Editorial: Addressing the long-term mortality risk in patients admitted with diverticulitis

Abstract

Diverticular disease is extremely common in the western world, and the commonest emergency manifestation of diverticular disease is diverticulitis. This commonly presents to emergency physicians, with a high rate of acute hospital admissions and a need for emergency surgical intervention in some patients. The rate of diverticulitis is likely to be increasing, especially in a younger population, with a subsequent increase in the rates of hospitalisation. Despite this the rate of complicated diverticulitis has remained relatively static.1,2 These findings may be due to the increased use of computed tomography, but none the less, diverticulitis places significant financial and resource burden on most modern healthcare systems.3 Diverticulitis is known to be more common in patients with obesity, smokers and in males, its incidence can be reduced with a healthy diet and regular physical activity. The shortterm outcomes in cohorts of patients treated for diverticulitis are relatively well understood, but few comparative studies are available. As would be expected these shortterm outcomes are worse with increasing age, comorbidities and the need for acute surgical intervention. Longer term outcomes in patients following diverticulitis are less well understood and specifically the longterm impact on mortality of an admission with diverticulitis is poorly documented. The ability to assess diverticulitis as a marker of risk, and to properly council our patients on the implication of their disease is therefore compromised. In this issue of GastroHep, Granlund et al present a large, welldesigned study comparing both the shortand longterm mortality in patients admitted with diverticulitis with a diseasefree cohort.4 The authors present a 20year nationwide cohort study comparing outcomes in patients admitted with a firsttime diagnosis of diverticulitis with matched diseasefree individuals. ICD coding was used to identify patients. Information on covariates including education level, civil status and comorbidities was also collated and entered into a cox regression. The primary outcome event of interest was mortality, with time periods of within 100 days and from 101 days5 years used. Over 83 000 patients with diverticulitis were included and compared to over eight hundred thousand matched diseasefree individuals. Mortality within 100 days was four times higher than diseasefree individuals with a significantly higher rate in those undergoing surgical intervention. From day 1015 years hazard rates were increased by 11%, again with highest rates in patients undergoing operative intervention. The proportion of individuals who died within 100 days and within five years or admission was 4.1% and 20.3% in the diverticulitis cohort compared to 0.8% and 14.5% in diseasefree individuals. The study is well designed with high numbers of patients, however, as the authors acknowledge, in keeping with all studies of this type, classification and coding of diverticulitis was not made according to strict criteria. Furthermore, ICD10 codes do not distinguish well between diverticular disease and diverticulitis. The rate of comorbidities was also higher in patients with diverticular disease, and it is possible that an element of confounding health characteristics contributed to the worse outcomes. This is likely to be a moot point, however, as the key findings of the study would remain. Patients admit with a first episode of diverticulitis have a significant increase in mortality at 100 days and at 5 years. These data enable clinicians to give patients admitted with a first episode of diverticulitis an honest appraisal of the effect on longterm mortality risk and to give health advice that may help to reduce this risk. It may also help to guide resource allocation to patients who require improvement in risk factors known to be associated with diverticulitis such as obesity, smoking and sedentary lifestyle.