Is colonoscopy indicated during an acute diverticulitis flare?

From the Guidelines

Colonoscopy is not indicated during an acute diverticulitis flare and should be deferred until 6-8 weeks after resolution of the acute episode. This recommendation is based on the most recent and highest quality study, which suggests that performing a colonoscopy during active inflammation increases the risk of complications such as perforation, as the bowel wall is weakened and more susceptible to injury from the colonoscope 1. Additionally, the presence of inflammation can obscure visualization and make it difficult to distinguish between diverticulitis and other conditions like malignancy.

During the acute phase, imaging studies such as CT scans are preferred for diagnosis and assessment of complications. Once the acute inflammation has resolved, a follow-up colonoscopy is recommended to exclude other pathologies, particularly colorectal cancer, which can sometimes mimic diverticulitis symptoms. This timing allows the bowel to heal sufficiently while still providing necessary evaluation for underlying conditions that may have contributed to or been masked by the diverticulitis episode. The American College of Physicians suggests that clinicians refer patients for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis in patients who have not had recent colonoscopy, with a conditional recommendation and low-certainty evidence 1.

Some key points to consider include:

• The risk of colon cancer is higher in patients with complicated diverticulitis compared to those with uncomplicated diverticulitis 1
• Colonoscopy should be delayed by 6–8 weeks or until complete resolution of the acute symptoms, whichever is longer 1
• The decision to perform a colonoscopy should be personalized based on the patient’s history, most recent colonoscopy, and disease severity and course 1
• Clinicians should assess whether patients have had a recent high-quality direct visualization colonoscopy for any reason, such as screening for CRC, iron deficiency anemia, or intestinal bleeding 1

Overall, the decision to perform a colonoscopy during an acute diverticulitis flare should be made on a case-by-case basis, taking into account the individual patient's risk factors, medical history, and current symptoms. However, in general, colonoscopy should be deferred until the acute inflammation has resolved, to minimize the risk of complications and ensure accurate visualization of the colon.

From the Research

Indications for Colonoscopy During Diverticulitis Flare

• The decision to perform a colonoscopy during an acute diverticulitis flare is a topic of debate among medical professionals 2, 3, 4, 5, 6.
• Some studies suggest that colonoscopy is feasible and safe in the absence of pericolic air on CT, but may not have added value compared to CT scans currently used 2.
• Other studies have found that post-diverticulitis screening colonoscopy does not result in a higher rate of colonic pathological findings, especially colonic neoplasia 3.
• The efficacy of colonoscopy after an episode of acute diverticulitis and the risk of colorectal cancer have been investigated, with some studies suggesting that routine colonoscopy may not be indicated after acute diverticulitis treated conservatively 4, 5.

Patient Selection for Colonoscopy

• Patient selection for colonoscopy after an episode of acute diverticulitis is crucial, with some studies suggesting that only patients with certain risk factors, such as alarm symptoms or identified risk factors for colorectal cancer, should undergo colonoscopy 5, 6.
• The presence of alarm symptoms, such as bleeding or changes in bowel habits, may increase the likelihood of detecting colorectal cancer during colonoscopy 5.
• The diagnostic impact of routine colonoscopy following acute diverticulitis has been investigated, with some studies suggesting that colonoscopy should be indicated only in selected patients 6.

Key Findings

• The detection rate of colorectal cancer during colonoscopy after acute diverticulitis is generally low, ranging from 0.2% to 0.25% in some studies 3, 5, 6.
• The detection rate of advanced adenomas is also relatively low, ranging from 2.7% to 6.7% in some studies 3, 6.
• Colonoscopy may be more beneficial in patients with complicated acute diverticulitis or those who are older than 70 years 4.