Global hospital-based disease management of acute diverticulitis: a prospective, international cohort study

Background: Acute diverticulitis is a common condition that can be a surgical emergency. Its prevalence is increasing worldwide, however optimal management remains unclear. This study aimed to determine current practice and short-term outcomes globally. Methods: A prospective, international cohort study of patients presenting with acute diverticulitis to secondary care units was undertaken. Countries were stratified by geographical region and income groups. Patients presenting over a 44-week recruitment period (1/10/2020–31/8/2021) were included. Patient and disease covariates, management and short-term outcomes were captured in a secure web application. The primary outcome of interest was the geographical variation in presentation and treatment. The secondary outcome was treatment success at 30-days. Findings: 6189 patients presenting with acute diverticulitis (confirmed by CT imaging and/or surgical findings) were recruited. 2798 of 6189 patients presented with uncomplicated disease of whom 849 (30.3%) were treated in an ambulatory manner. Overall antibiotic use ranged across geographical regions from 1838 of 1982 patients (92.7%) to 340 of 342 patients (99.4%). Surgical intervention was undertaken in 782 of 6189 patients (12.6%) varying between geographical regions from 29 of 342 patients (8.8%) to 59 of 195 patients (42.8%). 675 of 782 patients underwent resection, of whom 180 (26.6%) underwent formation of a primary anastomosis. 707 of 6189 (11%) patients experienced treatment failure, with an overall 30-day mortality of 2.8% (169/6189 patients). 30-day mortality was higher in patients with complicated disease (142/3391 patients, 4.5%) and in low-middle income units (20/335 patients, 6.2%). Interpretation: This large, global study reveals significant variation in the management and outcomes of patients presenting to hospital with acute diverticulitis. Antibiotic use and hospital admission for uncomplicated disease was high, and significant variation in stoma formation was observed. Patients presenting in low-middle income units were more likely to undergo emergency surgery and this was associated with a higher 30-day mortality rate. Funding: Bowel Research UK.