A Clinical Decision Rule to Establish the Diagnosis of Acute Diverticulitis at the Emergency Department

• Published in: Diseases of the colon & rectum Vol. 53; no. 6; pp. 896 - 904
• Main Authors: Laméris, Wytze, van Randen, Adrienne, van Gulik, Thomas M, Busch, Olivier R. C, Winkelhagen, Jasper, Bossuyt, Patrick M. M, Stoker, Jaap, Boermeester, Marja A
• Format: Journal Article
• Language: English
• Published: Hagerstown, MDc The ASCRS 01.06.2010; Lippincott Williams & Wilkins
• Subjects: Abdominal Pain - diagnosis; Acute Disease; Adult; Aged; Area Under Curve; Biological and medical sciences; C-Reactive Protein - analysis; Decision Support Techniques; Diagnosis, Differential; Diverticulitis, Colonic - diagnosis; Diverticulitis, Colonic - therapy; Emergency Service, Hospital; Female; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Logistic Models; Male; Medical sciences; Middle Aged; Other diseases. Semiology; Prospective Studies; Sensitivity and Specificity; Stomach. Duodenum. Small intestine. Colon. Rectum. Anus; Clinical decision rule; Accuracy; Emergency department; Acute diverticulitis; Diverticulitis; Acute; Diagnostic accuracy; Gastroenterology; Digestive diseases; Intestinal disease; Diagnosis; Decision rule
• ISSN: 0012-3706; 1530-0358
• DOI: 10.1007/DCR.0b013e3181d98d86

PURPOSE:The aim of this study was to identify patients in whom the clinical diagnosis of diverticulitis can be made with a high certainty, distinguishing them from patients requiring imaging. METHODS:We prospectively recorded clinical features in patients with acute abdominal pain presenting at the emergency department, before they underwent imaging. We identified features significantly associated with a final diagnosis of acute diverticulitis using multivariate logistic regression analysis and developed a decision rule based on these features. We evaluated the performance of the rule in identifying patients with a high probability of having diverticulitis. RESULTS:In total, 112 of the 1021 patients (11%) had a final diagnosis of diverticulitis. Of the 126 patients with clinically suspected diverticulitis, 80 had a final diagnosis of diverticulitis. In 32 patients with diverticulitis as their final diagnosis, another clinical diagnosis was made. A decision rule was based on the 3 strongest clinical featuresdirect tenderness only in the left lower quadrant, the absence of vomiting, and a C-reactive protein >50 mg/L. Of the 126 clinically suspected patients, 30 patients had all 3 features (24%), of whom 29 had a final diagnosis of acute diverticulitis (97%; 95% CI83%–99%). Of the 96 patients without all 3 features, 45 (47%) did not have diverticulitis. CONCLUSION:In a quarter of patients with suspected diverticulitis, the diagnosis can be made clinically based on a combination of direct tenderness only in the left lower quadrant, the absence of vomiting, and an elevated C-reactive protein. In patients without these features, imaging is required to reach adequate diagnostic accuracy.