Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights

Association of Diverticulitis with Prolonged Spondyloarthritis: An Analysis of the ASAS-COMOSPA International Cohort

This study examined the relationship between spondyloarthritis (SpA) duration and gastrointestinal comorbidities other than inflammatory bowel disease (IBD). We evaluated the association between SpA duration and upper gastrointestinal ulcers, hepatitis B (HBV), hepatitis C (HCV) and diverticulitis using data from a large international cross-sectional study. Binary regression models were created, adjusted for age, sex, body mass index (BMI), smoking, alcohol, non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying anti-rheumatic drugs (DMARDs), biologics, steroids, IBD history and country. Subgroup analysis was performed by disease phenotype. The data of 3923 participants were analysed. The prevalence of gastrointestinal conditions were 10.7% upper gastrointestinal ulcers; 4.7% viral hepatitis and 1.5% diverticulitis. While SpA duration was not associated with upper gastrointestinal ulcers, HBV or HCV, longer SpA duration was significantly associated with diverticulitis (odds ratios (OR) = 1.18, 95% confidence interval (CI): 1.03⁻1.34), reflecting an 18% increase for every five years of SpA duration. Other significant associations with diverticulitis were age and high alcohol intake but not medication history. In subgroup analyses, the association was strongest with those with axial SpA. The reasons for this association of increased diverticulitis with disease duration in SpA, especially those with axial disease, are unclear but may reflect shared underlying gut inflammation. Diverticulitis should be considered, in addition to IBD, when SpA patients present with lower gastrointestinal symptoms.

Menopausal Hormone Therapy and Risk of Diverticulitis

INTRODUCTION

Diverticulitis is a significant cause of morbidity among older women, and little attention has been paid to understanding its etiology. We have shown that menopausal hormone therapy (MHT) is associated with the risk of inflammatory bowel disease. In this study, we prospectively examined the association between MHT and the risk of incident diverticulitis.

METHODS

We studied 65,367 postmenopausal women enrolled in the Nurses' Health Study who provided detailed information on hormone use and other medical and lifestyle factors biennially, and on diet every 4 years. Between 2008 and 2014, participants reported any episodes of diverticulitis that required antibiotics and the date of occurrence. We used Cox proportional hazards regression models to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Over 24 years encompassing 1,297,165 person-years of follow-up, we documented 5,425 incident cases of diverticulitis. We observed an increased risk of diverticulitis among both current (HR 1.28; 95% CI 1.18-1.39) and past (HR 1.35; 95% CI 1.25-1.45) MHT users compared to never users. The increased risk was observed among participants using estrogen only (HR 1.30; 95% CI 1.20-1.41) and those using combined estrogen and progesterone (HR 1.31; 95% CI 1.21-1.42) compared to nonusers. The risk did not increase with longer duration of use (P-trend = 0.76). The association between MHT and diverticulitis was not modified by age, body mass index, past oral contraceptive use, or fiber intake (all P-interaction >0.11).

CONCLUSIONS

Menopausal hormone therapy was associated with an increased risk of diverticulitis. Further studies are needed to understand the potential mechanisms that may underlie this association.

Irritable bowel syndrome and colonic diverticular disease: overlapping symptoms and overlapping therapeutic approaches

PURPOSE OF REVIEW

Irritable bowel syndrome (IBS) is a common symptomatic disorder in the Western world and colonic diverticula are also prevalent; however, relationships between IBS-type symptoms and diverticula have been a source of much debate. Our goal was to reassess these relationships in the light of new data.

RECENT FINDINGS

On removing from consideration clinical scenarios which are directly related to diverticula (i.e., diverticulitis, diverticular hemorrhage, and complications of diverticulitis, such as stricture and fistula), relationships between IBS and diverticula can be seen to revolve around a number of questions. First, are IBS and symptomatic uncomplicated diverticular disease (SUDD) the same condition? Or, in other words is SUDD no more than IBS in an individual who just happens to have diverticula? Although coincident IBS and diverticula inevitably do occur there is some evidence to indicate that SUDD may be somewhat distinctive with SUDD being characterized by more frequent and severe pain. Second, and analogous to interactions between IBS and inflammatory bowel disease or celiac disease, can an episode of acute diverticulitis lead to the de novo development of IBS? There is now epidemiological and pathophysiological evidence to support this occurrence.

SUMMARY

Although relationships between uncomplicated diverticular disease and IBS have been reexamined their status remains unclear. As yet, however, none of the newer concepts related to this relationship have led to new therapeutic approaches in IBS or diverticular disease.

Gastrointestinal Tract Disorders in Older Age

Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.

Development and usefulness of the new endoscopic classification: DICA

Colonic Diverticulosis is one of the most common anatomical findings during colonoscopy. This condition has 60% incidence in the population over 60 years old. About 20% of patients will develop Diverticular Disease, and 5% of them will evolve into Diverticulitis. Until the last years there weren't any approaches for the endoscopic classification of this pathology. In 2013, in Florence, the first endoscopic classification was developed: DICA (Diverticular Inflammation and Complication Assessment). The aim of this article is to focus on the process of the development and the validation of the classification by the pool of gastroenterology experts, and, as well, its usefulness during the clinical practice.

The Natural History of Colonic Diverticulosis: Much Ado about Nothing?

BACKGROUND

Colonic diverticulosis is the most common incidental lesion found on routine colonoscopy. However, its true natural history is unclear. The aim of this review is to examine the epidemiology of colonic diverticulosis and the incidence of complications, namely acute diverticulitis and diverticular hemorrhage.

SUMMARY

Many studies have evaluated the epidemiology and risk factors of diverticulosis. Despite the common nature of this entity, little is known about the risk of complications in asymptomatic individuals. It has been suggested that the lifetime risk of acute diverticulitis is 10-25% and that of diverticular hemorrhage is 3-5%. These risk estimates were based on older literature without accurate studies on true prevalence. Three recent retrospective observational cohort studies including subjects identified at colonoscopy have addressed this issue, providing information on the long-term risk of complications of colonic diverticulosis. Cumulative data from these studies support an incidence of acute diverticulitis of 1.5-6.0 per 1,000 patient-years and 0.46 per 1,000 patient-years for diverticular hemorrhage.

KEY MESSAGES

Diverticulosis is a very common condition in individuals > 50 years of age. Based on population-based colonoscopy studies, the natural history of colonic diverticulosis appears favorable with a far lower incidence of complications than previously thought.

Role of TNFSF15 in the intestinal inflammatory response

Gastrointestinal diseases, specifically Crohn’s disease, ulcerative colitis, diverticular disease, and primary biliary cirrhosis are all characterized by complicated inflammation of the digestive tract. Their pathology is multifactorial, and risk factors encompass both genetic and environmental factors. Recent advances in the genetic component of inflammatory bowel diseases (IBDs) have revealed that the tumor necrosis factor superfamily member 15 (TNFSF15) contains a number of risk alleles associated not only with IBD but also with other diseases such as diverticular disease and primary biliary cirrhosis. These risk alleles in TNFSF15 and the altered expression of its gene product can serve as the common ground between these disorders by explaining at least some of the underlying processes that lead to a dysregulated immune response and subsequent chronic inflammation. Here, we aim to outline how the TNFSF15 gene is involved in the proliferation and cell fate of different populations of T cells and subsequently in the control of both pro- and anti-inflammatory cytokines. Furthermore, we summarize what is currently known of TNFSF15 control region variants, how they are associated with each mentioned disease, and how these variants can explain the autoimmune pathology of said diseases through altered TNFSF15 expression.

Diverticular Disease: An Update on Pathogenesis and Management

Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review.

Ulcerative colitis and the aging-related development of colonic diverticula

PURPOSE

Aim of this observational case-control study was to assess the prevalence, features, and risk factors of colonic diverticula in patients with ulcerative colitis (UC).

METHODS

The data of 896 UC patients aged ≥ 30 years from Brescia IBD database were retrospectively analyzed. Individuals with colonic diverticula were identified and prevalence was compared with that of control patients undergoing screening colonoscopy after gender/age matching. A nested cohort study was then conducted among UC patients in order to define eventual association of diverticula with specific clinico-pathologic parameters.

RESULTS

Prevalence of subjects with diverticula was 11.4% among 465 UC patients aged 49 years and older, significantly lower than 35.1% prevalence in control patients of same age and gender (p < 0.001). Advancing age was a significant risk factor for diverticula development in both groups. Among UC patients, a short duration and a late onset of UC were both significantly associated to the presence of diverticula. Moreover, UC patients with diverticula had a significantly lower frequency of flares per year, even if maximal flare severity and frequency of hospital admission were similar to those of subjects without diverticula. UC patients with diverticula had a trend toward more frequent extension of UC to the left colon, possibly because of their older age. The majority of those patients had few sigmoid diverticula without symptoms.

CONCLUSIONS

Development of colonic diverticula is substantially reduced in patients with UC, markedly among those with an early onset, a long history of inflammatory disease, and a high flare frequency. This study reinforces the hypothesis sustaining a protective role of UC against colonic diverticula.

Lifestyle Factors in Late Adolescence Associate With Later Development of Diverticular Disease Requiring Hospitalization

BACKGROUND & AIMS

The burden of diverticular disease on society is high and is increasing with an aging population. It is therefore important to identify risk factors for disease development or progression. Many lifestyle behaviors during adolescence affect risk for later disease. We searched for adolescent lifestyle factors that affect risk of diverticular disease later in life.

METHODS

We performed a retrospective analysis of data from 43,772 men (age, 18-20 y) conscripted to military service in Sweden from 1969 through 1970, with a follow-up period of 39 years. All conscripts underwent an extensive mental and physical health examination and completed questionnaires covering alcohol consumption, smoking, and use of recreational drugs; cardiovascular fitness was assessed using an ergometer cycle at the time of conscription. Outcome data were collected from national registers to identify discharge diagnoses of diverticular disease until the end of 2009. We performed Cox regression analysis to determine whether body mass index, cardiovascular fitness, smoking, use of recreational drugs, alcohol consumption, and risky use of alcohol, at time of conscription are independent risk factors for development of diverticular disease.

RESULTS

Overweight and obese men had a 2-fold increased risk of diverticular disease compared to normal-weight men (hazard ratio, 2.00; P < .001). A high level of cardiovascular fitness was associated with a reduced risk of diverticular disease requiring hospitalization (P = .009). Smoking (P = .003), but not use of recreational drugs (P = .11), was associated with an increased risk of diverticular disease requiring hospitalization. Risky use of alcohol, but not alcohol consumption per se, was associated with a 43% increase in risk of diverticular disease requiring hospitalization (P = .007).

CONCLUSIONS

In a retrospective analysis of data from 43,772 men in Sweden, we associated being overweight or obese, a smoker, a high-risk user of alcohol, and/or having a low level of cardiovascular fitness in late adolescence with an increased risk of developing diverticular disease requiring hospitalization later in life. Improving lifestyle factors among adolescents might reduce the economic burden of diverticular disease decades later.

An outcome analysis of laparoscopic management of diverticulitis

BACKGROUND

All operative procedures for simple or complicated diverticulitis, including primary resection and anastomosis (PRA) with or without a diverting stoma, Hartmann procedure (HP), or stoma reversal, whether done in an elective setting or as an emergency, can be performed laparoscopically. However, owing to low incidence of the disease and complexity of the procedure, there are very few studies on outcomes of laparoscopic surgery for sigmoid diverticulitis from India.

AIM

The present study was undertaken to evaluate outcomes of laparoscopically treated patients of sigmoid diverticulitis.

METHODS

Prospective observational study enrolled 37 patients with sigmoid diverticulitis managed laparoscopically from March 2015 to March 2017. Demographic, clinical, operative, postoperative, and complication data were entered into a patient proforma and analyzed.

RESULTS

Eleven simple and 26 complicated diverticulitis patients were operated laparoscopically, 22 in emergency setting and 15 in elective setting. Only three patients required conversion to open surgery-two due to dense adhesions and one due to chronic obstructive pulmonary disease (COPD). No patients had ureteric or bowel injury. Eighteen patients underwent laparoscopic PRA without stoma, 11 patients had PRA with stoma, 6 had HP, and 2 had laparoscopic lavage. Results showed lesser blood loss, shorter hospital stay, and fewer complications in the elective group and simple diverticulitis patients. None of the patients had anastomosis-related complications. Two patients had stoma-related complications.

CONCLUSION

Laparoscopic management of diverticulitis is feasible, safe, provides the benefits of less wound-related complications, and shorter hospital stay and should be the surgical procedure of choice in elective or emergency setting for simple/complicated diverticulitis.

High intake of dietary fibre from fruit and vegetables reduces the risk of hospitalisation for diverticular disease

BACKGROUNDS AND AIMS

High intake of dietary fibres has been associated with a reduced risk of DD. However, reports on which type of dietary fibre intake that is most beneficial have been conflicting. The aim of this study was to investigate the association between different dietary fibres and hospitalisation due to diverticular disease (DD) of the colon.

METHODS

This was a major cohort study. The Swedish Mammography Cohort and the Cohort of Swedish Men were linked to the Swedish Inpatient Register and the Causes of Death Register. Data on the intake of dietary fibre were collected through questionnaires. The effect of intake (in quartiles) of different types of dietary fibre on the incidence of hospitalisation due to DD was investigated using multivariable Cox regression. Estimates were adjusted according to age, BMI, physical activity, co-morbidity, intake of corticosteroids, smoking, alcohol intake and education level.

RESULTS

Women with intake of fruit and vegetable fibres in the highest quartile (median 12.6 g/day) had a 30% decreased risk of hospitalisation compared to those with the lowest intake (4.1 g/day). Men within the highest quartile (10.3 g/day) had a 32% decreased risk compared to those with a low intake (2.9 g/day). High intake of fibres from cereals did not affect the risk.

CONCLUSION

A high intake of fruits and vegetables may reduce the risk of hospitalisation due to DD. Intake of cereals did not influence the risk.

A critical appraisal of advances in the diagnosis of diverticular disease

Diverticulosis of the colon is a common condition, and about one-fourth of those people develop symptoms, which is called 'diverticular disease' (DD). Since there are still some concerns about the diagnosis of DD, the aim of this review was to analyze current and evolving advances in its diagnosis. Area covered: Analysis of clinical, radiology, laboratory, and endoscopic tools to pose a correct diagnosis of DD was performed according to current PubMed literature. Expert commentary: A combination of clinical characteristic of the abdominal pain and fecal calprotectin expression may help to differentiate between symptomatic uncomplicated diverticular disease and irritable bowel syndrome. Abdominal computerized tomography (CT) scan is still the gold standard in diagnosing acute diverticulitis and its complications. CT-colonography may be useful as a predicting tool on the outcome of the disease. Diverticular Inflammation and Complications Assessment (DICA) endoscopic classification shows a significant relationship between severity of DICA score inflammatory indexes, as well as with severity of abdominal pain. Moreover, it seems to be predictive of the outcome of the disease in terms of acute diverticulitis occurrence/recurrence and surgery occurrence. Finally, preliminary data found intestinal microbiota analysis is a promising tool in diagnosing and monitoring this disease.

Does inferior mesenteric artery ligation affect outcome in elective colonic resection for diverticular disease?

BACKGROUND

The aim of our study was to analyse the role of inferior mesenteric artery (IMA) ligation during elective colonic resection for diverticular disease (DD) with respect to surgical outcome.

METHODS

All patients who underwent elective laparoscopic or open colonic resection for DD from January 2006 to December 2012 were studied. The patients were divided into two groups based on IMA ligation or preservation. The primary end point was to compare anastomotic leakage in the two groups. The secondary end points were operative time, stoma formation, overall post-operative complications, restoration of bowel function and length of post-operative hospital stay.

RESULTS

During the study period, 219 elective colonic resections with primary anastomosis for DD were performed. A laparoscopic technique was employed in 132 (60.3%) cases. IMA ligation was performed in 66 patients (30.1%). Overall anastomotic leakage rate was 4.1%, 4.5% in IMA ligation and 3.9% in IMA preservation group, respectively (P = ns). Mean operative time was 225 ± 43.4 and 191 ± 41.7 min in IMA ligation and preservation group, respectively (P = 0.002). No differences were observed in the rate of overall complications, stoma formation, restoration of bowel function and post-operative length of hospital stay.

CONCLUSIONS

No differences were observed in surgical outcome in IMA ligation and preservation groups, particularly preservation or ligation of the IMA did not affect leakage rate.

Antibiotics in Uncomplicated Acute Diverticulitis: To Give or Not to Give?

Acute uncomplicated diverticulitis (AUD) is generally felt to be caused by obstruction and inflammation of a colonic diverticulum and occurs in about 4-5% of patients with diverticulosis. The cornerstone of AUD treatment has conventionally been antibiotic therapy, but with a paradigm shift in the underlying pathogenesis of the disease from bacterial infection to more of an inflammatory process, as well as concerns about antibiotic overuse, this dogma has recently been questioned. We will review emerging data that supports more selective antibiotic use in this population, as well as newer guidelines that advocate this position as well. While there are no discrete algorithms to guide us, we will attempt to suggest clinical scenarios where antibiotics may reasonably be withheld.

It's Actually a Little Complicated: Antibiotics for Uncomplicated Diverticulitis

The assumption that acute uncomplicated diverticulitis requires antibiotics has been challenged. In this issue, the Dutch Diverticular Disease Collaborative Study Group report the 2-year follow-up to their trial of observation vs. treatment with amoxicillin-clavulanic acid for acute uncomplicated diverticulitis. The new study provides useful insights on the natural history of acute uncomplicated diverticulitis. The most intriguing data compared rates of elective sigmoid resection between the groups. There was a trend toward more elective surgery in the observation group compared to those in the antibiotic group. It might be too soon to abandon antibiotics for uncomplicated diverticulitis.

Demographic and clinical features distinguish subgroups of diverticular disease patients: Results from an Italian nationwide registry

BACKGROUND

Clinical features and lifestyle factors associated with diverticulosis compared to diverticular disease (DD), either symptomatic uncomplicated diverticular disease (SUDD) or in patients who have had previous diverticulitis (PD), are unclear.

OBJECTIVE

The objective of this article is to compare cross-sectionally demographic and clinical features and quality of life (QoL) in diverticulosis, SUDD and PD patients.

METHODS

The REMAD Registry is a prospective, observational, multicentre, cohort study. Patients were categorised according to: diverticulosis; SUDD (recurrent abdominal symptoms attributed to diverticula in absence of overt inflammation) and PD (≥1 previous diverticulitis).

RESULTS

A total of 1217 patients (57.9% diverticulosis, 24.7% SUDD and 17.4% PD) were included. Compared to diverticulosis, female gender was associated to SUDD (OR 1.94; 95% CI: 1.43-2.62) and PD (OR 1.79; 95% CI: 1.24-2.56); age ≤ 60 years was associated to PD (OR 2.10; 95% CI: 1.42-3.08 vs diverticulosis, OR 1.57; 95% CI: 1.01-2.45 vs SUDD). PD patients showed an association with past bleeding (OR 29.29; 95% CI: 8.17-104.98 vs diverticulosis, OR 16.84; 95% CI: 3.77-75.25 vs SUDD). Compared to diverticulosis, family history for diverticula was associated to PD (OR 1.88; 95% CI: 1.27-2.78). Patients with diverticulosis showed higher QoL scores, both physical (p = 0.0001 and 0.0257) and mental (p < 0.0001 and 0.0038), in comparison to SUDD and PD.

CONCLUSION

Family history for diverticula and history of bleeding distinguish diverticulosis from DD. These clinical features should be kept in mind in the management of DD.

Pathophysiology of diverticular disease

Inflammation of diverticula, or outpouchings of the colonic mucosa and submucosa through the muscularis layer, leads to diverticulitis. The development of diverticular disease, encompassing both diverticulosis and diverticulitis, is a result of genetic predisposition, lifestyle, and environmental factors, including the microbiome. Areas covered: Previous reports implicated genetic predisposition, environmental factors, and colonic dysmotility in diverticular disease. Recent studies have associated specific host immune responses and the microbiome as contributors to diverticulitis. To review pertinent literature describing pathophysiological factors associated with diverticulosis or diverticulitis, we searched the PubMed database (March 2018) for articles considering the role of colonic architecture, genetic predisposition, environment, colonic motility, immune response, and the microbiome. Expert commentary: In the recent years, research into the molecular underpinnings of diverticular disease has enhanced our understanding of diverticular disease pathogenesis. Although acute uncomplicated diverticulitis is treated with broad spectrum antibiotics, evaluation of the microbiome has been limited and requires further comprehensive studies. Evidence suggests that a deregulation of the host immune response is associated with both diverticulosis and diverticulitis. Further examining these pathways may reveal proteins that can be therapeutic targets or aid in identifying biological determinants of clinical or surgical decision making.

Association Between Obesity and Weight Change and Risk of Diverticulitis in Women

BACKGROUND & AIMS

There is little evidence that adiposity associates with diverticulitis, especially among women. We conducted a comprehensive evaluation of obesity, weight change, and incidence of diverticulitis in a large cohort of women.

METHODS

We conducted a prospective cohort study of 46,079 women enrolled in the Nurses' Health Study who were 61-89 years old and free of diverticulitis, diverticular bleeding, cancers, or inflammatory bowel disease at baseline (in 2008). We used Cox proportional hazards models to examine the associations among risk of incident diverticulitis and body mass index (BMI), waist circumference, waist to hip ratio, and weight change from age 18 years to the present. The primary end point was first incident diverticulitis requiring antibiotic therapy or hospitalization.

RESULTS

We documented 1084 incident cases of diverticulitis over 6 years of follow-up, encompassing 248,001 person-years. After adjustment for other risk factors, women with a BMI ≥35.0 kg/m2 had a hazard ratio for diverticulitis of 1.42 (95% confidence interval [CI], 1.08-1.85) compared to women with a BMI <22.5 kg/m2. Compared to women in the lowest quintile, the multivariable hazard ratios among women in the highest quintile were 1.35 (95% CI, 1.02-1.78) for waist circumference and 1.40 (95% CI, 1.07-1.84) for waist to hip ratio; these associations were attenuated with further adjustment for BMI. Compared to women maintaining weight from age 18 years to the present, those who gained ≥20 kg had a 73% increased risk of diverticulitis (95% CI, 27%-136%).

CONCLUSIONS

During a 6-year follow-up period, we observed an association between obesity and risk of diverticulitis among women. Weight gain during adulthood was also associated with increased risk.

Cortical differences in diverticular disease and correlation with symptom reports

BACKGROUND

Recent studies have shown that the brain of patients with gastrointestinal disease differ both structurally and functionally from that of controls. Highly somatizing diverticular disease (HSDD) patients were also shown to differ from low somatizing (LSDD) patients functionally. This study aimed to investigate how they differed structurally.

METHODS

Four diseases subgroups were studied in a cross-sectional design: 20 patients with asymptomatic diverticular disease (ADD), 18 LSDD, 16 HSDD, and 18 with irritable bowel syndrome. We divided DD patients into LSDD and HSDD using a cutoff of 6 on the Patient Health Questionnaire 12 Somatic Symptom (PHQ12-SS) scale. All patients underwent a 1-mm isotropic structural brain MRI scan and were assessed for somatization, hospital anxiety, depression, and pain catastrophizing. Whole brain volumetry, cortical thickness analysis and voxel-based morphometry were carried out using Freesurfer and SPM.

KEY RESULTS

We observed decreases in gray matter density in the left and right dorsolateral prefrontal cortex (dlPFC), and in the mid-cingulate and motor cortex, and increases in the left (19, 20) and right (19, 38) Brodmann Areas. The average cortical thickness differed overall across groups (P = .002) and regionally: HSDD > ADD in the posterior cingulate cortex (P = .03), HSDD > LSDD in the dlPFC (P = .03) and in the ventrolateral PFC (P < .001). The thickness of the anterior cingulate cortex and of the mid-prefrontal cortex were also found to correlate with Pain Catastrophizing (Spearman's ρ = 0.24, P = .043 uncorrected and Spearman's ρ = 0.25, P = .03 uncorrected).

CONCLUSION & INFERENCES

This is the first study of structural gray matter abnormalities in diverticular disease patients. The data show brain differences in the pain network.

Epidemiology and Pathophysiology of Diverticular Disease

Colonic diverticular disease is a common health care issue which has historically been attributed to western countries and older age population. Recent studies have shown a rise in incidence among developing countries that have adopted western diets as well as rise in prevalence among younger patients. In this article, the authors discuss the incidence, epidemiology, and pathophysiology of colonic diverticular disease.

Colonic Diverticula Are Not Associated With Mucosal Inflammation or Chronic Gastrointestinal Symptoms

BACKGROUND & AIMS

Colonic diverticulosis has been reported to be associated with low-grade mucosal inflammation, possibly leading to chronic gastrointestinal symptoms. However, there is poor evidence for this association. We aimed to determine mucosal inflammation and whether diverticula are associated with chronic gastrointestinal symptoms. We explored whether inflammation was present among symptomatic participants with and without diverticula.

METHODS

We analyzed data from a prospective study of 619 patients undergoing a screening colonoscopy from 2013 through 2015 at the University of North Carolina Hospital in Chapel Hill, North Carolina. Among our participants, 255 (41%) had colonic diverticula. Colonic mucosal biopsy specimens were analyzed for levels of interleukin 6 (IL6), IL10, and tumor necrosis factor messenger RNAs by quantitative reverse-transcriptase polymerase chain reaction, and numbers of immune cells (CD4+, CD8+, CD57+, and mast cell tryptase) by immunohistochemistry. Gastrointestinal symptoms were assessed using Rome III criteria. Proportional odds models were used to estimate odds ratios (ORs) and 95% confidence interval (CIs).

RESULTS

After adjustment for potential confounders, there was no association between diverticulosis and tumor necrosis factor (OR, 0.85; 95% CI, 0.63-1.16), and no association with CD4+ cells (OR, 1.18; 95% CI, 0.87-1.60), CD8+ cells (OR, 0.97; 95% CI, 0.71-1.32), or CD57+ cells (OR, 0.80; 95% CI, 0.59-1.09). Compared with controls without diverticulosis, biopsy specimens from individuals with diverticulosis were less likely to express the inflammatory cytokine IL6 (OR, 0.59; 95% CI, 0.36-0.96). There was no association between diverticulosis and irritable bowel syndrome (OR, 0.53; 95% CI, 0.26-1.05) or chronic abdominal pain (OR, 0.68; 95% CI, 0.38-1.23). There was no evidence for inflammation in patients with symptoms when patients with vs without diverticulosis were compared.

CONCLUSIONS

We found no evidence that colonic diverticulosis is associated with mucosal inflammation or gastrointestinal symptoms. Among patients with symptoms and diverticula, we found no mucosal inflammation.

Inflammation management in acute diverticulitis: current perspectives

The pathogenesis of diverticular disease and acute diverticulitis is still unclear and many different hypotheses have been formulated. Seemingly, there are several related factors such as chronic inflammation, gut microbiome, obesity and the immunogenic properties of fat tissue and diet. Inflammation plays a pivotal role in diverticular disease and acute diverticulitis. The aim of the present review is to investigate the role of inflammation in diverticular disease as well as in mild and complicated acute diverticulitis with a focus on current research and treatment perspectives.

Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017

Diverticulosis is a common anatomical condition, which appears to be age-dependent. Individuals who develop chronic gastrointestinal symptoms or complications are referred to as having diverticular disease. Although the diagnosis of this condition can be relatively straightforward, randomized controlled trials are scarce and management often follows tradition rather than principles of evidence-based medicine. This report deals with the topics discussed during a symposium held during the United European Gastroenterology Week (Barcelona, October 2017). During the meeting, the role of dysbiosis in the pathogenesis of diverticular disease and its treatment were thoroughly discussed, by examining the efficacy and mechanisms of action of the currently used drugs. Recent studies have shown the presence of dysbiosis in patients with diverticular disease and suggest an imbalance in favor of bacteria with pro-inflammatory and pathogenetic potential. These microbiota changes correlate with mucosal immune activation, mirrored by a marked increase of macrophages in colonic mucosa, both in the diverticular region and at distant sites. The low-grade inflammation, driven by bacteria-induced immune activation, could be involved in the pathophysiology of symptoms. As a consequence, pharmacological approaches targeting enteric bacteria (with poorly absorbed antibiotics, like rifaximin, or probiotics) or intestinal inflammation (with 5-ASA derivatives or rifaximin) have shown capability of controlling symptoms and also preventing complications, albeit more research is needed to establish the optimal regimen (daily dose and duration) of therapy. Well-designed randomized-controlled trials (RCTs), including homogeneous populations of patients, are therefore needed. The future of management of many GI diseases, including symptomatic uncomplicated diverticular disease, will rely on the so-called 'microbiota-directed therapies'.

Increasing Diverticulosis in an Aging Population: A Colonoscopy-Based Study of 5-Year Trends in 26 463 Patients in Northern China

Background

Because such data are scarce in northern China, the purpose of this study was to determine trends in diverticulosis over the past 5 years.

Material/Methods

A total of 26 463 patients (27 558 examinations, including 1095 repeated colonoscopies) performed between January 2011 and December 2015 were reviewed respectively. The distributions of diverticulosis were recorded, which were classified as right-sided, left-sided, and bilateral type. The trends in diverticulosis were analyzed in terms of aging and yearly increase. Additionally, associations of the occurrence of diverticulosis with age (≤39, 40–59, and ≥60 years) and sex were determined using a logistic regression model.

Results

We identified 1045 patients with colonic diverticulosis, with an overall prevalence of 3.8% (1045/27 558). A preponderance of right-sided diverticulosis was demonstrated, accounting for 72.9% (693/951) of included subjects. The proportion of colonic diverticulosis increased significantly (P<0.001 for trend), from 2.78% (112/4028) in 2011 to 4.98% (309/6208) in 2015. The proportion of patients of all age groups with diverticulosis increased significantly (P<0.001 for trend) in correlation with yearly increase. There was a greater proportion of diverticulosis, regardless of the distribution, in patients aged ≥60 than in younger age groups (P<0.001 for trend). Multivariate analysis showed older age and male sex (P<0.001) were independent risk factor for diverticulosis.

Conclusions

Colonic diverticulosis has been increasing in northern China, where rapid aging is ongoing.

Diverticular Disease: The Old, the New, and the Ever-Changing View

Our understanding of diverticular disease has evolved significantly during the last 25 years, and as such, a reexamination is in order. We performed a literature search for the years 1960-2017 of PubMed, Medline, and Google Scholar for updates regarding the epidemiology, risk factors, and therapies for traditional diverticulitis as well as the recently described subtypes of diverticular disease, segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Although the prevalence of diverticulosis is still extremely common in the general population, the literature suggests that the incidence of diverticulitis is much less than previously believed and occurrences do not necessarily increase with age. In addition, the commonly held beliefs that low-fiber diets alone contribute to the development of diverticulosis and diverticulitis have not been verified; however, the combination of a low-fiber diet and a high red meat/high-fat diet is a risk factor for diverticulitis. Surgery continues to be the treatment for severe complications of diverticulitis, but new literature suggests that it has a poor utility in preventing a recurrence of diverticulitis in the long term; therefore, elective surgery after two episodes of diverticulitis is no longer the standard.

Meat intake and risk of diverticulitis among men

OBJECTIVE

Diverticulitis is a common disease with a substantial clinical and economic burden. Besides dietary fibre, the role of other foods in the prevention of diverticulitis is underexplored.

DESIGN

We prospectively examined the association between consumption of meat (total red meat, red unprocessed meat, red processed meat, poultry and fish) with risk of incident diverticulitis among 46 461 men enrolled in the Health Professionals Follow-Up Study (1986-2012). Cox proportional hazards models were used to compute relative risks (RRs) and 95% CIs.

RESULTS

During 651 970 person-years of follow-up, we documented 764 cases of incident diverticulitis. Compared with men in the lowest quintile (Q1) of total red meat consumption, men in the highest quintile (Q5) had a multivariable RR of 1.58 (95% CI 1.19 to 2.11; p for trend=0.01). The increase in risk was non-linear, plateauing after six servings per week (p for non-linearity=0.002). The association was stronger for unprocessed red meat (RR for Q5 vs Q1: 1.51; 95% CI 1.12 to 2.03; p for trend=0.03) than for processed red meat (RR for Q5 vs Q1: 1.03; 95% CI 0.78 to 1.35; p for trend=0.26). Higher consumption of poultry or fish was not associated with risk of diverticulitis. However, the substitution of poultry or fish for one serving of unprocessed red meat per day was associated with a decrease in risk of diverticulitis (multivariable RR 0.80; 95% CI 0.63 to 0.99).

CONCLUSIONS

Red meat intake, particularly unprocessed red meat, was associated with an increased risk of diverticulitis. The findings provide practical dietary guidance for patients at risk of diverticulitis.

Diverticular Disease-associated Colitis: What Do We Know? A Review of Literature

Diverticular disease (DD) is a leading cause of hospitalizations in developed countries affecting 30-50% of individuals older than 60 years. Identified as a distinct entity since 1980, diverticular disease-associated colitis (DAC) describes the occurrence of mucosal inflammation in a colon segment affected with DD with relative sparing of the rectum and proximal colon. Its prevalence is suggested around 1.3-3.8%. Pathogenesis is multifactorial with multiple reports noting clinicopathological overlap between DAC and inflammatory bowel disease (IBD) especially in patients with granulomatous colitis. In this setting, caution should be exercised to avoid an inappropriate diagnosis of IBD. Recurrence rates and long-term outcomes of DAC are not well defined and could range from a benign course to an overt IBD. More studies are needed in order to further characterize this entity.

The Multidisciplinary Management of Acute Complicated Diverticulitis

BACKGROUND

Acute complicated diverticulitis (ACD) is an important and increasing issue in Western countries that leads to a significant impact and burden for patients, but also for the society due to its effects on hospital costs. In recent years, essential progression has been made regarding the research and implementation of novel or improved treatment strategies for the various disease entities of ACD. Much debated topics in the multidisciplinary approach of patients with ACD, such as the choice for nonoperative treatment options, the role of percutaneous drainage for diverticular abscesses, the role of laparoscopic lavage for perforated diverticulitis with purulent peritonitis, and the role of sigmoidectomy with primary anastomosis for patients with perforated diverticulitis, require clinicians to attentively follow and participate in these discussions.

SUMMARY

The aim of this review article is to provide clinicians with a structured overview of the recent literature on the multidisciplinary management of complicated diverticulitis by a panel of experts on the topic. By performing an extensive literature search in the online medical databases MEDLINE (Ovid) and Embase, insights into nonoperative treatment, percutaneous drainage, minimally invasive and open surgical treatment of ACD are provided. Furthermore, a comprehensive algorithm for the treatment of ACD has been developed.

KEY MESSAGES

Accurate patient evaluation and selection based on patient and disease characteristics is of paramount importance to determine the appropriate treatment strategy for patients with complicated diverticulitis. The presence of an experienced surgeon with advanced skills in laparoscopic emergency colorectal surgery is crucial for the treatment of patients with perforated diverticulitis in order to properly evaluate, select and treat patients suitable for nonoperative or operative treatment with an open or laparoscopic approach.

Identification of a rare LAMB4 variant associated with familial diverticulitis through exome sequencing

Diverticulitis is a chronic disease of the colon in which diverticuli, or outpouching through the colonic wall, become inflamed. Although recent observations suggest that genetic factors may play a significant role in diverticulitis, few genes have yet been implicated in disease pathogenesis and familial cases are uncommon. Here, we report results of whole exome sequencing performed on members from a single multi-generational family with early onset diverticulitis in order to identify a genetic component of the disease. We identified a rare single nucleotide variant in the laminin β 4 gene (LAMB4) that segregated with disease in a dominant pattern and causes a damaging missense substitution (D435N). Targeted sequencing of LAMB4 in 148 non-familial and unrelated sporadic diverticulitis patients identified two additional rare variants in the gene. Immunohistochemistry indicated that LAMB4 localizes to the myenteric plexus of colonic tissue and patients harboring LAMB4 variants exhibited reduced LAMB4 protein levels relative to controls. Laminins are constituents of the extracellular matrix and play a major role in regulating the development and function of the enteric nervous system. Reduced LAMB4 levels may therefore alter innervation and morphology of the enteric nervous system, which may contribute to colonic dysmotility associated with diverticulitis.

COLONIC DIVERTICULOSIS AND DIVERTICULAR HEMORRHAGE IN A GERIATRIC FEMALE ORANGUTAN ( PONGO ABELII)

A 57-yr-old female Sumatran orangutan ( Pongo abelii) presented with signs of intermittent lethargy and inappetence, then subsequently developed profuse hemorrhagic diarrhea. Colonoscopy under anesthesia revealed diverticulosis of the descending colon, with multiple large diverticula containing fecoliths. There was no evidence of diverticulitis, but a regenerative anemia had developed following an acute diverticular bleed. The orangutan recovered with conservative therapy. Colonic diverticulosis has been reported in nonhuman primates and appears to have a similar clinical presentation to the condition as it occurs in humans. This is the first published report of colonic diverticulosis in a great ape.

Treatment of diverticular disease: an update on latest evidence and clinical implications

BACKGROUND

Diverticular disease (DD) is a common condition, especially in Western countries. In about 80% of patients, colonic diverticula remain asymptomatic (diverticulosis), while approximately 20% of patients may develop abdominal symptoms (symptomatic uncomplicated diverticular disease, SUDD) and, eventually complications as acute diverticulitis (AD). The management of this condition has been improved, and in the last five years European countries and the USA have published guidelines and recommendations.

SCOPE

To summarize the latest evidence and clinical implication in treatment of DD focusing the attention either on the treatment of diverticulosis, SUDD and AD together with the primary and secondary prevention of diverticulitis.

FINDINGS

The present review was based on the latest evidence in the treatment of DD in the last 10 years. In the last 5 years, six countries issued guidelines on DD with differences regarding covered topics and recommendations regarding treatments. At present there is a lack of rationale for drug use in patients with asymptomatic diverticulosis, but there are limited indications to suggest an increase in dietary fibre to reduce risk of DD. To achieve symptomatic relief in SUDD patients, several therapeutic strategies with fibre, probiotics, rifaximin and mesalazine have been proposed even if a standard therapeutic approach remained to be defined. Agreement has been reached for the management of AD, since recent guidelines showed that antibiotics can be used selectively, rather than routinely in uncomplicated AD, although use of antibiotics remained crucial in the management of complicated cases. With regard to treatment for the primary and secondary prevention of AD, the efficacy of rifaximin and mesalazine has been proposed although with discordant recommendations among guidelines.

CONCLUSION

Treatment of DD represented an important challenge in clinical practice, especially concerning management of SUDD and the primary and secondary prevention of AD.

Clinical and symptom scores are significantly correlated with fecal microbiota features in patients with symptomatic uncomplicated diverticular disease: a pilot study

BACKGROUND

There is growing consensus that symptomatic uncomplicated diverticular disease is a chronic inflammatory condition, and that alterations in the fecal microbiota may contribute to its pathogenesis.

OBJECTIVE

The aim of this study was to relate the fecal microbiota composition in symptomatic uncomplicated diverticular disease to measures of inflammation, symptoms, and history of previous acute diverticulitis.

PARTICIPANTS AND METHODS

Fecal microbiota composition in 28 individuals with symptomatic uncomplicated diverticular disease was characterized by 16S RNA gene amplicon sequencing. Microbiota composition was related to clinical history, symptom and inflammation measures, and demographic variables.

RESULTS

Previous acute diverticulitis was associated with higher relative abundance of Pseudobutyrivibrio, Bifidobacterium, Christensenellaceae family, and Mollicutes RF9 order (P=0.004, 0.006, 0.010, and 0.019, respectively), but not microbiota alpha or beta diversity. A higher bloating severity score was significantly correlated with a higher relative abundance of Ruminococcus (P=0.032), and significantly inversely correlated with the relative abundance of the Roseburia (P=0.002). Fecal calprotectin levels were positively correlated with alpha diversity (Shannon index, P=0.005) and the relative abundance of Lactobacillus (P=0.004). Pain score was positively correlated with the relative abundance of Cyanobacterium (adjusted P=0.032).

CONCLUSION

Patient symptoms in symptomatic diverticular disease are significantly correlated with features of the fecal microbiota. Our findings suggest the potential utility of therapies that target intestinal microbiology, such as dietary prebiotic supplements.

Colonic diverticulosis is not a risk factor for colonic adenoma

BACKGROUND AND AIMS

Colonic diverticulosis may represent a risk factor for colonic adenomas by virtue of the fact that evolving data suggest that these 2 conditions may share common risk factors such as Western dietary pattern and physical inactivity. This study aims to investigate the association between colonic diverticulosis and colonic adenomas in mainland China.

METHODS

We conducted a cross-sectional study on patients who underwent colonoscopic examination between October 2013 and December 2014 in a university hospital in mainland China. Age, gender, colonic adenomas, advanced adenomas, and distribution of diverticulosis were recorded during the procedures. Multivariate logistic regression and stratified analysis were used to evaluate the associations between the prevalence of diverticulosis and age, sex, and presence of colonic adenomas and advanced adenomas.

RESULTS

A total of 17,456 subjects were enrolled. The prevalence of colonic diverticulosis and adenoma was 2.4% and 13.2%, respectively. With regard to distribution of diverticula, most (365/424, 86.1%) were right-sided. Multiple logistic regression analysis suggested that age and male gender were independent risk factors for adenoma and advanced adenoma. There was no relationship between diverticulosis or location of diverticulosis and presence of adenoma and advanced adenoma adjusting by age and gender. In a stratified analysis according to age and gender, similar results were also noted.

CONCLUSION

There was no statistical relationship between diverticulosis and the risk of adenoma and advanced adenoma. Our results may not be generalized to the Western population due to the fact that left-sided diverticular cases were very small in our study.

5-aminosalicylic acid agents for prevention of recurrent diverticulitis: A systematic review and meta-analysis

BACKGROUND AND AIM

Prevalence of colonic diverticulosis is increasing worldwide with age, and up to 25% of patients who have colonic diverticulosis might experience diverticulitis. However, a definitive approach of preventing recurrent diverticulitis remains unknown. 5-aminosalicylic acid (5-ASA) agents are anti-inflammatory agents and have been used to prevent recurrent diverticulitis, and there have been some randomized clinical trials (RCTs). However, the efficacy results for secondary prevention in uncomplicated diverticulitis differed across studies. Our aim was to clarify the efficacy and safety of 5-ASA agents in the prevention of recurrent diverticulitis.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and the Cochrane library with no language restrictions. Two reviewers independently assessed and selected RCTs. The data were pooled using a random effect model and were presented in the pooled risk ratio (RR) and 95% confidence interval (CI). Cochrane's Q and I-squared statistics were used to assess heterogeneity. The protocol was registered at PROSPERO.

RESULTS

Seven articles with eight RCTs from 329 potentially relevant articles were included. 5-ASA agents were not superior to controls in preventing recurrent diverticulitis (RR 0.86, 95% CI 0.63 to 1.17, I²  = 60%) and the incidence of adverse events was not different between 5-ASA agents and controls (RR 0.97, 95% CI 0.84 to 1.11, I²  = 45%). However, some included studies were few in number of participants and substantial risk of bias.

CONCLUSIONS

5-aminosalicylic acid agents were not associated with prevention of recurrent diverticulitis.

Adherence to a Healthy Lifestyle is Associated With a Lower Risk of Diverticulitis among Men

OBJECTIVES

Diverticulitis is a common disease with high clinical burden. We evaluated the joint contribution of multiple lifestyle factors to risks of incident diverticulitis. We also estimated the proportion of diverticulitis preventable by lifestyle modifications.

METHODS

We prospectively examined the association between lifestyle factors (red meat, dietary fiber intake, vigorous physical activity (activity with metabolic equivalent ≥6), body mass index (BMI), and smoking) and risk of diverticulitis among participants in the Health Professionals Follow-Up Study.

RESULTS

We documented 907 incident cases of diverticulitis during 757,791 person-years. High intake of red meat, low intake of dietary fiber, low vigorous physical activity, high BMI, and smoking were independently associated with increased risks of diverticulitis (all P<0.05). Low-risk lifestyle was defined as average red meat intake <51 g per day, dietary fiber intake in the top 40% of the cohort (about 23 g per day), vigorous physical activity in the highest 50% among participants with non-zero vigorous physical activity (roughly 2 h of exercise weekly), normal BMI between 18.5-24.9 kg m^-2, and never-smoker. There was an inverse linear relationship between number of low-risk lifestyle factors and diverticulitis incidence (P for trend<0.001). Compared with men with no low-risk lifestyle factors, the multivariable relative risks of diverticulitis were 0.71 (95% confidence interval (CI): 0.59-0.87) for men with 1 low-risk lifestyle factor; 0.66 (95% CI: 0.55-0.81) for 2 low-risk factors; 0.50 (95% CI: 0.40-0.62) for 3 low-risk factors; 0.47 (95% CI: 0.35-0.62) for 4 low-risk factors, and 0.27 (95% CI: 0.15-0.48) for 5 low-risk factors. Adherence to a low-risk lifestyle could prevent 50% (95% CI: 20-71%) of incident diverticulitis.

CONCLUSIONS

Adherence to a low-risk lifestyle is associated with reduced incidence of diverticulitis.

Mesalamine (5-ASA) for the prevention of recurrent diverticulitis

BACKGROUND

Diverticular disease is a common condition that increases in prevalence with age. Recent theories on the pathogenesis of diverticular inflammation have implicated chronic inflammation similar to that seen in ulcerative colitis. Mesalamine, or 5-aminosalicylic acid (5-ASA), is a mainstay of therapy for individuals with ulcerative colitis. Accordingly, 5-ASA has been studied for prevention of recurrent diverticulitis.

OBJECTIVES

To evaluate the efficacy of mesalamine (5-ASA) for prevention of recurrent diverticulitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), in the Cochrane Library; Ovid MEDLINE (from 1950 to 9 September 2017); Ovid Embase (from 1974 to 9 September 2017); and two clinical trials registries for ongoing trials - Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform database (9 September 2017).We also searched proceedings from major gastrointestinal conferences - Digestive Disease Week (DDW), United European Gastroenterology Week (UEGW), and the American College of Gastroenterology (ACG) Annual Scientific Meeting - from 2010 to September 2017. In addition, we scanned reference lists from eligible publications, and we contacted corresponding authors to ask about additional trials.

SELECTION CRITERIA

We included randomised controlled clinical trials comparing the efficacy of 5-ASA versus placebo or another active drug for prevention of recurrent diverticulitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as defined by Cochrane. Three review authors assessed eligibility for inclusion. Two review authors selected studies, extracted data, and assessed methodological quality independently. We calculated risk ratios (RRs) for prevention of diverticulitis recurrence using an intention-to-treat principle and random-effects models. We assessed heterogeneity using criteria for Chi2 (P < 0.10) and I2 tests (> 50%). To explore sources of heterogeneity, we conducted a priori subgroup analyses. To assess the robustness of our results, we carried out sensitivity analyses using different summary statistics (RR vs odds ratio (OR)) and meta-analytical models (fixed-effect vs random-effects).

MAIN RESULTS

We included in this review seven studies with a total of 1805 participants. We judged all seven studies to have unclear or high risk of bias. Investigators found no evidence of an effect when comparing 5-ASA versus control for prevention of recurrent diverticulitis (31.3% vs 29.8%; RR 0.69, 95% confidence interval (CI) 0.43 to 1.09); very low quality of evidence).Five of the seven studies provided data on adverse events of 5-ASA therapy. The most commonly reported side effects were gastrointestinal symptoms (epigastric pain, nausea, and diarrhoea). No significant difference was seen between 5-ASA and control (67.8% vs 64.6%; RR 0.98, 95% CI 0.91 to 1.06; P = 0.63; moderate quality of evidence), nor was significant heterogeneity observed (I2 = 0%; P = 0.50).

AUTHORS' CONCLUSIONS

The effects of 5-ASA on recurrence of diverticulitis are uncertain owing to the small number of heterogenous trials included in this review. Rates of recurrent diverticulitis were similar among participants using 5-ASA and control participants. Effective medical strategies for prevention of recurrent diverticulitis are needed, and further randomised, double-blinded, placebo-controlled trials of rigorous design are warranted to specify the effects of 5-ASA (mesalamine) in the management of diverticulitis.

Multicentre, controlled, randomized clinical trial to compare the efficacy and safety of ambulatory treatment of mild acute diverticulitis without antibiotics with the standard treatment with antibiotics

PURPOSE

Acute diverticulitis (AD) is a highly prevalent disease in Spain. Its chronic-recurrent appearance and high rate of relapse mean that it has a major epidemiological and economic impact on our health system. In spite of this, it has not been studied in any great depth. Reassessing its etiopathology, recent studies have observed that it is an inflammatory disease-not, as classic theories had postulated, an infectious one. In the light of these findings, the suitability of antibiotics for its treatment has been reconsidered. At present, however, the evidence for incorporating these findings into clinical practice guidelines remains insufficient.

METHODS

This study was designed to analyse the safety and efficacy of a non-antibiotic treatment for mild AD. Patients with mild AD (grade 0 in the modified Neff classification) who meet the inclusion criteria will be randomly assigned to one of two outpatient treatment strategies: (a) classical treatment (antibiotics, anti-inflammatories and low-fibre diet) or (b) experimental treatment (anti-inflammatories and low-fibre diet). Clinical controls will be performed at 2, 7, 30, and 90 days. We will determine whether there are any differences in the clinical outcome between groups. The main objective is to demonstrate that antibiotics neither accelerate the resolution of the disease nor decrease the number of complications and/or recurrences in these patients, suggesting that their use may be unnecessary.

CONCLUSIONS

The results of this trial will help to optimize and homogenize the treatment of this highly prevalent disease. However, more studies are required before firm changes can be introduced in international clinical practice guidelines.

TRIAL REGISTRATION

The trial has been registered at the ClinicalTrials.gov database (ID: NCT02785549) and the EU Clinical Trials Register database (EudraCT number: 2016-001596-75).

End-colostomy diverticulitis with parastomal phlegmon: A case report

RATIONALE

Acute colonic diverticulitis is a well-known surgical emergency, which occurs in about 10 percent of patients known for diverticulosis.

PATIENT CONCERNS

The case of a 77-year-old woman is reported, with past history of abdominoperineal resection with end-colostomy for low rectal adenocarcinoma, and who developed an acute colonic diverticulitis in a subcutaneous portion of colostomy with parastomal phlegmon.

DIAGNOSES

Initial computed tomography imaging demonstrated a significant submucosal parietal edema with local fat tissues infiltration in regard of 3 diverticula.

INTERVENTIONS

A two-step treatment was decided: first a nonoperative treatment was initiated with 2 weeks antibiotics administration, followed by, 6 weeks after, a segmental resection of the terminal portion of the colon with redo of a new colostomy by direct open approach.

OUTCOMES

Patient was discharged on the second postoperative day without complications. Follow-up at 2 weeks revealed centimetric dehiscence of the stoma, which was managed conservatively until sixth postoperative week by stomatherapists.

LESSONS SUBSECTIONS

Treatment of acute diverticulitis with parastomal phlegmon in a patient with end-colostomy could primary be nonoperative. Delayed surgical treatment with segmental colonic resection was proposed to avoid recurrence and potential associated complications.

Helicobacter pylori infection is associated with reduced prevalence of colonic diverticular disease

BACKGROUND

Colonic diverticular disease is a common disorder with increasing incidence in Western societies. The intestinal microbiome may be among etiological factors. Helicobacter pylori may protect against some intestinal diseases, and incidence of H. pylori is decreasing in Western societies. Thus, we aimed to determine whether H. pylori is associated to decreased prevalence of registered colonic diverticular disease.

MATERIALS AND METHODS

In a historical cohort study, patients were enrolled from primary health care centers after urea breath test for H. pylori and then followed for a median of 6 years. The patient's diagnostic codes and country of birth were acquired from nationwide Danish administrative registries. We used logistic regression to compare prevalence and Cox regression to compare incidence of diverticular disease between H. pylori-positive and H. pylori-negative patients, adjusting for confounding variables.

RESULTS

Patients infected with H. pylori had lower prevalence of colonic diverticular disease (0.87% vs 1.14%, OR=0.62, 95% CI: 0.50-0.78). This phenomenon was observed whether we studied all registered diagnoses or only cases registered as primary diagnoses at discharge. After urea breath test, we observed no statistical difference in incidence rates of diverticular disease.

CONCLUSION

H. pylori is associated with reduced prevalence of colonic diverticular disease. The inverse association was absent after the urea breath test. Thus, we speculate that H. pylori may provide protection from colonic diverticular disease. Alternatively, H. pylori is a marker for other factors affecting disease development.

Gut Microbiota in Health, Diverticular Disease, Irritable Bowel Syndrome, and Inflammatory Bowel Diseases: Time for Microbial Marker of Gastrointestinal Disorders

Few data exist on differences in gut microbiota composition among principal gastrointestinal (GI) diseases. We evaluated the differences in gut microbiota composition among uncomplicated diverticular disease (DD), irritable bowel syndrome (IBS) and inflammatory bowel diseases (IBD) patients. DD, IBS, and IBD patients along with healthy controls (CT) were enrolled in our Italian GI outpatient clinic. Stool samples were collected. Microbiota composition was evaluated through a metagenomic gene-targeted approach. GI pathology represented a continuous spectrum of diseases where IBD displayed one extreme, while CT displayed the other. Among Phyla, Biplot PC2/PC3 and dendogram plot showed major differences in samples from IBS and IBD. DD resembled species CT composition, but not for Bacteroides fragilis. In IBS, Dialister spp. and then Faecalibacterium prausnitzii were the most representative species. Ulcerative colitis showed a reduced concentration of Clostridium difficile and an increase of Bacteroides fragilis. In Crohn's disease, Parabacteroides distasonis was the most represented, while Faecalibacterium prausnitzii and Bacteroides fragilis were significantly reduced. Each disorder has its definite overall microbial signature, which produces a clear differentiation from the others. On the other hand, shared alterations constitute the "core dysbiosis" of GI diseases. The assessment of these microbial markers represents a parameter that may complete the diagnostic assessment.

Colonic diverticular disease: A new risk factor for Parkinson's disease?

BACKGROUND

Colonic diverticular disease is a chronic gastrointestinal disorder. Previous studies have suggested that chronic gastrointestinal tract is involved in the pathophysiology of Parkinson's disease.

OBJECT

This study investigated the potential link between colonic diverticular disease and risk of Parkinson's disease.

METHODS

Data in this nationwide population-based cohort study were obtained from the National Health Insurance Research Database. Patients with colonic diverticular disease were identified from among 23.22 million insured Taiwanese residents who had been diagnosed between 2000 and 2005 and were aged ≥20 years (n = 23367). The comparison cohort included patients without colonic diverticular disease, matched by sex, age, and all comorbidities with the colonic diverticular disease patients cohort (n = 23367). Using univariable and multivariable Cox proportional hazard regression models, we estimated the adjusted hazard ratio (aHR) for PD with a 95% confidence interval (CI) after adjusting for age, sex, and all of comorbidities.

RESULTS

The risk of Parkinson's disease was higher in the CDD cohort than in the comparison cohort (HR = 1.27, 95%CI = 1.10-1.47). Compared with patients aged ≥65 years without CDD, the CDD patients in the equal age group had a 1.25-fold increased risk of PD (95% CI = 1.07-1.46).

CONCLUSION

Colonic diverticular disease may be associated with an increased risk of Parkinson's disease. Thus, the risk of this neurodegenerative disease should be considered in patients with colonic diverticular disease.

The effect of cyclic rifaximin therapy on symptoms of diverticular disease from the perspective of the gastroenterology outpatient clinic: a "real-life" study

Introduction

Symptomatic uncomplicated diverticular disease of the colon (SUDD) is one of the most common diseases with which patients present to a gastroenterologist. Mild forms of diverticulitis can also be treated using rifaximin. Although numerous randomised controlled trials have already demonstrated the efficacy of rifaximin therapy, there is still a lack of data from daily medical practice.

Aim

To assess the effect of rifaximin on the symptoms of diverticular disease (SUDD and mild diverticulitis) in patients undergoing routine treatment in gastroenterology outpatient clinics in Poland.

Material and methods

The retrospective study included 142 patients with a diagnosis of SUDD and mild diverticulitis, with a mean age of 60–69 years (41%), of whom 65% were women. Patients underwent three cycles of rifaximin therapy at a dose of 2 × 400 mg daily for 7 days over 3 consecutive months. Survey data were collected during monthly clinic appointments using a questionnaire completed by 48 gastroenterologists, and in selected cases standard inflammatory parameters were also determined.

Results

After just one cycle of therapy a significant reduction in disease symptoms was observed (abdominal pain, abdominal tenderness, bloating, disturbances in bowel habit), defined over a scale of 0–3 points. The mean intensity of symptoms decreased from 1.7 ±0.7 to 0.8 ±0.3 points (with a maximum symptom intensity of 3.0 points). After three cycles, the severity of symptoms decreased markedly to an average of 0.3 ±0.1, and as many as 75% of patients reported no abdominal pain (previously the percentage was only 4%). These differences were statistically significant, p < 0.001. The decrease in inflammatory parameters (white blood cell count, C-reactive protein and erythrocyte sedimentation rate) was statistically significant.

Conclusions

Rifaximin is highly effective in the symptomatic relief of uncomplicated diverticular disease of the large bowel, and it is also effective in the treatment of mild forms of diverticulitis. Although the effects were already visible after the first cycle of therapy, the highest efficacy was obtained after three cycles of therapy. Rifaximin can be successfully used in routine medical practice.

Limited evidence of abnormal intra-colonic pressure profiles in diverticular disease - a systematic review

AIM

Abnormal colonic pressure profiles and high intraluminal pressures are postulated to contribute to the formation of sigmoid colon diverticulosis and the pathophysiology of diverticular disease. This study aimed to review evidence for abnormal colonic pressure profiles in diverticulosis.

METHOD

All published studies investigating colonic pressure in patients with diverticulosis were searched in three databases (Medline, Embase, Scopus). No language restrictions were applied. Any manometry studies in which patients with diverticulosis were compared with controls were included. The Newcastle-Ottawa Quality Assessment Scale (NOS) for case-control studies was used as a measure of risk of bias. A cut-off of five or more points on the NOS (fair quality in terms of risk of bias) was chosen for inclusion in the meta-analysis.

RESULTS

Ten studies (published 1962-2005) met the inclusion criteria. The studies followed a wide variety of protocols and all used low-resolution manometry (sensor spacing range 7.5-15 cm). Six studies compared intra-sigmoid pressure, with five of six showing higher pressure in diverticulosis vs controls, but only two reached statistical significance. A meta-analysis was not performed as only two studies were above the cut-off and these did not have comparable outcomes.

CONCLUSION

This systematic review of manometry data shows that evidence for abnormal pressure in the sigmoid colon in patients with diverticulosis is weak. Existing studies utilized inconsistent methodology, showed heterogeneous results and are of limited quality. Higher quality studies using modern manometric techniques and standardized reporting methods are needed to clarify the role of colonic pressure in diverticulosis.

Rifaximin and diverticular disease: Position paper of the Italian Society of Gastroenterology (SIGE)

Management of diverticular disease has significantly improved in the last decade. Antibiotic treatment is used for symptom relief and prevention of complications. In Italy, the non-absorbable antibiotic rifaximin is one of the most frequently used drugs, and it is perceived as the reference drug to treat symptomatic diverticular disease. Its non-systemic absorption and high faecal concentrations have oriented rifaximin use to the gastrointestinal tract, where rifaximin exerts eubiotic effects representing an additional value to its antibiotic activity. This position paper was commissioned by the Italian Society of Gastroenterology governing board for a panel of experts (RC, GB, BA) to highlight the indications for treatment of diverticular disease. There is a lack of rationale for drug use for the primary prevention of diverticulitis in patients with diverticulosis; thus, rifaximin use should be avoided. The cyclic use of rifaximin, in association with high-fibre intake, is safe and useful for the treatment of symptomatic uncomplicated diverticular disease, even if the cost-efficacy of long-term treatment remains to be determined. The use of rifaximin in the prevention of diverticulitis recurrence is promising, but the low therapeutic advantage needs to be verified. No evidence is available on the efficacy of rifaximin treatment on acute uncomplicated diverticulitis.

Management of Acute Uncomplicated Diverticulitis May Exclude Antibiotic Therapy

Diverticulitis is a common ailment that is prevalent in the developed world. As such, the management of diverticulitis places a substantial economic burden on healthcare. Research is ongoing to further elucidate both the pathogenesis of the disease, as well as ways to reduce associated expenditures. One of these emerging areas of research calls into question the use of antibiotics during treatment of acute uncomplicated diverticulitis. Current guidelines are largely based on expert opinion, with little evidence supporting the standard practice of antibiotic therapy. In this literature review, we have compiled and analyzed the latest collection of evidence in managing acute uncomplicated diverticulitis. There have been two randomized controlled trials (RCTs) performed that assessed the possibility of treating acute uncomplicated diverticulitis without antibiotics. Both the Antibiotika Vid Okomplicerad Divertikulit (AVOD) study and Daniels, et al. have found that an observational approach to acute uncomplicated diverticulitis is not inferior to antibiotic treatment and does not result in increased complication or recurrence rates. We also reviewed a single-center cohort study, a prospective observational study, and two retrospective case-controlled studies comparing observational management versus antibiotic treatment in patients with acute uncomplicated diverticulitis. We found the results were comparable; there was no difference in complication rates or recurrence in any study. The consensus among the studies reviewed challenges the current practice guidelines issued by the American Gastroenterological Association. However, given the geographical difference in diverticular disease and inherent bias found in these studies, we cannot recommend a modification of the guidelines. Based on this literature review, we feel compelled to suggest, and strongly recommend, further research be conducted in the United States in order to bolster the already significant evidence against antibiotic therapy in acute uncomplicated diverticulitis.

Western Dietary Pattern Increases, and Prudent Dietary Pattern Decreases, Risk of Incident Diverticulitis in a Prospective Cohort Study

BACKGROUND & AIMS

Dietary fiber is implicated as a risk factor for diverticulitis. Analyses of dietary patterns may provide information on risk beyond those of individual foods or nutrients. We examined whether major dietary patterns are associated with risk of incident diverticulitis.

METHODS

We performed a prospective cohort study of 46,295 men who were free of diverticulitis and known diverticulosis in 1986 (baseline) using data from the Health Professionals Follow-Up Study. Each study participant completed a detailed medical and dietary questionnaire at baseline. We sent supplemental questionnaires to men reporting incident diverticulitis on biennial follow-up questionnaires. We assessed diet every 4 years using a validated food frequency questionnaire. Western (high in red meat, refined grains, and high-fat dairy) and prudent (high in fruits, vegetables, and whole grains) dietary patterns were identified using principal component analysis. Follow-up time accrued from the date of return of the baseline questionnaire in 1986 until a diagnosis of diverticulitis, diverticulosis or diverticular bleeding; death; or December 31, 2012. The primary end point was incident diverticulitis.

RESULTS

During 894,468 person years of follow-up, we identified 1063 incident cases of diverticulitis. After adjustment for other risk factors, men in the highest quintile of Western dietary pattern score had a multivariate hazard ratio of 1.55 (95% CI, 1.20-1.99) for diverticulitis compared to men in the lowest quintile. High vs low prudent scores were associated with decreased risk of diverticulitis (multivariate hazard ratio, 0.74; 95% CI, 0.60-0.91). The association between dietary patterns and diverticulitis was predominantly attributable to intake of fiber and red meat.

CONCLUSIONS

In a prospective cohort study of 46,295 men, a Western dietary pattern was associated with increased risk of diverticulitis, and a prudent pattern was associated with decreased risk. These data can guide dietary interventions for the prevention of diverticulitis.

Symptomatic Diverticular Disease in Patients With Severely Reduced Kidney Function: Higher Rates of Complications and Transfusion Requirement

Background

The prevalence of diverticulosis is increasing with 5-10% of patients developing diverticulitis and 5-15% developing symptomatic bleeding. Diverticulitis can result in abscess, perforation, fistula, or obstruction. Bleeding has combined morbidity and mortality rates of 10-20%. The purpose of this study was to compare diverticulitis-related complications and transfusion requirements for diverticular bleeding in patients with normal to moderately reduced kidney function (glomerular filtration rate (GFR) ≥ 30 mL/min/1.73 m²) and patients with severe renal impairment (GFR < 30 mL/min/1.73 m²), and identify factors associated with these outcomes.

Methods

We retrospectively reviewed records of all patients with diverticulitis and diverticular bleeding treated at our hospital from January 1, 2011 to July 31, 2016. Patients were evaluated for baseline characteristics, GFR, baseline hemoglobin, medications, comorbidities, length of stay (LOS), presence of perforations or abscesses and the need for transfusion.

Results

Of the 291 patients included, males were 167 (58%). Perforations and abscesses complicating diverticulitis developed in 31/136 (23%) of patients with GFR ≥ 30 mL/min/1.73 m², and in 13/26 (50%) of patients with GFR < 30 mL/min/1.73 m² (odds ratio (OR): 3.4; 95% confidence interval (CI): 1.423 - 8.06; P = 0.0073). Mean LOS (days) was 6.3 ± 4 in the GFR ≥ 30 mL/min/1.73 m² group and 8.5 ± 4.4 in GFR < 30 mL/min/1.73 m² group (P = 0.0001). Blood transfusion for diverticular bleeding occurred in 11/78 (14%) of patients with GFR ≥ 30 mL/min/1.73 m² and in 22/51 (43%) of patients with GFR < 30 mL/min/1.73 m² (OR: 4.6; 95% CI: 1.99 - 10.76; P = 0.0004). Among patients who needed transfusion, mean LOS was 8.5 ± 2.5 in GFR ≥ 30 mL/min/1.73 m² group and 9 ± 5 in those with GFR < 30 mL/min/1.73 m² (P = 0.04). There were no differences in age, gender or race between the study groups.

Conclusion

There was a significant increase in complicated diverticulitis cases, transfusion requirements for diverticular bleeding and LOS in patients with severely reduced kidney function compared to patients with normal-moderately reduced renal function.