 8.7 g/dL). The colonoscopy showed diverticulosis with signs of recent, but not current, bleeding.