Diverticulitis in the Young and in the Elderly
Diverticulitis in the Young and in the Elderly
Our search yielded 1721 citations (846 citations from MEDLINE and 875 from EMBASE). After the exclusion of duplications, 1080 citations remained. One thousand fifteen citations were initially excluded after reading titles and abstracts. Of the 65 potentially eligible studies, 41 were excluded (Fig. 1). We found 24 studies that compared the outcomes of patients with acute diverticulitis according to their age. Most studies used at least one imaging modality to establish the diagnosis of acute diverticulitis; 17 used CT, 2 used ultrasonography, 7 used contrast enema, 2 used endoscopy, and 1 used plain abdominal films. The remaining six did not detail the use of imaging modalities. Only 11 studies that used CT as the sole diagnostic method were included in our systematic review (one of them used surgical pathology for diagnosis, as well). The reference lists of these studies revealed another suitable study that was included. Overall, our analysis pooled data from 12 publications, including 4982 patients. Follow-up time ranged between 15 months and 8 years.
(Enlarge Image)
Figure 1.
Study flow. CT, computed tomography.
Table 1 shows the characteristics of the studies. Because no intervention was measured, no randomized, controlled trials were included. Two studies were prospective, and 10 retrospective.
The quality of the included studies was determined according to the modified Newcastle Ottawa Scale. The quality of the studies in total is moderate–low, and this stems from their retrospective nature and lack of complete comparability between the young and the elderly groups in each study.
The majority of the studies set a cut-off point of 50 years of age for their comparison of the age groups. A number of studies, however, set a different cut-off age (usually 40 years). We chose 50 years to be the cut-off for our meta-analysis. We presented results using 40 years as a cut-off in cases when the data for our chosen cut-off age, 50 years, was insufficient or when a contradictory trend was observed.
Table 2 describes the patients' characteristics, and the outcomes in each of the included studies separately. Some patient's and disease's characteristics (ethnicity, BMI, fever, leukocytosis, and localization of the disease) were omitted from analysis as they were scarcely reported in the studies included.
Table 3 summarizes the results of the meta-analysis.
Males significantly predominated the young age group (58.6% in patients < 50 years vs 42.4% in patients > 50; RR 1.37, 95% CI 1.07–1.76, five studies, I = 78.5%). Among studies that have set 40 years as their cut-off age, 77.0% of the young patients were males.
Four studies mentioned the comorbidities of the patients; however, they evaluated different parameters, precluding us from performing meta-analysis.
Prior episodes or symptoms thought to be attributable to diverticular disease were not different between young and elderly patients (22.8% in patients < 50 years compared with 25.0% in patients > 50 years; RR 0.95, 95% CI 0.63–1.43, four studies, I = 0%).
Diverticulitis-induced Complications at Admission Nine studies compared both age groups for complicated disease at admission. Their results show a high degree of variability. The rate of complicated disease at admission was not significantly different between young and elderly patients (27.8% in patients < 50 years compared with 19.0% in patients > 50; RR 0.95, 95% CI 0.46–1.97, seven studies, I = 92.8%). Setting the age cut-off to 40 years had no impact on these results (RR 1.29, 95% CI 0.87–1.91, three studies, I = 82.0%).
The prospective studies included in this review that evaluated complications at admission showed a tendency for more complications in the patients younger than 40 years of age, but in all cases, this tendency was not statistically significant.
Surgery Nine studies tested whether the operation rate during hospitalization varied according to the patients' age (Fig. 2). Overall, no significant difference was found between young and elderly patients in the operation rate during hospitalization. When the cut-off was set to 50 years old, young patients tended to undergo less surgeries during hospitalization; however, this tendency did not reach statistical significance (15.1% in patients < 50 years compared with 16.1% in patients > 50 years; RR 0.69, 95% CI 0.46–1.06, eight studies, I = 42.8%).This could be the result of the relatively small number of participants in those studies as well as of the weight given to the only one study that showed higher rate of surgeries in the young group.
(Enlarge Image)
Figure 2.
Surgery during hospitalization—rate of surgery during hospitalization tended to be lower among the patients younger than 50 years old. CI, confidence interval; RR, relative risk.
No significant differences were found in each subcategory of surgeries (primary and post-conservative treatment failure).
In light of the fact that in most of the study centers, young patients with an episode of diverticulitis were subject of an elective surgery, it was not surprising that our meta-analysis showed a higher rate of elective surgeries among young patients compared with the elderly ones (18.1% in patients < 50 years compared with 8.5% in patients > 50; RR 2.39, 95% CI 1.82–3.15, six studies, I = 69.4%).
Long-term Follow-up Overall mortality stratified by age was reported in four studies. No single case of mortality was reported in young patients, regardless the cut-off age (either 40 or 50 years old). However, no significant difference was noticed between the younger and elderly patient groups because of the relatively small amount of patients who died during the follow-up period in those studies (0% in patients < 50 years compared with 3.4% in patients > 50; RR 0.24, 95% CI 0.04–1.24, three studies, I = 0%).
Four studies, all with the cut-off age of 50 years, followed their patients in order to find recurrence of the disease (Fig. 3). The mean follow-up period ranged from 15 to 96 months. No study reported separately the mean/median follow-up period to each group (i.e. young vs elderly patients), neither there were any reports according to person life years. Recurrence rate was significantly higher in young patients (31.6% in patient < 50 years compared with 18.5% in patients > 50; RR 1.70, 95% CI 1.31–2.21, four studies, I = 0%).
(Enlarge Image)
Figure 3.
Recurrence rate—diverticulitis tends to recur in patients below the age of 50 years. CI, confidence interval; RR, relative risk.
Results
Our search yielded 1721 citations (846 citations from MEDLINE and 875 from EMBASE). After the exclusion of duplications, 1080 citations remained. One thousand fifteen citations were initially excluded after reading titles and abstracts. Of the 65 potentially eligible studies, 41 were excluded (Fig. 1). We found 24 studies that compared the outcomes of patients with acute diverticulitis according to their age. Most studies used at least one imaging modality to establish the diagnosis of acute diverticulitis; 17 used CT, 2 used ultrasonography, 7 used contrast enema, 2 used endoscopy, and 1 used plain abdominal films. The remaining six did not detail the use of imaging modalities. Only 11 studies that used CT as the sole diagnostic method were included in our systematic review (one of them used surgical pathology for diagnosis, as well). The reference lists of these studies revealed another suitable study that was included. Overall, our analysis pooled data from 12 publications, including 4982 patients. Follow-up time ranged between 15 months and 8 years.
(Enlarge Image)
Figure 1.
Study flow. CT, computed tomography.
Table 1 shows the characteristics of the studies. Because no intervention was measured, no randomized, controlled trials were included. Two studies were prospective, and 10 retrospective.
The quality of the included studies was determined according to the modified Newcastle Ottawa Scale. The quality of the studies in total is moderate–low, and this stems from their retrospective nature and lack of complete comparability between the young and the elderly groups in each study.
The majority of the studies set a cut-off point of 50 years of age for their comparison of the age groups. A number of studies, however, set a different cut-off age (usually 40 years). We chose 50 years to be the cut-off for our meta-analysis. We presented results using 40 years as a cut-off in cases when the data for our chosen cut-off age, 50 years, was insufficient or when a contradictory trend was observed.
Table 2 describes the patients' characteristics, and the outcomes in each of the included studies separately. Some patient's and disease's characteristics (ethnicity, BMI, fever, leukocytosis, and localization of the disease) were omitted from analysis as they were scarcely reported in the studies included.
Table 3 summarizes the results of the meta-analysis.
Characteristics of Patients
Males significantly predominated the young age group (58.6% in patients < 50 years vs 42.4% in patients > 50; RR 1.37, 95% CI 1.07–1.76, five studies, I = 78.5%). Among studies that have set 40 years as their cut-off age, 77.0% of the young patients were males.
Four studies mentioned the comorbidities of the patients; however, they evaluated different parameters, precluding us from performing meta-analysis.
Characteristics of the Disease
Prior episodes or symptoms thought to be attributable to diverticular disease were not different between young and elderly patients (22.8% in patients < 50 years compared with 25.0% in patients > 50 years; RR 0.95, 95% CI 0.63–1.43, four studies, I = 0%).
Outcomes
Diverticulitis-induced Complications at Admission Nine studies compared both age groups for complicated disease at admission. Their results show a high degree of variability. The rate of complicated disease at admission was not significantly different between young and elderly patients (27.8% in patients < 50 years compared with 19.0% in patients > 50; RR 0.95, 95% CI 0.46–1.97, seven studies, I = 92.8%). Setting the age cut-off to 40 years had no impact on these results (RR 1.29, 95% CI 0.87–1.91, three studies, I = 82.0%).
The prospective studies included in this review that evaluated complications at admission showed a tendency for more complications in the patients younger than 40 years of age, but in all cases, this tendency was not statistically significant.
Surgery Nine studies tested whether the operation rate during hospitalization varied according to the patients' age (Fig. 2). Overall, no significant difference was found between young and elderly patients in the operation rate during hospitalization. When the cut-off was set to 50 years old, young patients tended to undergo less surgeries during hospitalization; however, this tendency did not reach statistical significance (15.1% in patients < 50 years compared with 16.1% in patients > 50 years; RR 0.69, 95% CI 0.46–1.06, eight studies, I = 42.8%).This could be the result of the relatively small number of participants in those studies as well as of the weight given to the only one study that showed higher rate of surgeries in the young group.
(Enlarge Image)
Figure 2.
Surgery during hospitalization—rate of surgery during hospitalization tended to be lower among the patients younger than 50 years old. CI, confidence interval; RR, relative risk.
No significant differences were found in each subcategory of surgeries (primary and post-conservative treatment failure).
In light of the fact that in most of the study centers, young patients with an episode of diverticulitis were subject of an elective surgery, it was not surprising that our meta-analysis showed a higher rate of elective surgeries among young patients compared with the elderly ones (18.1% in patients < 50 years compared with 8.5% in patients > 50; RR 2.39, 95% CI 1.82–3.15, six studies, I = 69.4%).
Long-term Follow-up Overall mortality stratified by age was reported in four studies. No single case of mortality was reported in young patients, regardless the cut-off age (either 40 or 50 years old). However, no significant difference was noticed between the younger and elderly patient groups because of the relatively small amount of patients who died during the follow-up period in those studies (0% in patients < 50 years compared with 3.4% in patients > 50; RR 0.24, 95% CI 0.04–1.24, three studies, I = 0%).
Four studies, all with the cut-off age of 50 years, followed their patients in order to find recurrence of the disease (Fig. 3). The mean follow-up period ranged from 15 to 96 months. No study reported separately the mean/median follow-up period to each group (i.e. young vs elderly patients), neither there were any reports according to person life years. Recurrence rate was significantly higher in young patients (31.6% in patient < 50 years compared with 18.5% in patients > 50; RR 1.70, 95% CI 1.31–2.21, four studies, I = 0%).
(Enlarge Image)
Figure 3.
Recurrence rate—diverticulitis tends to recur in patients below the age of 50 years. CI, confidence interval; RR, relative risk.
Source...