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The Diagnostic Journey in Fistulizing Sigmoid Diverticulitis: A Multicenter Retrospective Study and Proposal for a
Lennart Zimniak1,2, Joerg-Peter Ritz3, Christoph Wullstein4
1Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Ruppin-Brandenburg (UKRB), Neuruppin, Germany, l.zimniak@ukrb.de.
None:
Introduction: Fistulizing sigmoid diverticulitis, most commonly involving colovesical or colovaginal fistulas, is a rare but debilitating complication of chronic diverticular disease. Despite pathognomonic symptoms, diagnostic pathways are often inconsistent, contributing to delayed surgical treatment and increased patient burden. This study examines the preoperative diagnostic pathway of patients with fistulizing diverticulitis in a multicenter cohort in Germany.
Methods:
In this retrospective study, patients with colovesical, colovaginal, or combined fistulas due to chronic sigmoid diverticulitis who underwent elective sigmoid resection at four tertiary centers between 2012 and 2023 were analyzed. Collected data included clinical symptoms, number and type of diagnostic investigations, time from symptom onset to surgery, and subgroup comparisons.
Results:
A total number of 101 patients were included in this analysis. The median time from symptom onset to surgery was 8 weeks (IQR 4-16). Recurrent urinary tract infections (78.2%) and pneumaturia (44.6%) were the most frequent symptoms. Patients underwent a median of 4 diagnostic procedures, with CT (90.1%), colonoscopy (81.2%), abdominal ultrasound (80.2%), and cystoscopy (55.4%) being most commonly used. Subgroup analysis revealed a significantly higher number of investigations in patients with surgical delay ≥10 weeks compared to those treated within 6 weeks (median 4 vs. 3; p = 0.0426), while other clinical characteristics did not differ significantly.
Conclusion:
The diagnostic workup for fistulizing diverticulitis remains heterogeneous and may contribute to treatment delays. Based on our findings, we propose a structured, symptom-guided diagnostic algorithm centered around early recognition, targeted use of high-yield modalities - including colonoscopy, cystoscopy, CT, and the poppy seed test - and prompt referral for surgical treatment. Standardization may improve diagnostic efficiency and reduce patient morbidity.
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