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Abstract
Left sided colonic diverticulitis is a common and costly gastrointestinal disease in Western countries, characterized by acute onset of often severe abdominal pain. Imaging is necessary to make an initial diagnosis and determine disease severity. Colonoscopy should be done six to eight weeks after diagnosis to rule out a missed colon malignancy. Antibiotic treatment is used selectively in immunocompetent patients with mild acute uncomplicated diverticulitis. The clinical course of diverticulitis commonly includes unpredictable recurrences and chronic gastrointestinal symptoms, which are a detriment to quality of life. A better understanding of prognosis has prompted a shift toward non-operative approaches. The decision to undergo prophylactic colon resection should be individualized to consider the severity of diverticulitis, the patient's health and immune status, and the patient's preferences and values, as well as benefits and risks. Because only a section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis with an abscess is treated with antibiotics that cover Gram negative and anaerobic bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent or feculent contamination of the peritoneal cavity is managed with surgery; primary resection and anastomosis is the procedure of choice in stable patients.
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Affiliation(s)
- Anne F Peery
- University of North Carolina School of Medicine, Chapel Hill, NC 27599-7555, USA
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Khor S, Flum DR, Strate LL, Hantouli MN, Harris HM, Lavallee DC, Spiegel BM, Davidson GH. Establishing Clinically Significant Patient-reported Outcomes for Diverticular Disease. J Surg Res 2021; 264:20-29. [PMID: 33744774 DOI: 10.1016/j.jss.2021.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/12/2021] [Accepted: 01/25/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Diverticular disease can undermine health-related quality of life. The diverticulitis quality of life (DV-QOL) instrument was designed and validated to measure patient-reported burden of diverticular disease. However, values reflecting meaningful improvement (i.e., minimal clinically important difference [MCID]) and the patient acceptable symptom state (PASS) have yet to be established. We sought to establish the MCID and PASS of the DV-QOL and describe the characteristics of those with DV-QOL above the PASS threshold. MATERIALS AND METHODS We performed a prospective cohort study of adults with diverticular disease from seven centers in Washington and California (2016-2018). Patients were surveyed at baseline, then quarterly up to 30 mo. To determine the MCID and PASS for DV-QOL, we applied various previously established distribution- and anchor-based approaches and compared the resulting values. RESULTS The study included 177 patients (mean age 57 y, 43% women). A PASS threshold of 3.2/10 distinguished between those with and without health-related quality of life-impacting diverticulitis with acceptable accuracy (area under the curve 0.76). A change of 2.2 points in the DV-QOL was the most appropriate MCID: above the distribution-based MCIDs and corresponding to patient perception of importance of change (AUC 0.70). Patients with DV-QOL ≥ PASS were more often men, younger, had Medicaid, had more serious episodes of diverticulitis, and had an occupational degree or high-school education or less. CONCLUSIONS Our study is the first to define MCID and PASS for DV-QOL. These thresholds are critical for measuring the impact of diverticular disease and the evaluation of treatment effectiveness.
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Affiliation(s)
- Sara Khor
- Department of Surgery, University of Washington, Seattle, Washington; The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington
| | - Lisa L Strate
- Department of Medicine, Division of Gastroenterology, Harborview Medical Center, Seattle, Washington
| | - Mariam N Hantouli
- Department of Surgery, University of Washington, Seattle, Washington
| | - Heather M Harris
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Brennan Mr Spiegel
- Department of Medicine, Division of Health Services Research, Cedars-Sinai, Los Angeles, California
| | - Giana H Davidson
- Department of Surgery, University of Washington, Seattle, Washington.
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High-Resolution Colonic Manometry Pressure Profiles Are Similar in Asymptomatic Diverticulosis and Controls. Dig Dis Sci 2021; 66:832-842. [PMID: 32399665 DOI: 10.1007/s10620-020-06320-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Elevated colonic pressures and increased colonic activity have been thought to contribute to the pathophysiology of diverticulosis. However, evidence for this has been limited to low-resolution manometry, which is of limited accuracy. AIMS This study aimed to evaluate the contraction pressures, counts, and distance of propagation recorded by high-resolution colonic manometry in diverticulosis vs control patients. METHODS High-resolution colonic manometry was used to record descending and sigmoid colon activity pre- and post-meal in patients with established, asymptomatic diverticulosis and in healthy controls. Antegrade and retrograde propagating contractions, distance of propagation (mm), and mean contraction pressures (mmHg) in the descending and sigmoid colon were compared between patients and controls for all isolated propagating contractions, the cyclic motor pattern, and high-amplitude propagating contractions independently. RESULTS Mean manometry pressures were not different between controls and diverticulosis patients (p > 0.05 for all comparisons). In the descending colon, diverticulosis patients had lower post-meal mean distance of propagation for all propagating contractions [10.8 (SE1.5) mm vs 20.0 (2.0) mm, p = 0.003] and the cyclic motor pattern [6.0 (2.5) mm vs 17.1 (2.8) mm, p = 0.01]. In the sigmoid colon, diverticulosis patients showed lower post-meal mean distance of propagation for all propagating contractions [10.8 (1.5) mm vs 20.2 (5.9) mm, p = 0.01] and a lower post-meal increase in retrograde propagating contractions (p = 0.04). CONCLUSIONS In this first high-resolution colonic manometry study of patients with diverticular disease, we did not find evidence for increased manometric pressures or increased colonic activity in patients with diverticular disease.
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Abu Baker F, Ganayem M, Mari A, Taher R, Suki M, Kopelman Y. Acute complicated diverticulitis is associated with an increased advanced neoplasia diagnosis rate: A retrospective study on 1852 patients. Medicine (Baltimore) 2021; 100:e24271. [PMID: 33592870 PMCID: PMC7870193 DOI: 10.1097/md.0000000000024271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/11/2020] [Indexed: 01/05/2023] Open
Abstract
Recent reports have documented an unchanged rate of occurrence of colorectal cancer (CRC) and have publicised doubts regarding the benefit of prompt colonoscopy procedures after an episode of acute diverticulitis (AD). These reports mandate further evaluation of colonoscopy yield and timing in this regard. The current study aims to determine whether the rate of advanced colonic neoplasia after AD differs from that of average-risk patients, and to identify risk factors that are associated with their development.In this retrospective study, we included all patients who had been hospitalized to the surgery ward in the years 2008 to 2016 with radiographically confirmed AD, and had completed colonoscopies within one year of index hospitalization. Patients who were referred for screening colonoscopies during the same years were included as a control group. We compared the rates of diagnosis of CRC and advanced polyps for both groups before and after adjustment for multiple confounders. Moreover, we investigated risk factors that were associated with increased rate of advanced neoplasia diagnosis.A total of 350 patients were included in the AD group and 1502 patients in the screening colonoscopy control group. The CRC diagnosis rates (1.7% vs 0.3%; P = .09) and overall diagnosis rates of advanced neoplasia (12.3% vs 9.6%; P = .19) were not significantly different when findings were compared between the AD and control groups, respectively. Cases of complicated diverticulitis, however, were associated with increased risk of advanced neoplasia diagnosis (odds ratio (OR) 3.729, 95% confidence interval (CI) 1.803-7.713; P = .01).The diagnosis rate for advanced neoplasia after AD was not significantly different from that of average-risk populations. A course of complicated AD, however, was a potential risk factor.
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Affiliation(s)
- Fadi Abu Baker
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Mohanad Ganayem
- Department of internal medicine, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Amir Mari
- Department of Gastroenterology, Nazareth EMMS Hospital, Affiliated with the Faculty of Medicine, Bar Illan University
| | - Randa Taher
- Department of internal medicine, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Mohamad Suki
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
| | - Yael Kopelman
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel, Affiliated to the Technion Faculty of Medicine, Haifa, Israel
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Risk factors and incidence of 90-day readmission for diverticulitis after an acute diverticulitis index admission. Int J Colorectal Dis 2021; 36:347-352. [PMID: 33025103 DOI: 10.1007/s00384-020-03769-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Acute diverticulitis is the third most frequent cause of gastrointestinal admission in the USA. We sought to determine the incidence of recurrence within a 90-day period and determine its impact on mortality and hospital utilization. METHODS Nationwide Readmission Database (NRD) 2016 was used to identify patients ≥ 18 years old with a principal diagnosis of acute diverticulitis who were readmitted for recurrence within 90 days. The primary outcome was 90-day readmission rate for acute diverticulitis, and predictors were analyzed using a multivariate regression analysis. Secondary outcomes were mortality and hospital resource utilization. RESULTS A total of 171,238 admissions were included which met inclusion criteria. Ninety-day readmission for acute diverticulitis after index diverticulitis hospitalization was 8.9%. Readmissions were associated with in-hospital additional total cost of $444,726,560 and 65,685 total hospital days and mortality rate of 4.69% compared with mortality rate of 5.20% on index hospitalization (p < 0.01). In multivariable analysis, increased odds of readmission were associated with disposition against medical advice (OR 1.75, 95% CI 1.31-2.33), younger age (OR 0.98, 95% CI 0.98-0.99), and shorter length of stay (OR 0.99, CI 0.98-0.99). CONCLUSIONS Acute diverticulitis is frequently associated with recurrence within 90 days and bears a substantial financial and mortality burden. Targeted interventions are needed to minimize readmissions in identified subpopulations.
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Soh YSA, Ooi SQD, Chan YH, Siah THK, Lee SE, Lee WJJ, Zhu F, Yeoh KG, Gwee KA. Rising prevalence of colonic diverticulosis in a westernized multi-ethnic Asian community. J Gastroenterol Hepatol 2021; 36:413-420. [PMID: 32602133 DOI: 10.1111/jgh.15165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/16/2020] [Accepted: 06/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM Singapore is a multi-ethnic country that has undergone rapid development over the last few decades, with increasing influence of western culture, and faces an aging population. Previously, a varying prevalence of colonic diverticulosis (CD) was reported by a few small studies. This study aims to evaluate the prevalence of CD in Singapore and identify associations with common gastrointestinal symptoms and risk factors. METHODS We reviewed retrospective data of 20 395 consecutive colonoscopies performed from 2006 to 2016 for presence of CD and indications of screening, diarrhea, constipation, and abdominal pain. RESULTS The prevalence of CD progressively increased from 2006 to 2016 (14.9% vs 23.9%, adjusted trend < 0.001), with an overall prevalence of 19.6%. Patients with CD were older and had higher body mass index (BMI). CD was significantly more prevalent in Chinese compared with Malay and Indian races (20.5% vs 18.9% vs 15.5%, P < 0.05), and in male patients compared with female patients (21.5% vs 17.6%, P < 0.05). Right-sided CD was more common than left-sided or pan diverticulosis (16.2% vs 8.3% vs 4.8%, P < 0.05). Age [odds ratio (OR), 1.060; 95% confidence interval (CI), 1.052-1.068], BMI (OR, 1.051; 95% CI, 1.028-1.075), male gender (OR, 1.317; 95% CI, 1.084-1.600), and abdominal pain (OR, 1.409; 95% CI, 1.168-1.699) were positively associated, while constipation (OR, 0.566; 95% CI, 0.452-0.709) was negatively associated with CD. CONCLUSION The prevalence of CD in Singapore has progressively increased over the last decade and is associated with older age, higher BMI, and abdominal pain. These findings may provide insights for healthcare resource planning in the region.
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Affiliation(s)
- Yu Sen Alex Soh
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shu Qin Delicia Ooi
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School Medicine, National University of Singapore, Singapore
| | - Tien-Ho Kewin Siah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Soh-Ee Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wei Jie Jonathan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Feng Zhu
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Khay Guan Yeoh
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kok-Ann Gwee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Viscido A, Ciccone F, Vernia F, Gabrieli D, Capannolo A, Stefanelli G, Necozione S, Valerii G, Ashktorab H, Latella G. Association of Colonic Diverticula with Colorectal Adenomas and Cancer. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020108. [PMID: 33504050 PMCID: PMC7910864 DOI: 10.3390/medicina57020108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Conflicting evidence is reported regarding any association between colonic diverticula with colorectal adenomas or cancer. The present study aimed to evaluate, in a cohort of Caucasian patients, the association between colonic diverticula and colorectal polyps and cancer. Materials and Methods: All consecutive patients undergoing colonoscopy at our institution were included in the study. The presence and location of diverticula, polyps, and cancers were recorded. Histologically, polyps were classified as adenoma (with low or high dysplasia), hyperplastic, or inflammatory. The relative risk of the association of polyps and cancer with diverticula was assessed. Multiple logistic regression analyses, including age, sex, family history for colorectal cancer (CRC), and family history for diverticula, were carried out. Results: During the study period, 1490 patients were enrolled; 37.2% (n = 555) showed colonic diverticula or polyps or CRC (308 males, mean age 66 years). Particularly, 12.3% (n = 183) patients presented only diverticula, 13.7% (n = 204) only polyps or cancer, 11.3% (n = 168) both diseases, and 62.7% (n = 935) neither diverticula nor polyps and cancer. A total of 38 patients presented colorectal cancer, 17 of which had also diverticula. A significant increase in relative risk (RR 2.81, 95% CI 2.27-3.47, p < 0.0001) of colorectal adenoma and cancer in patients with colonic diverticula was found. At multivariate analysis, only diverticula resulted to be significantly associated with colorectal adenomas and cancer (Odds Ratio, OR 3.86, 95% CI 2.90-5.14, p < 0.0001). Conclusions: A significant association of colonic diverticula with colorectal adenoma or cancer was found. This implies that patients with colonic diverticula require a vigilant follow-up procedure for the prevention of colorectal cancer from those applicable to the general population.
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Affiliation(s)
- Angelo Viscido
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.V.); (F.V.); (A.C.); (G.S.)
| | - Fabiana Ciccone
- Gastroenterology Unit, Giuseppe Mazzini Hospital, 64100 Teramo, Italy; (F.C.); (D.G.); (G.V.)
| | - Filippo Vernia
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.V.); (F.V.); (A.C.); (G.S.)
| | - Dolores Gabrieli
- Gastroenterology Unit, Giuseppe Mazzini Hospital, 64100 Teramo, Italy; (F.C.); (D.G.); (G.V.)
| | - Annalisa Capannolo
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.V.); (F.V.); (A.C.); (G.S.)
| | - Gianpiero Stefanelli
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.V.); (F.V.); (A.C.); (G.S.)
| | - Stefano Necozione
- Epidemiology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
| | - Giorgio Valerii
- Gastroenterology Unit, Giuseppe Mazzini Hospital, 64100 Teramo, Italy; (F.C.); (D.G.); (G.V.)
| | - Hassan Ashktorab
- Department of Medicine and Cancer Center, Howard University College of Medicine, Washington, DC 20059, USA;
| | - Giovanni Latella
- Gastroenterology Unit, Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (A.V.); (F.V.); (A.C.); (G.S.)
- Correspondence: ; Tel.: +39-0862-434735; Fax: +39-0862-433425
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Kousgaard SJ, Gade M, Petersen LJ, Thorlacius-Ussing O. Incidental detection of colorectal lesions on 18 F-FDG-PET/CT is associated with high proportion of malignancy: A study in 549 patients. Endosc Int Open 2020; 8:E1725-E1731. [PMID: 33269303 PMCID: PMC7671755 DOI: 10.1055/a-1266-3308] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Further diagnostics of incidental colorectal lesions on 18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is questionable. Therefore, we aimed to evaluate the clinical importance of incidentally detected colorectal lesions on FDG-PET/CT. Patients and methods In the North Denmark Region, a retrospective study was performed among 19,987 patients who had an FDG-PET/CT from January 2006 to December 2015. Among these patients, we identified patients with a colonoscopy within 12 months from the PET/CT scan and a description of incidental colorectal PET-avid lesions on the PET/CT. PET findings were compared with colonoscopy-detected lesions and eventually histopathology. Results Incidental PET-avid lesions were observed in 549 patients. Colonoscopy revealed lesions in 457 (83 %), among whom 338 patients had a final histopathological diagnosis. Malignant and premalignant lesions were found in 297 patients (54 % among patients with a PET-avid lesion). The lesions were cancer in 76 patients and adenoma in 221 patients of whom 30 had high-grade and 191 low-grade adenomas. The findings changed patient management in 166 cases (30 % of all patients with a PET-avid lesion). A colonoscopy-based surveillance program was initiated for 80 % of patients with high-grade adenoma. No patients with PET-avid lesions but normal colonoscopy developed colorectal cancer during 3 years of observation (median observation time 7 years). Conclusions Incidental colorectal FDG uptake was infrequently observed, but when present, it was associated with a high rate of malignant or premalignant lesions. Our results indicate that patients with incidental colorectal FDG uptake should be referred to diagnostic work-up including colonoscopy.
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Affiliation(s)
- Sabrina Just Kousgaard
- Department of Gastrointestinal Surgery and Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Michael Gade
- Department of Nuclear Medicine, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Jelstrup Petersen
- Department of Nuclear Medicine, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery and Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Rai V, Mishra N. Surgical Management of Recurrent Uncomplicated Diverticulitis. Clin Colon Rectal Surg 2020; 34:91-95. [PMID: 33642948 DOI: 10.1055/s-0040-1716700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.
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Affiliation(s)
- Vinay Rai
- Department of Surgery, University of New Mexico, Albuquerque, New Mexico
| | - Nitin Mishra
- Department of Surgery, Mayo Clinic College of Medicine, Phoenix, Arizona
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Optimizing medical management for diverticular disease: A systematic review and gap analysis. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 PMCID: PMC7575828 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent. To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether. The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables. Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing. Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known. The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy. After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy. For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”. Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary. For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents. Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance. Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key. Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease. While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined. Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Clinical Difference between Acute Appendicitis and Acute Right-Sided Colonic Diverticulitis. Emerg Med Int 2020; 2020:4947192. [PMID: 32953179 PMCID: PMC7481953 DOI: 10.1155/2020/4947192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/29/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022] Open
Abstract
Background Clinical presentations of acute appendicitis (AA) and acute right-sided colonic diverticulitis (ARCD) are similar. However, the usual treatment for each disease differs between surgical and conservative management. The aim of this study was to identify clinical differences between AA and ARCD. Method We performed a single-center retrospective study on adult patients, with uncomplicated AA and ARCD confirmed by computed tomography, who visited an emergency department between March 2018 and August 2019. Clinical variables including past medical history, presented symptoms and signs, and laboratory findings were compared between the two groups. A logistic regression analysis was subsequently performed to differentiate ARCD from AA based on results of univariate analyses. Results A total of 212 (79.1%) and 56 (20.9%) patients were enrolled in AA and ARSD groups, respectively. Logistic regression analysis revealed that a past history of diverticulitis [OR: 102.679 (95% CI: 9.964–1058.055), p < 0.001] was associated with ARCD, while ketonuria [OR: 2.907 (95% CI: 1.091–7.745), p=0.033], anorexia [OR: 21.544 (95% CI: 3.905–118.868), p < 0.001], and neutrophilia [OR: 3.406 (95% CI: 1.243–9.336), p=0.017] were associated with AA. Conclusion Anorexia, neutrophilia, and ketonuria were predictors of AA while a history of diverticulitis was a predictor of ARCD.
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Meyer DC, Hill SS, Bebinger DM, McDade JA, Davids JS, Alavi K, Maykel JA. Resolution of multiply recurrent and multifocal diverticulitis after fecal microbiota transplantation. Tech Coloproctol 2020; 24:971-975. [PMID: 32601752 DOI: 10.1007/s10151-020-02275-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The exact pathophysiology of diverticulitis is not well understood and may be multifactorial. Recent studies highlight dysbiosis as a plausible mechanism. FMT is a safe strategy to restore commensal colon microbiota and has proven to be an effective treatment for gastrointestinal dysbiosis such as Clostridium difficile infection (CDI). There have been no studies reporting the treatment of diverticulitis with FMT. Our aim was to describe the novel application of fecal microbiota transplantation (FMT) for the treatment of recurrent diverticulitis. CASE We report a case of a 63-year-old woman who had a 13-year history of multiply recurrent and multifocal diverticulitis previously treated with numerous short courses of intravenous and oral antibiotics for acute flares, two segmental colon resections, and suppressive antibiotic therapy for recurrent disease. Secondary to multiple courses of antibiotics , the patient developed CDI. She was treated with a single round of FMT and subsequently stopped all antibiotics at the time of FMT. RESULTS In 20 months of follow-up, the patient has had no further recurrence of diverticulitis or CDI. CONCLUSIONS FMT could prove to be a novel therapy for refractory diverticulitis but requires further investigation.
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Affiliation(s)
- D C Meyer
- Division of Colon and Rectal Surgery, University of Massachusetts Medical School, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA
| | - S S Hill
- Division of Colon and Rectal Surgery, University of Massachusetts Medical School, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA
| | - D M Bebinger
- Division of Infectious Disease and Immunology, University of Massachusetts Medical School, Worcester, MA, USA
| | - J A McDade
- Division of Colon and Rectal Surgery, University of Massachusetts Medical School, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA
| | - J S Davids
- Division of Colon and Rectal Surgery, University of Massachusetts Medical School, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA
| | - K Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts Medical School, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA
| | - J A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts Medical School, University of Massachusetts Memorial Medical Center, 67 Belmont Street, Worcester, MA, 01605, USA.
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Rook JM, Dworsky JQ, Curran T, Banerjee S, Kwaan MR. Elective surgical management of diverticulitis. Curr Probl Surg 2020; 58:100876. [PMID: 33933211 DOI: 10.1016/j.cpsurg.2020.100876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/17/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Jordan M Rook
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jill Q Dworsky
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Thomas Curran
- Medical University of South Carolina, Charleston, SC
| | - Sudeep Banerjee
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Mary R Kwaan
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
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Nasef NA, Mehta S. Role of Inflammation in Pathophysiology of Colonic Disease: An Update. Int J Mol Sci 2020; 21:E4748. [PMID: 32635383 PMCID: PMC7370289 DOI: 10.3390/ijms21134748] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023] Open
Abstract
Diseases of the colon are a big health burden in both men and women worldwide ranging from acute infection to cancer. Environmental and genetic factors influence disease onset and outcome in multiple colonic pathologies. The importance of inflammation in the onset, progression and outcome of multiple colonic pathologies is gaining more traction as the evidence from recent research is considered. In this review, we provide an update on the literature to understand how genetics, diet, and the gut microbiota influence the crosstalk between immune and non‑immune cells resulting in inflammation observed in multiple colonic pathologies. Specifically, we focus on four colonic diseases two of which have a more established association with inflammation (inflammatory bowel disease and colorectal cancer) while the other two have a less understood relationship with inflammation (diverticular disease and irritable bowel syndrome).
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Affiliation(s)
- Noha Ahmed Nasef
- Riddet Institute, Massey University, Private Bag 11222, Palmerston North 4442, New Zealand
| | - Sunali Mehta
- Department of Pathology, Dunedin School of Medicine, University of Otago, Dunedin 9054, New Zealand
- Maurice Wilkins Centre for Biodiscovery, University of Otago, Dunedin 9054, New Zealand
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Solitary Cecal Diverticulitis Mimicking Acute Appendicitis in a Child: Intraoperative Diagnosis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 53:433-436. [PMID: 32377122 PMCID: PMC7192303 DOI: 10.14744/semb.2017.76588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/06/2017] [Indexed: 11/20/2022]
Abstract
Right colonic and cecal diverticulitis can mimic acute appendicitis. A 14-year-old, 105-kg boy presented at the emergency department with symptoms mimicking acute appendicitis. Surgery revealed a case of perforated solitary cecal diverticulitis. Diverticulosis is a disease known to be common in adulthood, but the incidence is increasing in childhood. Therefore, emergency room residents and pediatric surgeons need to keep this diagnosis in mind in the differential diagnosis of acute appendicitis. Early clarification of the etiology will enable the planning of the best treatment strategy.
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67
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Causes of Lower Gastrointestinal Bleeding in Cirrhotics: Are the Most Commonly Reported Causes the Most Common? Am J Med Sci 2020; 359:191-192. [PMID: 32087943 DOI: 10.1016/j.amjms.2020.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Indexed: 11/13/2022]
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Tehranian S, Klinge M, Saul M, Morris M, Diergaarde B, Schoen RE. Prevalence of colorectal cancer and advanced adenoma in patients with acute diverticulitis: implications for follow-up colonoscopy. Gastrointest Endosc 2020; 91:634-640. [PMID: 31521778 PMCID: PMC7039754 DOI: 10.1016/j.gie.2019.08.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Guidelines recommend colonoscopy after an episode of diverticulitis to exclude neoplasia but the effectiveness of testing is uncertain. Patients with complicated diverticulitis may be at higher risk for neoplasia, but most patients have uncomplicated disease. We examined the incidence of colorectal cancer (CRC) and advanced adenoma (AA) in patients with diverticulitis compared with patients undergoing screening colonoscopy. METHODS CT scans from January 1, 2008, to May 1, 2013, at the University of Pittsburgh Medical Center (UPMC) were reviewed to identify those with confirmed acute diverticulitis. Subsequent surgical, colonoscopy, and pathology reports were abstracted to identify those with a diagnosis of AA and CRC. The incidence of neoplasia was compared with that reported for screening colonoscopy from a meta-analysis (n = 68,324), and from colonoscopy examinations at UPMC between 2013 and 2015 (n = 28,573). RESULTS A total of 5167 abdominal/pelvic CT scan reports identified 978 patients with acute diverticulitis, among which 474 (48.5%) patients had undergone at least 1 colonoscopy or gastrointestinal surgery to April 2015. The CRC rate in patients with diverticulitis (13/474, 2.7%) was significantly higher (P < .0001) compared with both the meta-analysis (0.8%) and UPMC (0.3%). The AA rate (19/474, 4.0%) was similar to the rate in the meta-analysis (5.0%, P = .39) but significantly lower than at UPMC (7.7%, P = .003). The incidence of AA or CRC in complicated diverticulitis (10/141, 7.1%) did not differ significantly (P = .85) from the incidence of AA or CRC in uncomplicated diverticulitis (22/332, 6.6%). CONCLUSIONS CRC after diverticulitis was significantly higher than that observed at screening colonoscopy and was not limited to complicated disease. Colonoscopy is advisable after the diagnosis of diverticulitis.
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Affiliation(s)
- Shahrzad Tehranian
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA
| | - Matthew Klinge
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA
| | - Melissa Saul
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michele Morris
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA
| | - Brenda Diergaarde
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, and UPMC Hillman Cancer Center, Pittsburgh, PA
| | - Robert E. Schoen
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA,Corresponding author: Robert E. Schoen, MD, MPH, Division of Gastroenterology, Hepatology and Nutrition, Mezzanine Level, C Wing, PUH, 200 Lothrop St, Pittsburgh, PA 15213-2582,
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Elective Laparoscopic Sigmoid Colectomy for Diverticulitis-an Updated Look at Recurrence After Surgery. J Gastrointest Surg 2020; 24:388-395. [PMID: 30671801 DOI: 10.1007/s11605-018-04083-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/13/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical management of diverticulitis is evolving and the decision to offer elective sigmoidectomy for diverticulitis has become more individualized. However, preoperative variables that may predict recurrent diverticulitis after resection and guide surgical decision-making were not well studied. METHODS This was a retrospective chart review with a prospective questionnaire follow-up of patients. Patients who underwent elective sigmoidectomy for diverticulitis from 2002 to 2016 at a tertiary academic colorectal surgery practice were included and their medical records reviewed. They were then contacted with a questionnaire to inquire about recurrence of diverticulitis since resection. The primary outcome was rate of recurrent diverticulitis after elective sigmoidectomy. The secondary outcome was risk factors for recurrence after sigmoidectomy. RESULTS Of 662 patients who underwent elective sigmoidectomy for diverticulitis, 361 had long-term follow-up data available. Mean follow-up was 86 months. Indication for surgery was uncomplicated recurrent diverticulitis in 50%. Recurrent diverticulitis developed in 15 (4.2%) patients. Mean time to recurrence was 55 (range, 6-109) months. All recurrences were confirmed by CT scan. Univariate analysis showed that preoperative diagnosis of irritable bowel syndrome and uncomplicated recurrent diverticulitis was significantly more prevalent in patients who experienced recurrent diverticulitis after sigmoidectomy (p = 0.049 and p = 0.02); however, these variables did not predict recurrence after resection. CONCLUSIONS Overall rate of recurrent diverticulitis after elective sigmoidectomy was 4.2%. Preoperative diagnosis of irritable bowel syndrome and uncomplicated recurrent diverticulitis was associated with but not significant predictor of recurrence after elective resection.
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Choi KK, Krautsak K, Martinolich J, Canete JJ, Valerian BT, Chismark AD, Lee EC. After Elective Sigmoid Colectomy for Diverticulitis, Does Recurrence-Free Mean Symptom-Free? Am Surg 2020. [DOI: 10.1177/000313482008600128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
After elective sigmoidectomy for diverticulitis, patients may experience persistent abdominal symptoms. This study aimed to determine the incidence and characteristics of persistent symptoms (PSs) and their risk factors in patients who had no reported recurrence after elective sigmoidectomy. Patients who underwent elective sigmoidectomy for diverticulitis from 2002 to 2016 at a tertiary academic colorectal surgery practice were included. After retrospective review of medical records, patients were contacted with a questionnaire to inquire about recurrence of diverticulitis and persistent abdominal symptoms since resection. Outcomes examined were prevalence of and risk factors for PSs after elective sigmoidectomy. Of 662 included patients, 346 completed the questionnaire and had no recurrent diverticulitis. PSs were reported by 43.9 per cent of the patients. The mean follow-up was 87 months. Female gender and preoperative diagnosis of irritable bowel syndrome were independent risk factors for PSs (Relative Risk 1.65, P < 0.001 and Relative Risk 1.41, P = 0.014). Previous IVantibiotics treatment was associated with PSs ( P = 0.034) but not with a significant risk factor. As the follow-up interval increased, prevalence of PSs decreased ( P = 0.006). More than 40 per cent of patients experienced persistent abdominal symptoms after sigmoidectomy for diverticulitis. Female patients and those with irritable bowel syndrome were at significantly increased risk.
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Affiliation(s)
- Karmina K. Choi
- From the Department of Surgery, Albany Medical Center, Albany, New York
| | - Kevin Krautsak
- From the Department of Surgery, Albany Medical Center, Albany, New York
| | | | | | - Brian T. Valerian
- From the Department of Surgery, Albany Medical Center, Albany, New York
| | - A. David Chismark
- From the Department of Surgery, Albany Medical Center, Albany, New York
| | - Edward C. Lee
- From the Department of Surgery, Albany Medical Center, Albany, New York
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72
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Persaud A, Ahmed A, Kakked G, Shulik O, Ahlawat S. A comparison of diverticulitis in Crohn's disease versusulcerative colitis. JGH Open 2019; 3:508-512. [PMID: 31832551 PMCID: PMC6891016 DOI: 10.1002/jgh3.12192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/10/2019] [Accepted: 04/17/2019] [Indexed: 11/15/2022]
Abstract
Background and Aim Inflammatory bowel disease (IBD) and diverticulitis both increase morbidity, especially when associated with in‐patient hospitalization. This study aimed to evaluate whether hospitalization burden differs for diverticulitis in patients with a history of Crohn's disease (CD) compared to ulcerative colitis (UC). Method All patients hospitalized for acute diverticulitis with pre‐existing UC or CD in 2014 were selected using the national in‐patient sample. Cases were identified using the International Classification of Diseases, Ninth Edition codes. Primary outcomes were mortality, cost of admission, length of stay (LOS), and colectomy. Results A total of 1815 patients were admitted with diverticulitis, and those with CD had a hospitalization associated with decreased cost (aOR −14 537, 95% CI −27 316 to −1758; P = 0.026) and LOS (aOR −1.31, 95% CI −2.41 to −0.208; P = 0.02) compared to UC. A second analysis comparing diverticulitis hospitalization between those with CD and those with the absence of IBD showed no significant difference in mortality (aOR 2.47, 95% CI 0.59 to 10.36; P = 0.22), LOS (aOR 0.03, 95% CI −0.47 to 0.54; P = 0.92), or cost of admission (aOR −2196, 95% CI −6933 to 2539; P = 0.36) between the cohorts. Conclusion Patients with UC have worsened hospitalization outcomes when being treated for diverticulitis compared to CD. While the findings may be a result of a difference in colectomy rates, the etiology may also be multifactorial. These conclusions have not been previously described, and further investigations would better characterize these associations.
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Affiliation(s)
- Alana Persaud
- Division of MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Ahmed Ahmed
- Division of MedicineRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Gaurav Kakked
- Division of MedicineMount Sinai West/St. Luke's RooseveltNew YorkNew YorkUSA
| | - Oleg Shulik
- Division of Gastroenterology and HepatologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
| | - Sushil Ahlawat
- Division of Gastroenterology and HepatologyRutgers New Jersey Medical SchoolNewarkNew JerseyUSA
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Treatment of Uncomplicated Acute Diverticulitis Without Antibiotics: A Systematic Review and Meta-analysis. Dis Colon Rectum 2019; 62:1533-1547. [PMID: 30663999 DOI: 10.1097/dcr.0000000000001330] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite low-quality and conflicting evidence, the Association of Coloproctology of Great Britain and Ireland recommends the routine use of antibiotics in the treatment of uncomplicated acute diverticulitis. Recent studies have shown that treatment without antibiotics did not prolong recovery. Some new guidelines currently recommend selective use of antibiotics. OBJECTIVE The purpose of this study was to compare the safety, effectiveness, and outcomes in treating uncomplicated acute diverticulitis without antibiotics with treatment with antibiotics. DATA SOURCES PubMed, Embase, Clinicaltrials.gov, and the Cochrane Library were searched with the key words antibiotics and diverticulitis. STUDY SELECTION All studies published in English on treating uncomplicated acute diverticulitis without antibiotics and containing >20 individuals were included. INTERVENTION Treatment without antibiotics versus treatment with antibiotics were compared. MAIN OUTCOME MEASURES The primary outcome was the percentage of patients requiring additional treatment or intervention to settle during the initial episode. The secondary outcomes were duration of hospital stay, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, and complication. RESULTS Search yielded 1164 studies. Nine studies were eligible and included in the meta-analysis, composed of 2505 patients, including 1663 treated without antibiotics and 842 treated with an antibiotic. The no-antibiotics group had a significantly shorter hospital stay (mean difference = -0.68; p = 0.04). There was no significant difference in the percentage of patients requiring additional treatment or intervention to settle during the initial episode (5.3% vs 3.6%; risk ratio = 1.48; p = 0.28), rate of readmission or deferred admission (risk ratio = 1.17; p = 0.26), need for surgical or radiological intervention (risk ratio = 0.61; p = 0.34), recurrence (risk ratio = 0.83; p = 0.21), and complications (risk ratio = 0.70-1.18; p = 0.67-0.91). LIMITATIONS Only a limited number of studies were available, and they were of variable qualities. CONCLUSIONS Treatment of uncomplicated acute diverticulitis without antibiotics is associated with a significantly shorter hospital stay. There is no significant difference in the percentage of patients requiring additional treatment or intervention to settle in the initial episode, rate of readmission or deferred admission, need for surgical or radiological intervention, recurrence, or complications.
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Bong J, Kang HW, Cho H, Nam JH, Jang DK, Kim JH, Lee JK, Lim YJ, Koh MS, Lee JH. Vegetarianism as a protective factor for asymptomatic colonic diverticulosis in Asians: a retrospective cross-sectional and case-control study. Intest Res 2019; 18:121-129. [PMID: 31661949 PMCID: PMC7000646 DOI: 10.5217/ir.2019.00106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023] Open
Abstract
Background/Aims Dietary fiber intake is considered a protective factor for diverticular disease such as diverticulitis. However, evidence for an inverse connection between dietary fiber consumption and asymptomatic colonic diverticulosis is lacking. Specifically, few studies have investigated this subject in Asians with different presentations of diverticulosis. Therefore, we assessed the protective effects of a vegetarian diet for asymptomatic colonic diverticulosis in Buddhist monks who are obligatory vegetarians for spiritual reasons compared with the general population. Methods A retrospective, cross-sectional, case-control study was conducted in age- and sex-matched Buddhist monks and the general population who underwent colonoscopy for screening at a Korean health promotion center from August 2005 to June 2018. We compared the prevalence of asymptomatic diverticulosis between the 2 groups using a self-administered questionnaire. Results In this study, a total of 1,316 individuals were included (Buddhist monks of 658 and general population of 658) with a mean age of 52.6±9.5 years. The prevalence of asymptomatic diverticulosis in Buddhist monks was lower compared with the general population (6.7% [44/658] vs. 10.8% [71/658], P=0.008). Buddhist monks had a higher rate of high body mass index (BMI) and metabolic syndrome. By a multivariate regression analysis model, a nonvegetarian diet (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.21–2.72, P=0.004), old age (OR, 4.53; 95% CI, 1.36–15.12; P=0.014), male sex (OR, 1.91; 95% CI, 1.28–2.85; P=0.002), and a high BMI (OR, 1.50; 95% CI, 1.01–2.23; P=0.047) were independent predictors of asymptomatic diverticulosis. Moreover, a nonvegetarian diet was associated with both right-sided and left-sided diverticulosis. Conclusions A nonvegetarian diet may increase a risk of asymptomatic colonic diverticulosis in Asians.
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Affiliation(s)
- Jihun Bong
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyeki Cho
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Ji Hyung Nam
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jae Hak Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Moon-Soo Koh
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jin Ho Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
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Disease phenotype rather than treatment strategy impacts the long-term quality of life in patients with diverticular disease. Int J Colorectal Dis 2019; 34:1749-1756. [PMID: 31492987 DOI: 10.1007/s00384-019-03385-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE To identify the impact of the severity of diverticular disease on long-term quality of life. METHODS Consecutive patients, hospitalized between October 2009 and November 2015 due to uncomplicated (UD) and complicated diverticulitis (CD) of the left colon, were analyzed. Patients undergoing emergent surgery for perforated disease were excluded. Primary endpoint was health-related quality of life (HrQol), measured by the Short Form 36 questionnaire (SF-36). Physical (PCS) and mental (MCS) compository scores were calculated from SF-36 subscales. To overcome bias, one-to-one propensity score matching and multivariable logistic regression analysis were performed. RESULTS Two hundred eighty of the overall 392 patients (Male 138, Female 142; mean age 60.5 years, range 27-91) answered the SF-36 questionnaire. The median follow-up period was 37.8 months (range 15-85). After propensity score matching, each group consisted of 51 patients. Results of the SF-36 questionnaires showed a statistically significant difference, favoring patients with CD in 5 of 8 domains. Also, PCS (56.3 vs. 52.9, p = 0.13) and MCS (53.3 vs. 46.7, p = 0.005) were higher in patients treated for CD. By a multivariate analysis, complicated disease was independently associated with a better scoring on 6 out of 8 SF-36 subscales and on MCS. Treatment strategy (surgery or conservative) did not have any impact on SF-36 subscales, MCS, or PCS on multivariate analysis. CONCLUSION In contrast to complicated disease, the uncomplicated diverticular disease is associated with an impaired long-term quality of life especially in domains composing mental health scores independently of chosen treatment strategy. STUDY REGISTRATION The study is registered with the Research Registry at June 19, 2019. Research registry UIN: researchregistry4959 .
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76
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Bae HJ, Kim ST, Hong SG, Lee H, Choi HS, Cho YK, Kim TH, Chung SH. Risk Factors for Asymptomatic Colon Diverticulosis. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:142-148. [PMID: 31554029 DOI: 10.4166/kjg.2019.74.3.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/24/2019] [Accepted: 06/30/2019] [Indexed: 12/23/2022]
Abstract
Backgrounds/Aims The etiology of colon diverticulosis is related to a range of genetic, biological, and environmental factors, but the risk factors for asymptomatic diverticulosis of the colon are unclear. This study examined the risk factors for asymptomatic colon diverticulosis. Methods This retrospective study included examinees who underwent a colonoscopy for screening at the health check-up center of SAM Hospital between January 2016 and December 2016. The examinees with colon diverticulosis found by colonoscopy were compared with those without diverticulosis. The comparison factors were age, gender, alcohol consumption, smoking status, medical history, lipid profile, body mass index, visceral fat area, waist-hip ratio, and severity of a fatty liver. Results This study included 937 examinees and the overall prevalence of diverticulosis was 8.1% (76/937). Fatty liver was found in 69.7% (53/76) in cases of colon diverticulosis and 50.3% (433/861) in the control group (p=0.001). The average waist-hip ratio was 0.92±0.051 in colon diverticulosis and 0.90±0.052 in the control group (p=0.052). Multivariate analysis revealed the waist-hip ratio (OR=1.035, 95% CI 1.000-1.070, p=0.043), moderate fatty liver (OR=2.238, 95% CI 1.026-4.882, p=0.043), and severe fatty liver (OR=5.519, 95% CI 1.236-21.803, p=0.025) to be associated with an increased risk of asymptomatic colon diverticulosis. Conclusions The waist-hip ratio, moderate fatty liver, and severe fatty liver are risk factors for asymptomatic colon diverticulosis. Central obesity, which can be estimated by the waist-hip ratio, and fatty liver might affect the pathogenesis of asymptomatic colon diverticulosis.
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Affiliation(s)
- Hyun Jin Bae
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea.,Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Taek Kim
- Department of Radiology, Anyang SAM Hospital, Anyang, Korea
| | - Seung Goun Hong
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea
| | - Hyunjeong Lee
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea
| | - Hyo Sun Choi
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea
| | - Yoo-Kyung Cho
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea
| | - Tae Hyung Kim
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea
| | - Sook Hee Chung
- Department of Internal Medicine, Anyang SAM Hospital, Anyang, Korea
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77
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Lowes H, Rowaiye B, Carr NJ, Shepherd NA. Complicated appendiceal diverticulosis versus low‐grade appendiceal mucinous neoplasms: a major diagnostic dilemma. Histopathology 2019; 75:478-485. [DOI: 10.1111/his.13931] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Hannah Lowes
- Gloucestershire Cellular Pathology Laboratory Cheltenham General Hospital CheltenhamUK
| | - Babatunde Rowaiye
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke UK
| | - Norman J Carr
- Peritoneal Malignancy Institute Basingstoke and North Hampshire Hospital Basingstoke UK
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory Cheltenham General Hospital CheltenhamUK
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Ma W, Nguyen LH, Song M, Jovani M, Liu PH, Cao Y, Tam I, Wu K, Giovannucci EL, Strate LL, Chan AT. Intake of Dietary Fiber, Fruits, and Vegetables and Risk of Diverticulitis. Am J Gastroenterol 2019; 114:1531-1538. [PMID: 31397679 PMCID: PMC6731157 DOI: 10.14309/ajg.0000000000000363] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Although low fiber intake has been considered a risk factor for diverticulitis, prospective evidence is limited in women despite having a disproportionate burden of disease, with little known about variation in the protective effects according to food sources. We assessed the associations of intakes of fiber and major food sources of fiber including fruits and vegetables with risk of diverticulitis in a large cohort of women. METHODS We followed 50,019 women in the Nurses' Health Study (1990-2014) who were aged 43-70 years and free of diverticulitis, cancer, and inflammatory bowel disease at baseline. Incident diverticulitis was identified through self-report with validity confirmed by review of medical records. RESULTS We documented 4,343 incident cases of diverticulitis, encompassing 1,106,402 person-years of follow-up. Compared with participants in the lowest quintile, the multivariable hazard ratio of diverticulitis in the highest quintile of total fiber intake was 0.86 (95% confidence interval: 0.78-0.95; P-trend = 0.002). Fiber from fruits and cereals, but not vegetables, was associated with a decreased risk of diverticulitis. Furthermore, intake of total whole fruit intake and specific fruits such as apples/pears and prunes were associated with reduced risk of diverticulitis with a multivariable hazard ratio for diverticulitis of 0.95 (0.92-0.98; P-trend < 0.001) for every serving increase of total whole fruit intake per day. DISCUSSION Higher intake of dietary fiber and fiber from different food sources, except for vegetable fiber, are associated with a lower risk of diverticulitis in women. A greater intake of whole fruit is also associated with reduced risk.
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Affiliation(s)
- Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
| | - Long H. Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - Manol Jovani
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
| | - Po-Hong Liu
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
| | - Yin Cao
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO 63110
| | - Idy Tam
- Tufts University School of Medicine, Boston, MA 02111
| | - Kana Wu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115
| | - Edward L. Giovannucci
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
| | - Lisa L. Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA 98122
| | - Andrew T. Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
- Broad Institute of MIT and Harvard, Cambridge, MA 02142
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Response to Tursi. Am J Gastroenterol 2019; 114:1350-1351. [PMID: 31313712 DOI: 10.14309/ajg.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Camilleri M, Sandler RS, Peery AF. Etiopathogenetic Mechanisms in Diverticular Disease of the Colon. Cell Mol Gastroenterol Hepatol 2019; 9:15-32. [PMID: 31351939 PMCID: PMC6881605 DOI: 10.1016/j.jcmgh.2019.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 02/08/2023]
Abstract
This article reviews epidemiological evidence of heritability and putative mechanisms in diverticular disease, with greatest attention to 3 recent studies of genetic associations with diverticular disease based on genome-wide or whole-genome sequencing studies in large patient cohorts. We provide an analysis of the biological plausibility of the significant associations with gene variants reported and highlight the relevance of ANO1, CPI-17 (aka PPP1R14A), COLQ6, COL6A1, CALCB or CALCA, COL6A1, ARHGAP15, and S100A10 to colonic neuromuscular function and tissue properties that may result in altered compliance and predispose to the development of diverticular disease. Such studies also identify candidate genes for future studies.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Robert S Sandler
- Center for Gastrointestinal Biology and Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne F Peery
- Center for Gastrointestinal Biology and Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Abstract
PURPOSE OF REVIEW While few diseases are limited solely to the elderly, diverticular disease is clearly more prevalent with increasing age and therefore the aim of this review is to focus on the clinical implications of diverticular disease in the elderly. RECENT FINDINGS Diverticulitis in the elderly is best managed with an individualized treatment approach including considerations for selective antibiotic usage even in uncomplicated disease. Furthermore, due to the increased prevalence of ischemic colitis in the elderly and the similarities in presentation with diverticular hemorrhage, there needs to be a high index of suspicion and appropriate evaluation for ischemic colitis in patients with hematochezia, particularly if they have abdominal pain. The elderly are a vulnerable population where the index of suspicion for complications of diverticular disease should be high.
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Affiliation(s)
- Mona Rezapour
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Neil Stollman
- Alta Bates Summit Medical Center, East Bay Center for Digestive Health, 300 Frank H Ogawa Plaza, Suite 450, Oakland, CA, 94612, USA.
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82
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Broad JB, Wu Z, Ng J, Arroll B, Connolly MJ, Jaung R, Oliver F, Bissett IP. Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care? PLoS One 2019; 14:e0219818. [PMID: 31314796 PMCID: PMC6636816 DOI: 10.1371/journal.pone.0219818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed. AIM To estimate how often DDI is managed in primary care, using antibiotics dispensing data. DESIGN AND SETTING Hospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics. METHOD Patients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use. RESULTS From almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation. CONCLUSION DDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.
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Affiliation(s)
- Joanna B. Broad
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Zhenqiang Wu
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Jerome Ng
- Institute for Innovation and Improvement, Waitematā District Health Board, Auckland, New Zealand
| | - Bruce Arroll
- Department of General Practice and Primary Healthcare, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Martin J. Connolly
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
- Waitematā District Health Board, Auckland, New Zealand
| | - Rebekah Jaung
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Frances Oliver
- Department of Geriatric Medicine, University of Auckland, Auckland, New Zealand
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
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Mali J, Mentula P, Leppäniemi A, Sallinen V. Determinants of treatment and outcomes of diverticular abscesses. World J Emerg Surg 2019; 14:31. [PMID: 31320921 PMCID: PMC6615185 DOI: 10.1186/s13017-019-0250-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/11/2019] [Indexed: 12/16/2022] Open
Abstract
Background Diverticular abscess diameter of 3-6 cm is generally accepted as a cutoff determining whether percutaneous drainage is recommended in addition to antibiotics, but this is not based on high-quality evidence. The aim of this study was to analyze the treatment choices and outcomes of patients with diverticular abscesses. Methods This was a retrospective cohort study conducted in an academic teaching hospital functioning as a secondary and tertiary referral center. Altogether, 241 patients with computer tomography-verified acute left-sided colonic diverticulitis with intra-abdominal abscess were collected from a database containing all patients treated for colonic diverticulitis in our institution during 2006-2013. The main measured outcomes were need of emergency surgery and 30-day mortality, and these were compared between antibiotics only and percutaneous drainage groups. Treatment choices, including surgery, were also analyzed for all patients. Results Abscesses under 40 mm were mostly treated with antibiotics alone with a high success rate (93 out of 107, 87%). In abscesses over 40 mm, the use of emergency surgery increased and the use of antibiotics alone decreased with increasing abscess size, but the proportion of successful drainage remained at 13-18% regardless of the abscess size. There were no differences in failure rate, 30-day mortality, the need of emergency surgery, permanent stoma, recurrence, or length of stay in patients treated with percutaneous drainage vs. antibiotics alone, even when groups were adjusted for potential confounders. Conclusions Percutaneous drainage as a treatment for large abscess does not seem to be superior to the treatment with only antibiotics.
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Affiliation(s)
- Juha Mali
- 1Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Panu Mentula
- 1Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Ari Leppäniemi
- 1Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland
| | - Ville Sallinen
- 1Department of Abdominal Surgery, University of Helsinki and HUS Helsinki University Hospital, Haartmaninkatu 4, 00029 HUS, Helsinki, Finland.,2Department of Transplantation and Liver Surgery, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
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Cremon C, Carabotti M, Cuomo R, Pace F, Andreozzi P, Barbaro MR, Annibale B, Barbara G. Italian nationwide survey of pharmacologic treatments in diverticular disease: Results from the REMAD registry. United European Gastroenterol J 2019; 7:815-824. [PMID: 31316786 PMCID: PMC6620876 DOI: 10.1177/2050640619845990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although diverticular disease is a common condition, its effective treatment is challenging in clinical practice. OBJECTIVE The objective of this article is to assess pharmacological management in different clinical settings of diverticular disease and factors associated with treatment using the Italian registry Registro Malattia Diverticolare (REMAD). METHODS At study enrolment, patients were categorised into subgroups: diverticulosis, symptomatic uncomplicated diverticular disease and previous diverticulitis. We registered demographic, clinical and lifestyle factors, quality of life and the use of treatments for diverticular disease in the last year. Logistic regression analysis assessed the association between clinical factors and treatment consumption. RESULTS A total of 500 of the 1206 individuals included had had at least one treatment for diverticular disease in the last year: 23.6% (166/702) of patients with diverticulosis, 55.9% (165/295) of patients with symptomatic diverticular disease, and 80.9% (169/209) of patients with previous diverticulitis (p < 0.001). In multivariate analysis, the following factors were significantly associated with treatment use: female gender, family history of colonic diverticula, organic digestive comorbidity and impaired physical quality of life components. CONCLUSION Individuals with diverticular disease take medications based on the different clinical settings of disease. We identified different features associated with treatment use in the distinct clinical entities of diverticular disease.ClinicalTrial.gov Identifier: NCT03325829.
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Affiliation(s)
- Cesare Cremon
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Rosario Cuomo
- Sant’Anna and San Sebastiano Hospital, Gastroenterology and Digestive Endoscopy Unit, Caserta, Italy
| | - Fabio Pace
- Unit of Gastroenterology, “Bolognini” Hospital, Bergamo, Italy
| | - Paolo Andreozzi
- Sant’Anna and San Sebastiano Hospital, Gastroenterology and Digestive Endoscopy Unit, Caserta, Italy
| | - Maria Raffaella Barbaro
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
- Giovanni Barbara, St Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, Building #5, Via Massarenti, 9, I-40138 Bologna, Italy.
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Broad JB, Wu Z, Clark TG, Musson D, Jaung R, Arroll B, Bissett IP, Connolly MJ. Diverticulosis and nine connective tissue disorders: epidemiological support for an association. Connect Tissue Res 2019; 60:389-398. [PMID: 30719942 DOI: 10.1080/03008207.2019.1570169] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Purpose: An underlying connective tissue disorder (CTD) may predispose to formation of intestinal diverticula. We assess the association of diverticulosis with nine selected CTDs, to inform the pathophysiology of diverticula. Methods: A population-based period-prevalence study. Individuals (3.5 million New Zealand residents born 1901-1986) with a health system record 1999-2016 were grouped into those with a hospital diagnosis of diverticulosis or diverticulitis (ICD-10-AM K57), and those without. Also recorded were any hospital diagnoses of nine selected CTDs. The association of exposure to diverticulosis and each CTD was assessed using logistic regressions adjusted for age, gender, ethnicity and region. Results: In all, 85,958 (2.4%) people had a hospital diagnosis of diverticulosis. Hospitalisation with diverticulosis was highly significantly associated with rectal prolapse (adjusted odds ratio [OR] = 3.9), polycystic kidney disease (OR = 3.8), heritable syndromes (Marfan or Ehlers-Danlos) (OR = 2.4), female genital prolapse (OR = 2.3), non-aortic aneurysm (OR = 2.3), aortic aneurysm (OR = 2.2), inguinal hernia (OR = 1.9) and dislocations of shoulder and other joints (OR = 1.7), but not subarachnoid haemorrhage (OR = 1.0). Conclusion: People with diverticulosis are more likely to have colonic extracellular matrix (ECM)/connective tissue alterations in anatomical areas other than the bowel, suggesting linked ECM/connective tissue pathology. Although biases may exist, the results indicate large-scale integrated studies are needed to investigate underlying genetic pathophysiology of colonic diverticula, together with fundamental biological studies to investigate cellular phenotypes and ECM changes.
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Affiliation(s)
- Joanna B Broad
- a Freemasons' Department of Geriatric Medicine , University of Auckland , Auckland , New Zealand
| | - Zhenqiang Wu
- a Freemasons' Department of Geriatric Medicine , University of Auckland , Auckland , New Zealand
| | - Taane G Clark
- b Faculty of Epidemiology and Population Health & Faculty of Infectious and Tropical Diseases , London School of Hygiene and Tropical Medicine , London , UK
| | - David Musson
- c Department of Medicine , University of Auckland , Auckland , New Zealand
| | - Rebekah Jaung
- d Department of Surgery , University of Auckland , Auckland , New Zealand
| | - Bruce Arroll
- e Primary Care, Department of General Practice and Primary Healthcare , University of Auckland , Auckland , New Zealand
| | - Ian P Bissett
- d Department of Surgery , University of Auckland , Auckland , New Zealand
| | - Martin J Connolly
- f Waitemata District Health Board , University of Auckland, and Geriatrician , Auckland , New Zealand
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86
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Yeo LX, Tseng TH, Chen WL, Kao TW, Wu LW, Fang WH, Chang YW, Peng TC. Hypertension control and risk of colonic diverticulosis. Therap Adv Gastroenterol 2019; 12:1756284819855734. [PMID: 31244897 PMCID: PMC6580716 DOI: 10.1177/1756284819855734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/15/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The prevalence of diverticulosis has increased in our aging population, but the risk factors for diverticulosis are not fully understood. The role of hypertension in the risk of diverticulosis remains uncertain. This study investigated whether hypertension is associated with asymptomatic colorectal diverticulosis. METHODS This study enrolled asymptomatic patients who received a colonoscopy as part of a health check. Hypertension was defined by actual measured blood pressure. Logistic regression models were used to examine the relationship between hypertension and diverticulosis. In addition, we established three logistic regression models for covariate adjustment, and further stratified patients with hypertension into three subgroups based on their type of hypertension. RESULTS The study group consisted of 2748 participants, including 141 participants with diverticulosis and 2607 participants without diverticulosis. After adjustments for potential covariates, the odds ratio (OR) for having diverticulosis was 1.83 (95% confidence interval, 1.21-2.75, p = 0.004) in the hypertension group compared with the group without hypertension. In subgroup analyses, hypertension without antihypertensive medication use, and hypertension despite the use of antihypertensive medication were also significantly associated with the occurrence of asymptomatic diverticulosis (OR = 1.73, p = 0.028; OR = 2.07, p = 0.013, respectively). Current normal blood pressure under antihypertensive drug therapy was not associated with diverticulosis (OR = 1.74, p = 0.092). CONCLUSIONS Our findings suggest a positive association between hypertension and diverticulosis. Participants with poorly controlled blood pressure were found to have a higher risk of asymptomatic diverticulosis. Our study presents epidemiologic evidence for future prevention strategies against diverticulosis.
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Affiliation(s)
- Li-Xian Yeo
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei
| | - Tzu-Hsiang Tseng
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei
| | - Wei-Liang Chen
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Division of Geriatric Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Graduate Institute of Medical Sciences, National
Defense Medical Center, Taipei
| | - Tung-Wei Kao
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Division of Geriatric Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Graduate Institute of Clinical Medicine, College
of Medicine, National Taiwan University, Taipei
| | - Li-Wei Wu
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Division of Geriatric Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Graduate Institute of Medical Sciences,
National Defense Medical Center, Taipei
| | - Wen-Hui Fang
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei
| | - Yaw-Wen Chang
- Division of Family Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei,Division of Geriatric Medicine, Department of
Family and Community Medicine, Tri-Service General Hospital; and School of
Medicine, National Defense Medical Center, Taipei
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87
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Alaburda P, Lukosiene JI, Pauza AG, Rysevaite-Kyguoliene K, Kupcinskas J, Saladzinskas Z, Tamelis A, Pauziene N. Ultrastructural changes of the human enteric nervous system and interstitial cells of Cajal in diverticular disease. Histol Histopathol 2019; 35:147-157. [PMID: 31187871 DOI: 10.14670/hh-18-136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In spite of numerous advances in understanding diverticular disease, its pathogenesis remains one of the main problems to be solved. We aimed to investigate the ultrastructural changes of the enteric nervous system in unaffected individuals, in asymptomatic patients with diverticulosis and in patients with diverticular disease. METHODS Transmission electron microscopy was used to analyse samples of the myenteric, outer submucosal and inner submucosal plexuses from patients without diverticula (n=9), asymptomatic patients with diverticulosis (n=7) and in patients with complicated diverticular disease (n=9). We described the structure of ganglia, interstitial cells of Cajal and enteric nerves, as well as their relationship with each other. The distribution and size of nerve processes were analysed quantitatively. RESULTS In complicated diverticular disease, neurons exhibited larger lipofuscin-like inclusions, their membranous organelles had larger cisterns and the nucleus showed deeper indentations. Nerve remodeling occurred in every plexus, characterised by an increased percentage of swollen and fine neurites. Interstitial cells of Cajal had looser contacts with the surrounding cells and showed cytoplasmic depletion and proliferation of the rough endoplasmic reticulum. In asymptomatic patients with diverticulosis, alterations of enteric nerves and ICC were less pronounced. CONCLUSIONS In conclusion, the present findings suggest that most ultrastructural changes of the enteric nervous system occur in complicated diverticular disease. The changes are compatible with damage to the enteric nervous system and reactive remodeling of enteric ganglia, nerves and interstitial cells of Cajal. Disrupted architecture of enteric plexuses might explain clinical and pathophysiological changes associated with diverticular disease.
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Affiliation(s)
- Paulius Alaburda
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jaune I Lukosiene
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audrys G Pauza
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Present address: Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol, United Kingdom
| | | | - Juozas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Algimantas Tamelis
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Neringa Pauziene
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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88
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Schieffer KM, Kline BP, Harris LR, Deiling S, Koltun WA, Yochum GS. A differential host response to viral infection defines a subset of earlier-onset diverticulitis patients. JOURNAL OF GASTROINTESTINAL AND LIVER DISEASES : JGLD 2019; 27:249-255. [PMID: 30240468 DOI: 10.15403/jgld.2014.1121.273.sch] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Diverticulitis is the chronic inflammation of diverticula. Whether the pathophysiology of earlier-onset patients differs from later-onset patients is unknown. We profiled the colonic transcriptomes of these two patient populations to gain insight into the molecular underpinnings of diverticulitis. METHODS We conducted deep RNA sequencing (RNA-seq) on colonic segments surgically resected from earlier-onset (<42 years old, n=13) and later-onset (>65 years old, n=13) diverticulitis patients. We used bioinformatic approaches to cluster the patients based on the relationship of differentially expressed genes and to inform on the molecular pathways that segregated the clusters. RESULTS Principal component analysis identified three patient clusters; diverticulitis later-onset (DVT-LO), diverticulitis mixed-onset (DVT-MO), and diverticulitis earlier-onset (DVT-EO). The patients comprising DVT-EO, which was the majority of earlier-onset patients, displayed increased expression of anti-viral response genes. This finding was confirmed using an independent weighted co-expression network analysis (WGCNA) of differentially expressed genes. CONCLUSIONS We found that the majority of patients with earlier-onset disease contained elevated expression of host genes involved in the anti-viral response. Thus, susceptibility to a viral pathogen may offer one explanation why some individuals develop diverticulitis at an earlier age.
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Affiliation(s)
- Kathleen M Schieffer
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, USA
| | - Bryan P Kline
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, USA
| | - Leonard R Harris
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, USA
| | - Sue Deiling
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, USA
| | - Walter A Koltun
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, USA
| | - Gregory S Yochum
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey;Department of Biochemistry & Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA,
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89
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Petruzziello C, Migneco A, Cardone S, Covino M, Saviano A, Franceschi F, Ojetti V. Supplementation with Lactobacillus reuteri ATCC PTA 4659 in patients affected by acute uncomplicated diverticulitis: a randomized double-blind placebo controlled trial. Int J Colorectal Dis 2019; 34:1087-1094. [PMID: 31011868 DOI: 10.1007/s00384-019-03295-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Acute uncomplicated diverticulitis (AUD) is an inflammation of the colon diverticulum. We tested the efficacy of Lactobacillus reuteri 4659 (L. reuteri) in treating AUD. Primary outcome was reduced abdominal pain and inflammatory markers (C-RP). Secondary outcome was reduced hours of hospitalization. PATIENTS AND METHODS A double-blind, placebo RCT was conducted with 88 (34M/54F mean age 61.9 ± 13.9) patients with a diagnosis of AUD. Group A (44 patients, 26F): ciprofloxacin 400 mg/bid and metronidazole 500 mg/tid for 1 week, plus L. reuteri/bid for 10 days. Group B (44 patients, 28F): same antibiotic therapy for 1 week, plus placebo/bid for 10 days. All patients completed a daily visual analog scale (VAS) for abdominal pain. RESULTS Between days 1 and 3, the group A pain decreased by 4.5 points; group B decreased by 2.36 points (p < 0.0001). Between days 1 and 5, the group A decreased by 6.6 points; group B by 4.4 points (p < 0.0001). Between days 1 and 7, the group A decreased by 7.6 points; group B decreased by 5.6 points (p < 0.0001). Between days 1 and 10, the group A decreased by 8.1 points; group B decreased by 6.7 points (p < 0.0001). For C-RP value, the mean decrease between admission and after 72 h was 45.3 mg/L for group A and 27.49 mg/L for group B (p < 0.0001). CONCLUSIONS Our RCT showed that supplementation of the standard AUD therapy with L. reuteri strain 4659 significantly reduced abdominal pain and inflammatory markers compared with the placebo group. It also resulted in a shorter period of hospitalization, and thus has economic benefits. TRIAL REGISTRATION TRIALGOV: NCT03656328.
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Affiliation(s)
| | - Alessio Migneco
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Cardone
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marcello Covino
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Francesco Franceschi
- Università Cattolica del Sacro Cuore, Rome, Italy
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Veronica Ojetti
- Università Cattolica del Sacro Cuore, Rome, Italy.
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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90
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Renzi C, Lyratzopoulos G, Hamilton W, Maringe C, Rachet B. Contrasting effects of comorbidities on emergency colon cancer diagnosis: a longitudinal data-linkage study in England. BMC Health Serv Res 2019; 19:311. [PMID: 31092238 PMCID: PMC6521448 DOI: 10.1186/s12913-019-4075-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 04/08/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND One in three colon cancers are diagnosed as an emergency, which is associated with worse cancer outcomes. Chronic conditions (comorbidities) affect large proportions of adults and they might influence the risk of emergency presentations (EP). METHODS We aimed to evaluate the effect of specific pre-existing comorbidities on the risk of colon cancer being diagnosed following an EP rather than through non-emergency routes. The cohort study included 5745 colon cancer patients diagnosed in England 2005-2010, with individually-linked cancer registry, primary and secondary care data. In addition to multivariable analyses we also used potential-outcomes methods. RESULTS Colon cancer patients with comorbidities consulted their GP more frequently with cancer symptoms during the pre-diagnostic year, compared with non-comorbid cancer patients. EP occurred more frequently in patients with 'serious' or complex comorbidities (diabetes, cardiac and respiratory diseases) diagnosed/treated in hospital during the years pre-cancer diagnosis (43% EP in comorbid versus 27% in non-comorbid individuals; multivariable analysis Odds Ratio (OR), controlling for socio-demographic factors and symptoms: men OR = 2.40; 95% CI 2.0-2.9 and women OR = 1.98; 95% CI 1.6-2.4. Among women younger than 60, gynaecological (OR = 3.41; 95% CI 1.2-9.9) or recent onset gastro-intestinal conditions (OR = 2.84; 95% CI 1.1-7.7) increased the risk of EP. In contrast, primary care visits for hypertension monitoring decreased EPs for both genders. CONCLUSIONS Patients with comorbidities have a greater risk of being diagnosed with cancer as an emergency, although they consult more frequently with cancer symptoms during the year pre-cancer diagnosis. This suggests that comorbidities may interfere with diagnostic reasoning or investigations due to 'competing demands' or because they provide 'alternative explanations'. In contrast, the management of chronic risk factors such as hypertension may offer opportunities for earlier diagnosis. Interventions are needed to support the diagnostic process in comorbid patients. Appropriate guidelines and diagnostic services to support the evaluation of new or changing symptoms in comorbid patients may be useful.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Georgios Lyratzopoulos
- Department of Behavioural Science and Health, ECHO (Epidemiology of Cancer Healthcare & Outcomes) Research Group, University College London, 1-19 Torrington Place, London, WC1E 6BT UK
| | - Willie Hamilton
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Camille Maringe
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Bernard Rachet
- Department of Non-communicable Disease Epidemiology, Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
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91
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Choe EK, Lee JE, Chung SJ, Yang SY, Kim YS, Shin ES, Choi SH, Bae JH. Genome-wide association study of right-sided colonic diverticulosis in a Korean population. Sci Rep 2019; 9:7360. [PMID: 31089239 PMCID: PMC6517584 DOI: 10.1038/s41598-019-43692-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 04/27/2019] [Indexed: 02/06/2023] Open
Abstract
Diverticulosis results from complex interactions related to aging, environmental factors and genetic predisposition. Despite epidemiologic evidence of genetic risk factors, there has been no attempt to identify genes that confer susceptibility to colonic diverticulosis. We performed the first genome-wide association study (GWAS) on susceptibility to diverticulosis in a Korean population. A GWAS was carried out in 7,948 healthy individuals: 893 patients and 1,075 controls comprised the test set, and 346 patients and 305 controls comprised the replication set. Diverticulosis was diagnosed by colonoscopy during comprehensive medical check-ups, and single-nucleotide polymorphisms (SNPs) related to diverticulosis were detected with the Affymetrix Axiom KORV1.1-96 Array. In all, 9 SNPs were identified in three SNP aggregates in the test set (P < 10−3, within 200 kb) after adjusting for sex. All the SNPs were replicated in the replication set (P < 0.05). Three SNPs were near the WNT4 gene, four near the RHOU gene, and two in the OAS1/3 genes. The top SNP associated with right-sided colonic diverticulosis was rs22538787, located near the WNT4 gene [combined set, P-value = 3.128 × 10−6, odds ratio = 1.415 (95% confidence interval: 1.223–1.637)]. These 9 novel SNP alleles associated with the WNT4, RHOU, and OAS1/3 genes are possibly involved in the underlying genetic susceptibility to right-sided diverticulosis. Our results provide basic knowledge about the development of diverticulosis in an Asian population.
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Affiliation(s)
- Eun Kyung Choe
- Department of Surgery, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | | | - Su Jin Chung
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | - Sun Young Yang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | - Young Sun Kim
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | | | - Seung Ho Choi
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | - Jung Ho Bae
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea.
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92
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Sköldberg F, Granlund J, Discacciati A, Hjern F, Schmidt PT, Olén O. Incidence and lifetime risk of hospitalization and surgery for diverticular disease. Br J Surg 2019; 106:930-939. [PMID: 31012495 DOI: 10.1002/bjs.11143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/06/2018] [Accepted: 01/24/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Studies on incidence rates of first-time colonic diverticular disease are few, and population-based estimates of lifetime risk are lacking. In this observational study, the incidence, admission rates and lifetime risks of hospitalization and surgery for diverticular disease were investigated. METHODS Considering the entire Swedish population as an open cohort, incidence and admission rates, and lifetime risk estimates (considering death as a competing risk) of hospitalization and surgery for diverticular disease were calculated using data from cross-linked national registers and population statistics from 1987 to 2010. RESULTS In total, there were 144 107 hospital admissions for diverticular disease in 95 049 individual patients. Of these, 17 599 were admissions with bowel resection or stoma formation in 16 824 patients. The total number of person-years in the population during the study period was 213 949 897. Age-standardized incidence rates were 47·4 (95 per cent c.i. 47·1 to 47·7) for first-time hospitalization with diverticular disease and 8·4 (8·2 to 8·5) per 100 000 person-years for diverticular disease surgery. The corresponding admission rates (including readmissions) were 70·8 (70·4 to 71·2) and 8·7 (8·6 to 8·9) per 100 000 person-years. Following an increase in 1990-1994, rates stabilized. Based on incidence and mortality rates from 2000 to 2010, the estimated remaining lifetime risk of hospitalization from 30 years of age was 3·1 per cent in men and 5·0 per cent in women. The corresponding risk of surgery was 0·5 per cent in men and 0·8 per cent in women. CONCLUSION Diverticular disease is a common reason for hospital admission, particularly in women, but rates are stable and the lifetime risk of surgery is low.
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Affiliation(s)
- F Sköldberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - J Granlund
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - A Discacciati
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - F Hjern
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - P T Schmidt
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - O Olén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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93
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Abstract
Diverticulitis was thought to be a simple complication of an even simpler disease (diverticulosis), but may in fact result from an entirely new set of complex pathologies. Considering diverticulitis is increasing in annual incidence and becoming more prevalent in younger populations, the implications of appropriate management become more vital than ever. This article reviews old and new understandings of diverticulitis and current recommendations for prevention and clinical management.
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94
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Curciarello R, Canziani KE, Docena GH, Muglia CI. Contribution of Non-immune Cells to Activation and Modulation of the Intestinal Inflammation. Front Immunol 2019; 10:647. [PMID: 31024529 PMCID: PMC6467945 DOI: 10.3389/fimmu.2019.00647] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/11/2019] [Indexed: 12/27/2022] Open
Abstract
The mucosal immune system constitutes a physical and dynamic barrier against foreign antigens and pathogens and exerts control mechanisms to maintain intestinal tolerance to the microbiota and food antigens. Chronic alterations of the intestinal homeostasis predispose to inflammatory diseases of the gastrointestinal tract, such as Inflammatory Bowel Diseases (IBD). There is growing evidence that the frequency and severity of these diseases are increasing worldwide, which may be probably due to changes in environmental factors. Several stromal and immune cells are involved in this delicate equilibrium that dictates homeostasis. In this review we aimed to summarize the role of epithelial cells and fibroblasts in the induction of mucosal inflammation in the context of IBD. It has been extensively described that environmental factors are key players in this process, and the microbiome of the gastrointestinal tract is currently being intensively investigated due to its profound impact the immune response. Recent findings have demonstrated the interplay between dietary and environmental components, the gut microbiome, and immune cells. "Western" dietary patterns, such as high caloric diets, and pollution can induce alterations in the gut microbiome that in turn affect the intestinal and systemic homeostasis. Here we summarize current knowledge on the influence of dietary components and air particulate matters on gut microbiome composition, and the impact on stromal and immune cells, with a particular focus on promoting local inflammation.
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Affiliation(s)
- Renata Curciarello
- Instituto de Estudios Inmunológicos y Fisiopatológicos, CONICET, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina.,Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Karina Eva Canziani
- Instituto de Estudios Inmunológicos y Fisiopatológicos, CONICET, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina.,Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Guillermo Horacio Docena
- Instituto de Estudios Inmunológicos y Fisiopatológicos, CONICET, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina.,Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Cecilia Isabel Muglia
- Instituto de Estudios Inmunológicos y Fisiopatológicos, CONICET, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina.,Departamento de Ciencias Biológicas, Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
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95
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche J, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres J, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche JM, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres JI, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:220-240. [PMID: 31014749 DOI: 10.1016/j.rgmx.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
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Affiliation(s)
| | - N Salgado-Nesme
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - R Carmona-Sánchez
- Unidad de Médica Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México.
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - J Aguilera-Carrera
- Hospital de Especialidades Médicas de la Salud, San Luis Potosí, S.L.P., México
| | | | - C Arnaud-Carreño
- Departamento de Cirugía, Hospital General «Dr. Aurelio Valdivieso», Secretaría de Salud del Estado de Oaxaca, Oaxaca, Oaxaca, México
| | | | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | | | - F Esquivel-Ayanegui
- Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - F Roesch-Dietlen
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A López-Colombo
- Direccción de Educación e Investigación, UMAE Hospital de Especialidades CMN Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - J I Muñoz-Torres
- Facultad de Medicina, Universidad Autónoma de Baja California, Mexicali, BC, México
| | | | | | - J Suazo-Barahona
- Centro de Enfermedades Digestivas, Hospital del Valle, San Pedro Sula, Honduras
| | - M Stoopen-Rometti
- Departamento de Radiología e Imagen, CT Scanner Lomas Altas, Ciudad de México, México
| | - E Torres-Flores
- Hospital General de Zona # 1, Instituto Mexicano del Seguro Social, Pachuca, Hidalgo, México
| | | | - O Vergara-Fernández
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
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97
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Tague LK, Adams W, Young KA, Kwon OJ, Mahoney E, Lowery EM. Association between diverticular disease requiring surgical intervention and mortality in the postlung transplant population - a retrospective cohort study. Transpl Int 2019; 32:739-750. [PMID: 30793380 DOI: 10.1111/tri.13417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/05/2018] [Accepted: 02/18/2019] [Indexed: 12/25/2022]
Abstract
Lung Transplant recipients are at increased risk of complicated diverticular disease. We aim to assess the rate of diverticular surgery in a postlung transplantation population and identify risk factors for surgery. We performed a retrospective cohort study of lung transplant recipients from 2007 to 2011. Demographic variables were evaluated with the Mann-Whitney U and chi-squared tests. Cox regression was performed to evaluate 1- and 2-year landmark survival, assess predictor variables of diverticular surgery and evaluate impact of surgery on CLAD development. Of 17 of 158 patients (10.7%) underwent diverticular-related surgery. Surgical patients had significantly worse survival than nonsurgical patients at 1 year [aHR 2.93 (1.05-8.21), P = 0.041] and 2 year [aHR 4.17 (1.26-13.84), P = 0.020] landmark analyses. Transplant indication of alpha-1 antitrypsin disease and cystic fibrosis were significantly associated with the need for diverticular surgery. Emergent surgery was associated with poorer survival [aHR 5.12(1.00-26.27), P = 0.050]. Lung transplant patients requiring surgery for complicated diverticular disease have significantly poorer survival than those who do not require surgery. Surgery was more common in patients transplanted for A1AT and CF. Optimal assessment and risk stratification of diverticular disease is necessary to prevent excessive morbidity and mortality following transplantation.
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Affiliation(s)
- Laneshia K Tague
- Department of Medicine, Division of Pulmonary and Critical Care, Washington University in St. Louis, St. Louis, MO, USA
| | - William Adams
- Department of Public Health, Loyola University Chicago Health Science Division, Maywood, IL, USA
| | - Katherine A Young
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago Health Science Division, Maywood, IL, USA
| | - Oh Jin Kwon
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Erin Mahoney
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago Health Science Division, Maywood, IL, USA
| | - Erin M Lowery
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Loyola University Chicago Health Science Division, Maywood, IL, USA.,Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
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98
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Abstract
Acute diverticulitis is a major health-care concern. The optimal management of this common condition has been critically examined in recent years leading to a number of paradigm changes. In many areas, the debate continues. Acute uncomplicated diverticulitis may be safely managed without antibiotics. A number of randomized controlled trials have examined the role of laparoscopic lavage vs resection for purulent peritonitis. In cases where resection is indicated the traditional Hartmann's procedure is being trialled against resection with primary anastomosis. In the follow up of an acute uncomplicated episode, the value of colonoscopy is being questioned but remains in current guidelines. In the elective setting, more recent studies have led to a trend away from resection to prevent complications but towards resection to improve quality of life. This article presents an overview of the current guidance, areas of controversy and the associated evidence base.
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Affiliation(s)
- Alex J Sagar
- Core Surgical Trainee 2, Surgical Emergency Unit, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 0LQ
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99
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Renzi C, Lyratzopoulos G, Hamilton W, Rachet B. Opportunities for reducing emergency diagnoses of colon cancer in women and men: A data-linkage study on pre-diagnostic symptomatic presentations and benign diagnoses. Eur J Cancer Care (Engl) 2019; 28:e13000. [PMID: 30734381 PMCID: PMC6492167 DOI: 10.1111/ecc.13000] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 09/17/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To identify opportunities for reducing emergency colon cancer diagnoses, we evaluated symptoms and benign diagnoses recorded before emergency presentations (EP). METHODS Cohort of 5,745 colon cancers diagnosed in England 2005-2010, with individually linked cancer registry and primary care data for the 5-year pre-diagnostic period. RESULTS Colon cancer was diagnosed following EP in 34% of women and 30% of men. Among emergency presenters, 20% of women and 15% of men (p = 0.002) had alarm symptoms (anaemia/rectal bleeding/change in bowel habit) 2-12 months pre-diagnosis. Women with abdominal symptoms (change in bowel habit/constipation/diarrhoea) received a benign diagnosis (irritable bowel syndrome (IBS)/diverticular disease) more frequently than men in the year before EP: 12% vs. 6% among women and men (p = 0.002). EP was more likely in women (OR = 1.20; 95% CI 1.1-1.4), independently of socio-demographic factors and symptoms. Benign diagnoses in the pre-diagnostic year (OR = 2.01; 95% CI 1.2-3.3) and anaemia 2-5 years pre-diagnosis (OR = 1.91; 95% CI 1.2-3.0) increased the risk of EP in women but not men. The risk was particularly high for women aged 40-59 with a recent benign diagnosis vs. none (OR = 4.41; 95% CI 1.3-14.9). CONCLUSIONS Women have an increased risk of EP, in part due to less specific symptoms and their more frequent attribution to benign diagnoses. For women aged 40-59 years with new-onset IBS/diverticular disease innovative diagnostic strategies are needed, which might include use of quantitative faecal haemoglobin testing (FIT) or other colorectal cancer investigations. One-fifth of women had alarm symptoms before EP, offering opportunities for earlier diagnosis.
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Affiliation(s)
- Cristina Renzi
- Department of Behavioural Science and HealthUniversity College LondonLondonUK
- Cancer Survival Group, Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Bernard Rachet
- Cancer Survival Group, Department of Non‐communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
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Abstract
INTRODUCTION Low-grade chronic inflammation has been suggested to play a role in uncomplicated asymptomatic and symptomatic diverticular disease. However, population-based studies are lacking. We investigated whether community participants with diverticulosis, with or without symptoms, would have colonic inflammation on histology and serology. METHODS In a nested case-control study of 254 participants from the population-based colonoscopy (PopCol) study, colonic histological inflammatory markers and serological C-reactive protein levels were analyzed in cases with diverticulosis and controls without diverticulosis. Statistical methods included logistic and linear regression models. RESULTS Background variables including age (P = 0.92), sex (P = 1.00), body mass index (P = 0.71), smoking (P = 0.34), and recent antibiotic exposure (P = 0.68) were similar between cases and controls. Cases reported more abdominal pain (P = 0.04) and diarrhea symptoms (mushy and high-frequency stools) than controls (P = 0.01 and P = 0.03, respectively) but were otherwise similar. The median C-reactive protein levels were similar among cases and controls [1.05 mg/L (0.3, 2.7) vs 0.8 (0.4, 2.2), P = 0.53]. There was a trend of increased numbers of cecal lymphoid aggregates in cases vs controls (P = 0.07), but no other associations between diverticulosis and inflammatory markers on histology were found. Similarly, no serological or mucosal inflammation was associated with symptomatic cases of diarrhea or abdominal pain vs asymptomatic controls. CONCLUSIONS In a general community sample, both asymptomatic and symptomatic diverticulosis are not associated with colonic mucosal inflammation. Other explanations for symptomatic colonic diverticulosis need to be identified.
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