Natural History of Sigmoid Diverticulitis: The Geneva Cohort Study
Natural History of Sigmoid Diverticulitis: The Geneva Cohort Study
Aim: This is a longitudinal cohort study to assess long-term clinical outcome of patients who
 were admitted in our institution for a first episode of uncomplicated sigmoid diverticulitis.

 Methods: All patients who were diagnosed with a first episode of sigmoid diverticulitis will
 be evaluated for inclusion in the study, pending informed consent. Those patients who have
 evidence of complicated diverticulitis (fistula, abscess) will receive a recommendation to
 undergo elective sigmoid resection, while those who have a simple attack will be recruited in
 the cohort. Follow-up will be performed at yearly intervals through telephone interview with
 the patient. The duration of study is expected to last 10 years (2010-2020), with >50 new
 patients/year, for a total of >500 patients.

 Endpoints:

 1. the occurrence of a second episode of diverticulitis

 2. severity and outcome of recurrent diverticulitis

 3. evolution in digestive symptoms and quality of life (QoL)

 4. need for subsequent elective or emergency sigmoid resection

 Rationale: This study will help in determining the risk/benefit of the current approach for
 this common condition, which is to manage patients conservatively with antibiotics and adopt
 a wait-and-see attitude. Specifically, the following events will be assessed quantitatively:

 -  the rate of relapse in an urban community.

 -  the burden of this common disease on QoL and digestive function

 -  the percentage of patients who may need emergency surgery
Colonic diverticulosis is an increasingly common condition in the Western societies; in our
 country, a third of the population is affected by the 6th decade and two-thirds by the 9th
 decade. Fortunately, a majority of patients with diverticulosis remain asymptomatic;
 diverticulitis, the most common presentation of diverticular disease, has an estimated
 incidence of 10 patients per 100,000/year.

 The diagnosis of sigmoid diverticulitis is usually suspected clinically in a patient
 presenting with acute lower abdominal pain, associated with an inflammatory syndrome with
 elevated CRP and/or leukocytes count. The preferred imaging modality to establish definitive
 diagnosis is computerized tomography (CT) scan with triple (oral, intravenous and
 intra-rectal) administration of contrast. CT scan may also influence management by
 demonstrating whether sigmoid diverticulitis is simple (phlegmonous, showing an infiltration
 of pericolic fat and a thickening of intestinal wall) or complicated (abscess, fistula or
 peritonitis).

 A majority of patients present with simple diverticulitis, and will be conservatively and
 successfully managed with antibiotics alone. Full colonoscopy is performed eventually, in
 order to rule out an associated condition, most notably cancer and Crohn's disease. Colonic
 diverticular disease is usually restricted to the sigmoid colon, and conservative treatment
 with antibiotics is indicated in cases of a first attack of uncomplicated diverticulitis, the
 rationale being that a majority of patients treated for a first episode of acute inflammation
 will eventually recover and have no further problems.

 Elective sigmoidectomy is currently recommended in the following clinical situations:

 -  Patients who had two episodes of uncomplicated diverticulitis.

 -  Patients who had one episode of complicated (perforated) diverticulitis, with either
 pericolic of pelvic abscesses (Hinchey stage I and II respectively), fistula formation
 and/or stenosis.

 These guidelines, however, reflect expert consensus rather than scientific evidence;
 currently, there is no way to predict for each patient the risk for developing subsequent
 complications and recurrences. Thus, the important question is to determine whether a
 conservative approach is not simply delaying definitive treatment and expose patients to
 additional complications and alterations in quality of life.

 3. OBJECTIVES

 The main objective of this study is to assess the natural history of sigmoid diverticulitis
 in a cohort of patients living in an urban community, who had radiological and endoscopic
 evidence of diverticular disease, who benefited initially from adequate antibiotherapy,
 received dietary counselling, and were followed for a long period of time. In order to do
 that, we will assess prospectively the following variables:

 3.1. Primary endpoints

 -  Annual rate of recurrent diverticulitis

 -  Severity and timing of recurrent episodes

 -  Quality of Life and gastrointestinal symptoms assessed with the GIQLI questionnaire

 3.2. Secondary endpoints

 -  Risk for undergoing emergency surgery

 -  Surgical morbidity/mortality
4.2. Inclusion criteria

 -  Informed consent

 -  A first episode of uncomplicated diverticulitis (see definitions), which was
 documented with CT scan, required hospital admission, and was successfully managed
 with intravenous antibiotics Or

 -  A first episode of complicated diverticulitis (Hinchey I or II - see definition),
 requiring CT scan-guided percutaneous drainage, and successfully managed without
 surgery in a patient either unfit for, or refusing to undergo elective sigmoid
 resection Exclusion criteria

 -  Age < 18 or > 90

 -  Associated condition of the colon or rectum (cancer, IBD, polyps)

 -  Patient unable to communicate in French, English or German