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Controversy of Colonoscopy in Acute Diverticulitis

Colonoscopy is commonly performed routinely in all acute diverticulitis patients to exclude the possibility of colorectal cancer. However, the latest scientific evidence refuses it and suggests that performing colonoscopy is only for certain groups of patients.

Acute diverticulitis is inflammation of the diverticula sac formed by the herniation. Acute diverticulitis is considered to increase the risk of colorectal cancer, so colonoscopy is recommended to be done routinely in patients with acute diverticulitis.

Computed tomography (CT) scans with contrast, and accompanied with typical clinical features of acute diverticulitis, have generally been accepted as the gold standard for the diagnosis of acute diverticulitis. CT scan also functions as equipment to assess the severity of the disease and its associated complications, such as diverticular abscesses or perforations.

The triad signs of acute diverticulitis on CT imaging are colonic diverticula, thickening of the large intestine wall> 4 mm, and increased soft tissue density in abdominal fat adjacent to the lesion.

Colonoscopy in Acute Diverticulitis
Colonoscopy in Acute Diverticulitis

Colonoscopy for Colorectal Cancer Exclusion in Acute Diverticulitis.

Several clinical guidelines recommend doing colonoscopy routinely to exclude the possibility of colorectal cancer in acute diverticulitis because of the colorectal cancer symptoms is almost similar to symptoms of acute diverticulitis. In addition, CT scans features of acute diverticulitis (for example, thickening of the colonic wall) can also be found on CT scans of colon cancer.

The American Society of Colon and Rectal Surgeons and The American College of Gastroenterology Recommendations
The American Society of Colon and Rectal Surgeons and The American College of Gastroenterology recommend acute diverticulitis patients to undergo colonoscopy as a process of exclusion of possible colon cancer after acute diverticulitis. The procedure is performed within 6 to 8 weeks after the patient is discharged from the hospital to prevent complications of perforation if the colonoscopy is performed early.

The Netherlands Society of Surgery and the World Society of Emergency Surgery Recommendations
The Netherlands Society of Surgery and the World Society of Emergency Surgery do not recommend colonoscopy routinely. Both of these clinical guidelines recommend not to perform colonoscopy regularly in patients with asymptomatic after episodes of acute diverticulitis or in patients with acute diverticulitis without complications.

Disclaimer of Routine Colonoscopy Recommendations for Colorectal Cancer Exclusion in Acute Diverticulitis

The 2017 literature review provided a refutation of the above recommendations. The literature rated that the recommendations regarding routine colonoscopy in patients with acute diverticulitis were not supported by adequate scientific evidence.

This study found a low risk of colorectal cancer in uncomplicated diverticulitis patients. In addition, the prevalence of colon cancer in diverticulitis is also not significantly different from the general asymptomatic population.

Colonoscopy should not be done routinely and only done in the following conditions:

- Acute diverticulitis with complications (eg, abscesses or fistulas).
- Acute diverticulitis without complications with colorectal cancer risk factors such as positive occult blood stool test results or a history of relatives/parents with colorectal cancer before the age of 55 years.
- Acute diverticulitis without complications in patients aged 50 years and over

The 2019 meta-analysis also stated that colonoscopy should not be done routinely in patients with acute diverticulitis. Colonoscopy is only recommended in patients with complicated acute diverticulitis or patients with persistent symptoms after therapy.

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8.Andeweg CS, Mulder IM, Felt-Bersma RJF, et al. Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis. 2013. Digestive Surgery, 30(4-6),278-292.
9.McSweeney, William and Srinath, Havish. Diverticular disease practice points. AFP VOL.46, NO.11, NOVEMBER 2017: 829-832. Available from: https://www.racgp.org.au/download/Documents/AFP/2017/November/AFP-2017-11-Clinical-Diverticular.pdf
10.De Vries, HS et al. Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review. Surgical Endoscopy · February 2014. Available from: https://www.researchgate.net/profile/Hilbert_De_Vries/publication/260040868_Routine_colonoscopy_is_not_required_in_uncomplicated_diverticulitis_A_systematic_review/links/546352450cf2c0c6aec39a57/Routine-colonoscopy-is-not-required-in-uncomplicated-diverticulitis-A-systematic-review.pdf?origin=publication_detail

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