Prognostic role of the

endoscopic classification

DICA

Antonio TURSI

Territorial Gastroenterology Service

Sanitary District n°4

Barletta

ASL BAT – Andria

Italy

Current Classifications of Diverticular Disease

Sheth AA. AJG 2008;103:1550-6

Kruis W. Digestion 2014;90:190-207

….what about endoscopy?

130 pts followed after an episode of acute uncomplicated diverticulitis

Colonoscopy with biopsy performed at 6, 12 and 24 months

Different clinical, anatomical, and endoscopic characteristics may

explain conflicting literature data on the treatment of Diverticular

Disease

Although diverticulosis of the colon is the most frequent endoscopic

diagnosis during colonoscopy, an endoscopic classification of

diverticular disease able to give objective description of the colon

harbouring diverticula was still lacking.

Development of an endoscopic classification of

Diverticular Disease was therefore needed

From February to December 2012, 32 Italian endoscopists developed and validated the DICA (Diverticular Inflammation and

Complication Assessment) endoscopic classification for diverticulosis and diverticular disease.

Items in constructing score with DICA Classification

Edema/Hyperemia

(points: 1)

Erosions

(points: 2)

SCAD

(points: 3)

Grade I: ≤ 15 diverticula

(points: 0)

Grade II: >15 diverticula

(points: 1)

Number of diverticula

(each district)

Infiammation

If two subitems are contemporarely, only the most severe is considred (i.e. erosions instead of hyperemia).

Complications

Rigidity

(points: 4)

Stenosis

(points: 4) Pus

(points: 4)

Bleeding

(points: 4)

Absence

(points: 0)

Location

Left

(points: 2)

Right

(points: 1)

DICA Classification Numerical Score

DICA 1 From 1 to 3 points

DICA 2 From 4 to 7 points

DICA 3 > 7 points

Tursi A. Dig Dis 2015;33:68-76

Development of DICA

Overall Fleiss’ kappa to assess agreement was 0.847 (95% CI 0.812 to 0.893):

DICA score 1: Fleiss’ kappa was 0.878 (95% CI 0.832 to 0.895);

DICA score 2: Fleiss’ kappa was 0.765 (95% CI 0.735 to 0.786);

DICA score 3: Fleiss’ kappa was 0.891 (95% CI 0.845 to 0.7923).

With respect to intra-observer agreement kappa was 0.91 (95% CI 0.886 to 0.947).

Fleiss’ kappa for inter-rater reliability for endoscopic items in DICA classification.

Endoscopic item Fleiss’ kappa 95% CI

Extension of diverticula 0.957 0.911 to 0.983

Number of diverticula 0.827 0.745 to 0.912

Presence of inflammation 0.877 0.853 to 0.902

Rigidity of the colon 0.925 0.849 to 0.983

Stenosis 1 -

Pus 0.989 0.977 to 0.993

Bleeding 1 -

Validation of DICA

A significant correlation with DICA classification was found both for ESR and CRP values (ESR vs DICA, p=0.0001; CRP vs

DICA, p=0.0001). A significant correlation was found between pain score and DICA classification (p=0.0001).

Tursi A. Dig Dis 2015;33:68-76

Multicenter, international, retrospective cohort study, enrolling patients

from tertiary, secondary and primary clinical centers:

Italy: 22 Centres Brazil: 2 Centres

Venezuela: 1 Center Norway: 1 Center

From December 31, 2014, patients with endoscopic diagnosis of DD were

selected if they met the following criteria:

- cases were at the first endoscopic diagnosis of diverticulosis/diverticular

disease;

- properly recorded on electronic database;

- complete clinical and endoscopic data available. If clinical follow-up data

were incomplete, they could be completed by telephone interview.

The following information was recorded from each patient:

- age at the time of diagnosis of DD

- DICA score at diagnosis

- presence of abdominal pain

- C-reactive protein >5mg/L and fecal calprotectin test positivity at diagnosis

(if available)

- therapy (if any) during follow-up to maintain remission

- months of follow-up

- time to occurrence/recurrence of diverticulitis

- need for colonic surgery

Primary endpoints:

(a) To assess occurrence/recurrence of diverticulitis, defined as detection of

acute left lower quadrant pain associated with thickening of colonic wall

harbouring diverticula (at ultrasonography or at abdominal

computerized tomography) and/or increased white blood cells count

and/or C-Reactive Protein and/or fever

(b) To assess needs for surgery

Secondary point:

To assess whether DICA classification may have an impact on scheduled

therapies for preventing diverticulitis occurrence/recurrence. Hence, we

recorded if the patient was taking the scheduled therapy or not, and which

type of treatment was prescribed.

We classified therapies as follows, in order to have groups as homogeneous as

possible: rifaximin-based, mesalazine-based, mesalazine+rifaximin, and other

(including any other treatment, i.e. fiber, probiotics, spasmolithics, systemic

antibiotics).

The study enrolled 1651 patients according to the above reported criteria.

Characteristics of the study group.

Characteristics

DICA 1

(939 pts)

DICA 2

(501 pts)

DICA 3

(211 pts)

P*

Mean age, years (95% CI)

66.7 (66.0 to

67.4)

66.3 (65.4 to 67.3)

66.6 (65.2 to

68.3)

Sex, male

454 (48.3)

259 (51.7)

80 (37.9)

0.003

Abdominal pain

367 (39.1)

386 (77.0)

182 (86.2)

<0.0001

C-reactive protein >5 mg/L

92/502 (18.3)

247/385 (64.1)

171/189 (90.5)

<0.0001

Fecal calproctectin,

positive

141/290 (48.6)

218/246 (88.6)

152/163 (93.2)

<0.0001

Values are expressed as n (%) of patients, unless otherwise specified. CI, confidence interval.

* Chi-square test, 2 degrees of freedom.

The median (interquartile range) follow-up was 24 months.

Acute diverticulitis occurrence/recurrence during the follow-up

Predictors of acute diverticulitis occurrence/recurrence during follow-up.

Univariate Cox PH model

Multivariate analysis Cox PH model

χ2(DF)

P

HR

95% CI

HR

95% CI

P

DICA score

405.029 (2)

<0.0001

-

-

4.319

3.639 to 5.126

<0.000

1

DICA 2 vs DICA 1

106.308 (1)

<0.0001

5.872

4.174 to 8.261

-

-

-

DICA 3 vs DICA 1

459.293 (1)

<0.0001

18.992

12.267 to 29.40

6

-

-

-

DICA 3 vs DICA 2

93.648 (1)

<0.0001

3.283

2.432 to 4.432

-

-

-

Therapy

7.135 (1)

0.0076

1.406

1.100 to 1.796

1.161

0.888 to 1.518

0.2765

Sex

0.073 (1)

0.7872

1.034

0.811 to 1.318

1.105

0.862 to 1.416

0.4324

Age <65 years

2.911 (1)

0.0880

0.811

0.632 to 1.039

1.109

0.868 to 1.418

0.4081

DICA, Diverticular Inflammation and Complication Assessment; PH, proportional hazards; DF, degree of freedom; HR, hazard ratio; CI, confidence

interval.

Surgery occurrence during the follow-up

Predictors of surgery during follow-up.

Univariate Cox PH model

Multivariate Cox PH model

χ2(DF)

P

HR

95% CI

HR

95% CI

P

DICA score

147.795 (2)

<0.0001

-

-

6.826

4.526 to 10.295

<0.0001

DICA 2 vs DICA 1

28.669 (1)

<0.0001

12.815

5.549 to 29.597

-

-

-

DICA 3 vs DICA 1

159.848 (1)

<0.0001

59.538

24.196 to 146.49

9

-

-

-

DICA 3 vs DICA 2

37.919 (1)

<0.0001

4.703

2.541 to 8.704

-

-

-

Therapy

1.370 (1)

0.2418

1.378

0.816 to 2.329

1.248

0.698 to 2.231

0.458

Sex

1.461 (1)

0.2268

0.727

0.432 to 1.223

1.744

1.024 to 2.872

0.052

Age <65 years

0.531 (1)

0.4661

0.823

0.481 to 1.407

1.031

0.609 to 1.746

0.908

DICA, Diverticular Inflammation and Complication Assessment; PH, proportional hazards; DF, degree of freedom; HR, hazard ratio; CI, confidence interval.

Effect of scheduled therapy on the acute diverticulitis

occurrence/recurrence according to DICA classification

DICA 1 DICA 2 DICA 3

Kaplan-Maier analysis of cumulative rates of

acute diverticulitis occurrence/recurrence

during follow-up by type of therapy in DICA

2 group.

p=0.006, log rank test p=0.109, log rank test p=0.437, log rank test

Bookmark with DICA classification being distributed to

Italian Gastroenterologists

…… and the future?

PREDICTIVE VALUE OF THE “DICA” ENDOSCOPIC

CLASSIFICATION ON THE OUTCOME OF THE

DIVERTICULAR DISEASE OF THE COLON:

A PROSPECTIVE, MULTICENTER STUDY

USA 2 centres

Italy 48 centres

Europe 12 centres

Brasil 2 centres

Mexico 1 centre

Venezuela 1 centre

Australia 1 centre

TAKE HOME MESSAGES

• DICA classification is a new and practical instrument that can be used by

clinicians for the objective description of the colon harbouring diverticula.

• This classification is simple to use, has an excellent reproducibility, and

correlates significantly with biochemical and clinical disease markers.

• At retrospective analysis, DICA classification seems to be predictive of the

course of the disease in terms of acute diverticulitis occurrence/recurrence

and needs of surgery.

• Although it seems to be attractive in clinical practice, further prospective

studies are needed in order to confirm whether its use may really impact

the natural history of DD.