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Original research
Prognostic performance of the ‘DICA’ endoscopic classification and the ‘CODA’ score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study
  1. Antonio Tursi1,2,
  2. Giovanni Brandimarte3,
  3. Francesco Di Mario4,
  4. Walter Elisei5,
  5. Marcello Picchio6,
  6. Leonardo Allegretta7,
  7. Maria Laura Annunziata8,
  8. Mauro Bafutto9,
  9. Gabrio Bassotti10,
  10. Maria Antonietta Bianco11,
  11. Raffaele Colucci12,
  12. Rita Conigliaro13,
  13. Dan Dumitrascu14,
  14. Ricardo Escalante15,
  15. Luciano Ferrini16,
  16. Giacomo Forti17,
  17. Marilisa Franceschi18,
  18. Maria Giovanna Graziani19,
  19. Frank Lammert20,
  20. Giovanni Latella21,
  21. Giovanni Maconi22,
  22. Gerardo Nardone23,
  23. Lucia Camara de Castro Oliveira24,
  24. Enio Chaves Oliveira25,
  25. Alfredo Papa26,
  26. Savvas Papagrigoriadis27,
  27. Anna Pietrzak28,
  28. Stefano Pontone29,
  29. Tomas Poskus30,
  30. Giuseppe Pranzo31,
  31. Matthias Christian Reichert20,
  32. Stefano Rodinò32,
  33. Jaroslaw Regula33,34,
  34. Giuseppe Scaccianoce35,
  35. Franco Scaldaferri36,
  36. Roberto Vassallo37,
  37. Costantino Zampaletta38,
  38. Angelo Zullo39,
  39. Daniele Piovani40,41,
  40. Stefanos Bonovas40,41,
  41. Silvio Danese42
  1. 1Azienda Sanitaria Locale Barletta Andria Trani, Andria, Italy
  2. 2Department of Medical and Surgical Sciences, Catholic University, Roma, Italy
  3. 3Ospedale Cristo Re, Roma, Italy
  4. 4Ospedale Maggiore di Parma, Parma, Italy
  5. 5Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
  6. 6Ospedale P Colombo, Velletri, Italy
  7. 7Ospedale Santa Caterina Novella, Galatina, Italy
  8. 8Istituto Policlinico San Donato, San Donato Milanese, Italy
  9. 9Institute of Gastroenterology and Digestive Endoscopy, Goiânia, Brazil
  10. 10Gastroenterology and Hepatology Section, San Sisto (Perugia), Italy
  11. 11Ospedale T Maresca, Torre del Greco, Italy
  12. 12Ospedale di San Matteo degli Infermi, Spoleto, Italy
  13. 13Nuovo Ospedale Civile Sant'Agostino Estense di Baggiovara, Modena, Italy
  14. 142nd Medical Department, 'Iuliu Hatieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania
  15. 15Central University of Venezuela, Loira Medical Center, Caracas, Venezuela, Bolivarian Republic of
  16. 16Casa di Cura Villa dei Pini, Civitanova Marche, Italy
  17. 17Ospedale Santa Maria Goretti, Latina, Italy
  18. 18AULSS 4 Alto Vicentino, Bassano del Grappa, Italy
  19. 19Azienda Ospedaliera San Giovanni-Addolorata, Roma, Italy
  20. 20Department of Medicine II, Saarland University Medical Center, Homburg, Germany
  21. 21Division of Gastroenterology, Department of Life, Health & Environmental Sciences, Hepatology and Nutrition, "San Salvatore" Hospital, University of L'Aquila, L'Aquila, Italy
  22. 22Azienda Ospedaliera L Sacco, Milan, Italy
  23. 23Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
  24. 24Department of Anorectal Physiology, 'São José” Home Care, Rio de Janeiro, Brazil
  25. 25Department of Colorectal Surgery, Federal University of Goiás, Goiânia, Goiás, Brazil
  26. 26Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
  27. 27King's College London, London, UK
  28. 28Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education and Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
  29. 29Department of Surgical Sciences, 'Sapienza'-University of Rome, Roma, Italy
  30. 30Institute of Clinical Medicine, Vilnius University Hospital, Vilnius, Lithuania
  31. 31Ospedale Valle d'Itria, Martina Franca, Italy
  32. 32Azienda Ospedaliera Pugliese Ciaccio, Catanzaro, Italy
  33. 33Gastroenterology, Medical Centre for Postgraduate Education, Warsaw, Poland
  34. 34Gastroenterology, the Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
  35. 35Ospedale di Altamura, Altamura, Italy
  36. 36Department of Medical and Surgical Sciences, Internal Medicine, Gastroenterology Division, Catholic University of Rome, Roma, Italy
  37. 37Division of Gastroenterology and Digestive Endoscopy, 'Bucchieri-La Ferla' Hospital, Palermo, Italy
  38. 38Ospedale di Belcolle, Viterbo, Italy
  39. 39Gastroenterology, Presidio Territoriale di Prossimità Nuovo Regina Margherita, Roma, Italy
  40. 40Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
  41. 41IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
  42. 42Gastroenterology and Endoscopy, IRCCS Ospedale "San Raffaele" and University "Vita-Salute San Raffaele", Milano, Italy
  1. Correspondence to Professor Antonio Tursi, Azienda Sanitaria Locale Barletta Andria Trani, Andria, Puglia, Italy; antotursi{at}tiscali.it

Abstract

Objective To investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA).

Design A multicentre, prospective, international cohort study.

Setting 43 gastroenterology and endoscopy centres located in Europe and South America.

Participants 2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications.

Interventions A 3-year follow-up was performed.

Main outcome measures To predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score).

Results The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).

Conclusions DICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score.

Trial registration number NCT02758860.

  • diverticular disease
  • endoscopy

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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Footnotes

  • Correction notice This article has been corrected since it published Online First. The author, Enio Chavez de Oliveira, and affiliation 41 have been added.

  • Collaborators DICA International Group: Marco Astegiano, Division of Gastroenterology, “Molinette” University Hospital, Torino – Italy. Gianluca Baldassarre, Digestive Endoscopy Unit, ULSS7 Alto Vicentino, Santorso (VI) - Italy. Fabio Baldi, Digestive Endoscopy Unit, Civil Hospital, Tarquinia (VT) – Italy. deceased. Edoardo Borsotti, Division of Gastroenterology, “San Donato” Hospital, San Donato Milanese (MI) – Italy. Claudio Cassieri, Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, Roma – Italy. Alessia Cazzato, Division of Gastroenterology, “Santa Caterina Novella” Hospital, Galatina (LE) - Italy. Stefania Chiri, Division of Gastroenterology, “Santa Caterina Novella” Hospital, Galatina (LE) - Italy. Antonio Ciccone,Department of Life, Health & Environmental Sciences, Division of Gastroenterology, Hepatology and Nutrition, San Salvatore Hospital, University of L'Aquila, L’Aquila. Debora Compare, Department of Clinical Medicine and Surgery, Division of Gastroenterology and Hepatology, Federico II” University Hospital, Naples - Italy. Alberto Damiani, Service of Digestive Endoscopy, “Villa dei Pini” Home Care, Civitanova Marche (MC) – Italy. Patrizia De Colibus, Division of Gastroenterology, “T. Maresca” Hospital, Torre del Greco (NA) - Italy. Roberto Faggiani, Division of Gastroenterology, “S. Camillo” Hospital, Roma - Italy. Fabio Finocchiaro, Division of Gastroenterology, “Molinette” University Hospital, Torino – Italy. Serafina Fiorella, Division of Gastroenterology, “San Pio da Pietrelcina” Hospital, Vasto (CH) - ItalyA. Francesca Foschia, Territorial Gastroenterology Service, ASL Roma 2, Roma – Italy. Federica Furfaro, IBD Unit, “Humanitas” University Hospital, Rozzano (MI) – Italy. Sara Gallina, Division of Gastroenterology, “Belcolle” Hospital, Viterbo – Italy. Gian Marco Giorgetti, Digestive Endoscopy and Nutritional Unit, “S. Eugenio” Hospital, Roma – Italy. Simona Grad, 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca – Romania. Giuseppe Grande, Digestive Endoscopy Unit, “Sant’Agostino Estense” Hospital, Baggiovara (MO) – Italy. Antonio Grandolfo, Division of Gastroenterology, “S. Paolo” Hospital, Bari - Italy. Maria Antonia Lai, Division of Gastroenterology – “Monserrato” University Hospital, University of Cagliari, Cagliari - Italy. Loris Riccardo Lopetuso, Division of Internal Medicine and Gastroenterology, IRCCS “A. Gemelli” Hospital, Fondazione Policlinico Gemelli, Catholic University, Roma – Italy. Antonio Penna, Division of Gastroenterology, “S. Paolo” Hospital, Bari - Italy. Piero Portincasa, Internal Medicine Unit, “A. Murri” Medical Clinic, Policlinico University Hospital, Bari - Italy. Giannenrico Rizzatti, Division of Internal Medicine and Gastroenterology, IRCCS “A. Gemelli” Hospital, Fondazione Policlinico Gemelli, Catholic University, Roma – Italy. Giovanni Luca Rizzo, Division of Gastroenterology, “Perrino” Hospital, Brindisi – Italy. Stefania Scanni, Territorial Gastroenterology Service, ASL Roma 2, Roma – Italy. Luigi Schiffino, Division of Gastroenterology and Surgical Endoscopy, “Grassi” Hospital, Ostia, Roma – Italy. Erasmo Spaziani, Department of Surgery, “Sapienza” University of Rome-Polo Pontino, Terracina (LT) – Italy. Ieva Stundiene, Institute of Clinical Medicine, Vilnius University Hospital, Vilnius - Lithuania. Antonino Tesoriere, Digestive Endoscopy Unit, Civil Hospital, Tarquinia (VT) - Italy. Gabriele Torti, Department of Medicine and Surgery, Gastroenterology and Hepatology Unit, “Santa Maria della Misericordia” University Hospital, University of Perugia, Perugia - Italy. Riccardo Urgesi, Division of Gastroenterology and Digestive Endoscopy “S. Giovanni-Addolorata” Hospital, Roma - Italy. Paolo Usai, Division of Gastroenterology – “Monserrato” University Hospital, University of Cagliari, Cagliari – Italy.

  • Contributors Guarantor of the Article: AT; Authorship Conception and design: AT; FDM, GB, E.S.; Acquisition and collection of data: AT, GB, WE, LA, MLA, MA, MB, F, B†, GB, MAB, RC, RC, DD, RE, RF, LF, SF, GF, MF, GM, SG, MGG, MAL, FL, GL, DL, GM, GN, LCCO, ECO, AP, SP, AP, AP, SP, PP, TP, GP, MCR, GLR, SR, JR, GS, FS, LS, IS, RV, CZ, AZ, SD, GB, EB, CC, AC, SC, AC, DC, AD, PDC, FF, FF, FF, SG, GG, AG, PGL, LRL, FP, GR, SS, AT, GT, RU,PU; Analysis and interpretation of data: AT, WE, MP, DP, SB, SD; Final approval of the version to be published: AT, GB, WE, LA, MLA, MA, MB, F, B†, GB, MAB, RC, RC, DD, RE, RF, LF, SF, GF, MF, GM, SG, MGG, MAL, FL, GL, DL, GM, GN, LCCO, ECO, AP, SP, AP, AP, SP, PP, TP, GP, MCR, GLR, SR, JR, GS, FS, LS, IS, RV, CZ, AZ, SD, GB, EB, CC, AC, SC, AC, DC, AD, PDC, FF, FF, FF, SG, GG, AG, PGL, LRL, FP, GR, SS, AT, GT, RU, PU.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SD served as speaker, consultant and/or advisory board member for AbbVie, Allergan, Alfa Wassermann, Biogen, Boehringer Ingelheim, Celgene, Celltrion, Ferring, Gilead, Hospira, Johnson and Johnson, Merck, MSD, Mundipharma, Pfizer, Sandoz, Takeda, Tigenix, UCB Pharma, Vifor. GM served as speaker and/or advisory board fees for AlfaSigma, Arena, Janssen, Gilead, Roche. GN received funding for target projects from Apharm and Sofar. APserved as lecturer for AlfaSigma and Polpharma. JR served as lecturer for AlfaSigma, Takeda, Ipsen and Servier. FS served as lecturer for Sanofi.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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