• What is the Best way to Manage Diverticulitis, and how Many People Have it?

What is the Best way to Manage Diverticulitis, and how Many People Have it?

Not all patients with multiple episodes of diverticulitis should undergo preventative surgery, shows a Markov decision model published in the January 2016 issue of Clinical Gastroenterology and Hepatology. Elective surgery after 2 episodes produces fewer quality-adjusted life-years (QALYs) than surgery after 3 episodes or conservative or medical treatments, the model found.

There is little evidence for the appropriate management of recurrent diverticulitis. Surgery is considered, but there is debate over its optimal timing. Surgery can prevent recurrence but poses a risk for complications. According to the recent guidelines, elective resection should be considered after 2 well-documented attacks of diverticulitis, depending on the severity of the attack and age and medical fitness of the patient.

To determine the best strategy for patients with recurrent episodes of diverticulitis, Caroline S. Andeweg et al designed a state-transition Markov model to compare surgical and conservative treatment approaches, using quality of life as the primary outcome measure.

The authors examined the effects of (1) surgery after the second uncomplicated episode (early surgery, the traditional standard of care), (2) surgery after the third uncomplicated episode (late surgery), (3) conservative treatment after 3 episodes of diverticulitis, and  (4) medical treatment after 3 episodes of diverticulitis (mesalamine and rifaximin).

Box plot with results of generated QALYs in 10 years for all 4 treatment strategies with Monte Carlo simulation (probabilistic sensitivity analysis).

Box plot with results of generated QALYs in 10 years for all 4 treatment strategies with Monte Carlo simulation (probabilistic sensitivity analysis).

They found that during a 10-year period, the strategy of colonic resection after 2 episodes of diverticulitis was associated with the lowest quality-adjusted survival of 8.66 QALYs.

The strategies of colonic resection or conservative treatment or medical treatment after the third episode of diverticulitis were comparable in terms of quality-adjusted survival, with 8.78 QALYs, 8.76 QALYs, and 8.74 QALYs, respectively.

Persistent abdominal complaints were lowest among patients receiving the medical treatment strategy.

Overall mortality was comparable between the strategies of colonic resection (7.8%), conservative treatment (7.6%), and medical treatment after the third episode of diverticulitis (7.6%).

In an editorial that accompanies the article, Marc S. Piper and Sameer D. Saini say that although the model makes a compelling case for less aggressive surgical management of recurrent diverticulitis, its findings should be interpreted with caution. Simulation models are subject to underlying assumptions, such as the long-term benefits and harms of medical therapy.

Additionally, the model does not consider patient preferences, although it does highlight the need for more nuanced case-by-case approaches in the management of recurrent diverticulitis. Piper and Saini recommend the use of decision aids to help patients consider the pros and cons of treatment to improve informed decision-making.

In the same issue of the journal, Chelle L. Wheat and Lisa L. Strate investigated trends in diverticular disease using a nationally representative dataset of discharge diagnoses from US hospitals.

They write that complications of diverticular disease—diverticulitis and diverticular bleeding—are the leading gastrointestinal indication for hospital admission in the US. In 2009, an estimated 280,000 individuals were hospitalized for diverticular complications. Some studies reported a large increase in the prevalence of diverticulitis since the mid-1990s.

Wheat and Strate found that the prevalence of hospitalizations for diverticulitis increased through 2008 and then plateaued. In contrast, the prevalence of hospitalizations for diverticular bleeding decreased from 2004 to 2010, by 17%. The authors’ data confirmed diverticular bleeding to be a disease of the elderly—45% of diverticular bleeding cases occurred in patients older than 80 years.

Diverticulitis was rare in patients younger than 40 years old. However, after age 40, the prevalence was similar regardless of age. Diverticulitis was more common in women than in men. Whites had the highest prevalence of diverticulitis, whereas blacks had the highest prevalence of diverticular bleeding.

In their editorial, Piper and Saini explain that changing environmental factors such as diet, physical activity, and use of medicines such as nonsteroidal anti-inflammatory drugs could be involved in the changing prevalence of these syndromes. Alternatively, the rising prevalence might result from increased detection, due to changes in clinical practice, such as more frequent use of cross-sectional imaging.

Wheat and Strate proposed that the severity of diverticulitis is decreasing, because the proportion of patients who required surgical management decreased from 25% to 15% over the 10-year period. However this could reflect a change in surgical practice.

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