Acute diverticulitis: beyond the diagnosis: predictive role of CT in assessing risk of recurrence and clinical implications in non-operative management of acute diverticulitis

Abstract

Purpose: The aim of the study is to identify CT findings that are predictive of recurrence of acute uncomplicated colonic diverticulitis, to better risk-stratify these patients for whom guidelines recommend a conservative outpatient treatment and to determine the appropriate management with an improvement of health costs.

Materials and methods: Over the past year, 33 patients enrolled in an outpatient integrated care pathway (PDTA) for uncomplicated acute diverticulitis with 1-year follow-up period, without recurrence, and 33 patients referred to Emergency Department for a recurrent acute diverticulitis were included. Images of admission CT were reviewed by two radiologists and the imaging features were analyzed and compared with Chi-square and Student t tests. Univariate and multivariate Cox regression models were employed to identify parameters that significantly predicted recurrence in 1-year follow-up period and establish cutoff and recurrence-free rates. The maximally selected rank statistics (MSRS) were used to identify the optimal wall thickening cutoff for the prediction of recurrence.

Results: Patients with recurrence showed a greater mean parietal thickness compared to the group without recurrence (16 mm vs. 11.5 mm; HR 1.25, p < 0.001) and more evidence of grade 4 of peridiverticular inflammation (40% vs. 12%, p = 0.009, HR 3.44). 12-month recurrence-free rates progressively decrease with increasing thickness and inflammation. In multivariate analysis, only parietal thickness maintained its predictive power with an optimal cutpoint > 15 mm that causes a sixfold increased risk of recurrence (HR 6.22; 95% CI, 3.05-12.67; p < 0.001). Beyond thickness and peridiverticular inflammation, predictive value of early recurrence within 90 days from the 1st episode resulted also an Hinchey Ib on admission CT.

Conclusions: The maximum wall thickening and the grade of peridiverticular inflammation can be considered as predictive factors of recurrence and may be helpful in selecting patients for a tailored treatment to prevent the risk of recurrence.

Keywords: Hinchey classification; Integrated care pathway; Outpatient management; Uncomplicated diverticular disease.

Fig. 1

A axial and coronal measurement of involved colon segment length; B measurement of maximum parietal thickness (serosa-to-mucosal surface) of inflamed segment with visible lumen and measurement of maximum parietal thickness (serosa-to-serosa surface) of inflamed segment without visible lumen

Fig. 2

Axial CT showing peridiverticular inflammation grades: (1) Minimal: rare fine threads of high attenuation. (2) Mild: multiple threads of high attenuation that remain distinct, vessels are clearly visible. (3) Moderate: many threads difficult to resolve individually, vessels difficult to discern. (4) Severe: dominant pattern of increased attenuation in the fat could be mistaken for fluid collection, vessels not visible

Fig. 3

Kaplan–Meier plot for recurrence-free probability stratified by colonic wall maximum thickness groups during 1-year follow-up. Patients with a parietal thickness > 15 mm had a 12-month recurrence-free probability < 0,25 (log-rank test p < 0.001)

Fig. 4

Kaplan–Meier plot for recurrence-free probability stratified by peridiverticular inflammation groups during 1-year follow-up. Patients with a grade 1 and 2 of peridiverticular inflammation had a significantly higher recurrence-free probability at 12 months than those with 3 and 4 grades (log-rank test p < 0.001)

Fig. 5

Scatter plot of maximally selected rank statistic shows the cutoff value of colonic wall thickness that predicts risk of recurrence

Fig. 6

Kaplan–Meier curve according to the new cutoff value of colonic wall thickness (thickness high is > 15 mm and thickness low is < 15 mm)