Does uncomplicated diverticular disease produce symptoms?

Probiotics in Gastroenterology: How Pro Is the Evidence in Adults?

Probiotic usage has become popular with both medical practitioners and the community in general; patients commonly seek advice regarding what, if any, such preparation would be useful for their own diseases. Since such advice should be evidence-based, identified randomized clinical trials (RCTs) for a number of gastrointestinal conditions were reviewed; the data were organized by individual probiotic genera/species. Only trials in adults were considered. Most of the identified RCTs were small and low-quality, so any conclusions to be drawn will be limited at least by methodologic problems. Using the GRADE system to consider the reliability of the evidence generated from these RCTs, it did appear that the use of fecal microbial transplantation to treat recurrent Clostridium difficile infection is well justified. Given the methodologic issues, there was moderately good evidence for preventing antibiotic-associated diarrhea with Lactobacillus, Bifidobacterium, Streptococcus, or Saccharomyces boulardii and for using Lactobacillus, Bifidobacterium, or Saccharomyces as adjunct therapy in the treatment of Helicobacter pylori. There were other conditions for which some supportive evidence was available. These conditions include VSL#3 for maintaining remissions in patients with pouchitis or treating active ulcerative colitis (UC), fecal microbial transplantation for treating active UC, Bifidobacterium for treating patients with UC in remission, Lactobacillus in patients with painful diverticulosis, a variety of probiotics (Lactobacillus, Bifidobacterium, Streptococcus, or VSL#3) in patients with minimal hepatic encephalopathy, and providing synbiotics to patients postoperatively after liver transplantation. Unfortunately, other limitations in the evidence made it very likely that future research will have an effect on the estimated benefit; these interventions cannot yet be recommended for routine use.

Association between colonic diverticulosis and bowel symptoms: A case-control study of 1629 Asian patients

BACKGROUND

It remains unclear whether diverticulosis, absent inflammation, is responsible for chronic bowel symptoms. We examined the association between bowel symptoms and asymptomatic diverticulosis.

METHOD

This case-control study included 543 patients with diverticulosis and 1086 age and sex-matched controls (1:2) without diverticulosis on screening colonoscopy. Eleven symptoms (abdominal discomfort, hunger discomfort, borborygmus, abdominal distension, flatus, constipation, diarrhea, loose stools, hard stools, fecal urgency, and incomplete evacuation) were evaluated using a gastrointestinal symptoms rating scale (GSRS) at baseline and second questionnaire. Associations between diverticulosis and symptoms were estimated using odds ratios (ORs) and 95 confidence interval (CI).

RESULTS

In multivariate analysis, constipation (OR, 0.85 [0.78-0.93]) and hard stools (OR, 0.86 [0.78-0.94]) were negatively associated with diverticulosis. The other nine symptoms showed no association with diverticulosis. Diverticulosis was negatively associated with constipation (OR, 0.93 [0.74-0.93]), hard stools (OR, 0.85 [0.76-0.96]), and incomplete evacuation (OR, 0.88 [0.79-0.99]) in males, and positively associated with diarrhea (OR, 1.39 [1.14-1.69]) and loose stools (OR, 1.28 [1.05-1.55]) in females. No bowel symptoms were positively associated with any of right-sided, left-sided, or bilateral diverticulosis. Test-retest reliability of GSRS (mean interval, 4.4 months) was moderate (Mean Kappa, 0.568) in males and good (Mean Kappa, 0.652) in females.

CONCLUSIONS

This large, colonoscopy-based, case-control study demonstrated that neither constipation nor hard stools were associated with an increased risk of diverticulosis, regardless of diverticulum location. In females, but not males, diarrhea and loose stools were positively associated with diverticulosis. Long-term test-retest reliability suggested that these symptoms remain consistent over a given period.

Acute abdominal pain in the older adult

Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.

Uncomplicated diverticular disease is not a common cause of colonic symptoms

BACKGROUND

Colonic diverticular disease is common among older individuals whereas colonic symptoms, such as those of irritable bowel syndrome, are frequent in the general population.

AIM

To determine among patients in secondary care, if uncomplicated diverticular disease is a common cause of colonic symptoms.

METHODS

Patients aged ≥50 years attending gastroenterology out-patient clinics or scheduled for colonoscopy or barium enema in a secondary care hospital were invited to take part. Those with structural gastrointestinal diseases were excluded. Participants completed a locally validated Rome II questionnaire on colonic symptoms. Patients with diverticular disease were compared with those without.

RESULTS

Seven hundred and eighty four patients with no structural pathology other than diverticular disease or benign colonic polyps completed the study. A total of 744 patients underwent colonoscopy, 40 barium enema. Of these, 281 patients had diverticular disease. Among patients with and without diverticular disease, the frequency of abdominal pain, diarrhoea, constipation and irritable bowel syndrome were 123 (44%) and 226 (46%), 44 (16%) and 80 (17%), 38 (14%) and 80 (17%) and 66 (25%) and 119 (25%), respectively (N.S.).

CONCLUSION

Uncomplicated colonic diverticular disease is not a common cause of colonic symptoms among patients in secondary care.

History, incidence, and epidemiology of diverticulosis

Diverticulosis of the colon is a very common condition. Described as early as the 17th century, most of the information we now have is based on much of the work during the 20th century. Age, sex, race, and geography all play a specific role in the development of diverticula. It is the merging of these factors that changes the prevalence of diverticula and their manifestations. Symptomatic diverticula can lead to serious complications requiring both medical and surgical interventions to treat these complications when they occur. This review will focus on the history and epidemiology of diverticulosis in regard to age, sex, race, geography, and the epidemiology of complicated diverticular disease.

Diagnostic yield of colonoscopy based on symptoms

OBJECTIVE

There are only a few data on the diagnostic yield of colonoscopy in different symptoms. The aim of this study was to assess the outcome of colonoscopy in patients with various gastrointestinal symptoms and to estimate the relation between the findings and the presenting symptoms.

MATERIAL AND METHODS

1121 consecutive colonoscopies were registered during 1 year. Asymptomatic subjects and patients with known inflammatory bowel disease (IBD) were excluded, leaving 767 eligible for the study. Symptoms, findings and clinical judgement about their relation were recorded.

RESULTS

In patients with bleeding symptoms (n=405), serious colonic pathology--cancers and adenomas >1 cm, IBD and angiodysplasia--was found in 54 (13.3%), 83 (20.5%) and 20 (4.9%) patients, respectively; 162 (40%) patients had findings that could be related to the symptom. In 173 subjects with non-bloody diarrhoea, the diagnostic yield was 31.2%, i.e. mostly IBD and microscopic colitis. In 189 subjects with other gastrointestinal symptoms, the diagnostic yield was 13.2%. Serious colonic pathology was found in 8 of 362 (2.2%) subjects examined because of non-bleeding symptoms.

CONCLUSION

The diagnostic yield of colonoscopy is high in patients with bleeding symptoms or diarrhoea, while the prevalence of significant findings is equal to a screening population in patients with other symptoms.

Management of diverticular disease: is there room for rifaximin?

Treatment of symptomatic diverticular disease of the colon is aimed at the relief of symptoms and the prevention of major complications. The efficacy of fiber supplementation and of anticholinergic and spasmolytic agents remains controversial. Antibiotics are commonly used in the treatment of inflammatory complications of diverticular disease. Data from open labelled and randomized controlled trials do suggest the efficacy of rifaximin in obtaining symptomatic relief in patients with diverticular disease. Approximately 30% therapeutic gain compared to fiber supplementation only can be expected after one year of intermittent treatment with rifaximin. Considering the safety and tolerability of rifaximin, this drug can be recommended for patients with symptomatic uncomplicated diverticular disease.

Patterns of pain in diverticular disease and the influence of acute diverticulitis

BACKGROUND

While the association of recurrent bouts of abdominal pain with colonic diverticulosis is well recognized, the cause of this pain is obscure since in most cases it occurs without obvious diverticulitis or other potential causes.

AIMS

To define the patterns of pain in diverticular disease and the influence of acute diverticulitis.

METHODS

Two studies were undertaken to establish the relationship between bouts of prolonged abdominal pain (> 24 h) presumed to be due to inflammatory diverticulitis and recurrent short-lived pain. In Study 1, 261 patients with a barium enema showing diverticulosis completed a postal questionnaire concerning episodes of both prolonged and short-lived pain. In Study 2, 26 patients previously admitted to hospital with a firm diagnosis of diverticulitis were interviewed for details of their bowel habits since discharge.

RESULTS

Study 1: 94/261 patients experienced recurrent, short-lived pain on a median of five days a month, with a median duration of 3 h. In addition, 51/261 patients described episodes of prolonged pain with a median duration of three days. Of these, 31/51 (61%) experienced recurrent, short-lived pain compared with 63/210 (30%) who had not had an episode of prolonged pain. More specifically, 12/17 (71%) who received antibiotic treatment for presumed acute diverticulitis during their bout of prolonged pain experienced recurrent pain compared with 82/244 (34%) who did not experience such an episode. Study 2: 18/26 patients hospitalized for acute diverticulitis developed new, recurrent, short-lived abdominal pain following discharge, with a median duration of 4 h.

CONCLUSION

Episodes of prolonged, presumed inflammatory pain due to diverticulitis are frequently followed by recurrent, short-lived pain similar to that seen in irritable bowel syndrome.

Origin of symptoms in diverticular disease

BACKGROUND

A significant number of patients with colonic diverticula experience unexplained, recurrent, short-lived but often debilitating abdominal pain and alteration in bowel habit. Such patients account for many medical consultations every year but, as our understanding of the cause of their symptoms remains imperfect, treatment options are limited. This article reviews the possible mechanisms that may be responsible for the symptoms of diverticular disease.

METHODS

Medline and Science Citation Index searches were performed to locate English language articles relating to colonic diverticula and symptoms published between January 1966 and July 2002. Manual cross-referencing was also performed and some historical articles were included.

RESULTS AND CONCLUSION

Several theories now exist about the mechanisms underlying the symptoms of diverticular disease. Initial studies suggested that they may be due to alterations in the intracolonic pressure, extrapolating earlier thoughts on the likely pathogenesis of diverticula. It seems more likely, however, that several inter-related processes, such as muscular dysfunction, visceral hypersensitivity and inflammation, are involved in symptom generation.

The effect of non-pathogenic Escherichia coli in symptomatic uncomplicated diverticular disease of the colon

BACKGROUND

The effect of probiotics in symptomatic uncomplicated diverticular disease of the colon has not been followed.

DESIGN

Treatment (T1) with an intestinal antimicrobial (dichlorchinolinol) and absorbent (active coal tablets) was compared with the same set-up supplemented with non-pathogenic Escherichia coli(T2) in a prospective open trial.

SETTING

The study was performed at the outpatient department of a tertiary centre.

PARTICIPANTS

Fifteen subjects (5 males, 10 females) aged 68-91 years (average 74.8 years) presented with abdominal pain, irregular defecation, bloating and excessive flatulence. Diagnosis was established with colonoscopy, double-contrast barium enema, or both.

INTERVENTIONS

The T1 regimen was administered for 1 week. In the T2 regimen, the application of E. coli strain Nissle (Mutaflor capsules, 2.5 x 10(10) viable bacteria/capsule) followed immediately after T1 for an average of 5.2 weeks.

MAIN OUTCOME MEASURES

The lengths of two successive remissions with the T1 set-up were compared with the length of remission after T2. The intensity of symptoms before and after administration of the probiotic was also evaluated. RESULTS The lengths of two successive remissions after T1 amounted to 2.66 and 2.20 months (average 2.43 months). The average length of remission after T2 was 14.1 months (P < 0.001). All symptoms after T2 decreased significantly (P < 0.001).

CONCLUSIONS

Non-pathogenic strain Nissle significantly prolonged the remission period and improved the abdominal syndrome in symptomatic uncomplicated diverticular disease. A randomized, placebo-controlled study is recommended.

Epidemiology of diverticular disease

Diverticulosis, which is an acquired condition marked by mucosal herniation through defects in the colonic wall, has been termed both a "disease of the 20th century" and a "disease of Western civilization" due to its increasing prevalence in modern times and its striking geographical variability. Both of these epidemiological observations may provide interesting insights into the pathophysiology of diverticulosis. This chapter will review the known epidemiology of diverticulosis coli and its main complications: diverticulitis and diverticular haemorrhage. Where possible, attempts will be made to place these observational reports in the context of both the cause and clinical behaviour of this disorder.

Colonic diverticulosis in Hong Kong: distribution pattern and clinical significance

This is a retrospective study on the prevalence of diverticulosis in Hong Kong Chinese adults. Eight-hundred and fifty-eight consecutive barium enema examinations over a period of 18 months (January 1995-June 1996) were analysed. Results show that the prevalence of diverticulosis in our community is 25.1% with no significant difference between male and female adults. The prevalence is lower than Western countries but higher than in Asia. Moreover, the peak prevalence is at the 50-79 years age group with lower prevalence in the older age groups. This may be explained by the rapid rise in prevalence in the younger age groups so that the age-related increase in prevalence become obscured. We postulate that this may be due to Western cultural influence in our diet and lifestyle. There is no significant difference in the symptomatology of patients with and without diverticulosis, supporting the idea that diverticulosis alone is usually asymptomatic. There is predominance of right hemicolon involvement in our subjects, in contrast to the left hemicolon predominance in the Caucasian population. Of patients with diverticulosis, 55.3% have only right-sided involvement and 32.6% have bilateral involvement. Only 12.1% of patients with diverticulosis have exclusively left hemicolon involvement. Caecal and ascending colon diverticula are found in 6.4% and 17.6% of all the adults under study, respectively. Clinicians caring for patients from our community should take note of this high frequency of caecal and ascending colon diverticulosis as caecal and ascending colon diverticulitis is notoriously difficult to diagnose clinically.

A prospective study of dietary fiber types and symptomatic diverticular disease in men

To examine prospectively dietary fiber calculated from food composition values based on analytic techniques and specific dietary fiber types in relation to risk of diverticular disease, we analyzed data from a prospective cohort of 43,881 U.S. male health professionals 40-75 y of age at base line; subjects were free of diagnosed diverticular disease, colon or rectal polyps, ulcerative colitis and cancer. The insoluble component of fiber was inversely associated with risk of diverticular disease relative risk (RR) = 0. 63, 95% confidence interval (CI), 0.44-0.91, P for trend = 0.02, and this association was particularly strong for cellulose (RR = 0.52, 95% CI, 0.36-0.75, P for trend = 0.002). The association between diverticular disease and total dietary fiber intake calculated from the AOACstandards method was not appreciably different from results using the Southgate or Englyst method [for AOAC method, RR = 0.60, 95% CI, 0.41-0.87; for Southgate method, RR = 0.61, 95% CI, 0.42-0. 88; for Englyst method, RR = 0.60, 95% CI, 0.42-0.87, for the highest quintiles]. Our findings provide evidence for the hypothesis that a diet high in dietary fiber decreases the risk of diverticular disease, and this result was not sensitive to the use of different analytic techniques to define dietary fiber. Our findings suggest that the insoluble component of fiber was significantly associated with a decreased risk of diverticular disease, and this inverse association was particularly strong for cellulose.

Efficacy of rifaximin in the treatment of symptomatic diverticular disease of the colon. A multicentre double-blind placebo-controlled trial

BACKGROUND AND AIMS

In a recent open trial we have shown the efficacy of long term intermittent administration of a poorly absorbable antibiotic (rifaximin) in obtaining symptomatic relief in uncomplicated diverticular disease of the colon. The aim of this double-blind placebo-controlled trial was to test our previous observations.

METHODS

One hundred and sixty-eight outpatients with symptomatic uncomplicated diverticular disease were treated with fibre supplementation (glucomannan 2 g/day) plus rifaximin 400 mg b.d. for 7 days every month (84 patients), or with glucomannan 2 g/day plus placebo two tablets b.d. for 7 days every month (84 patients). Clinical evaluation was performed at admission and at three-month intervals for 12 months.

RESULTS

After 12 months, 68.9% of the patients treated with rifaximin were symptom-free or mildly symptomatic, compared to 39.5% in the placebo group (P = 0.001). Symptoms such as bloating and abdominal pain or discomfort were primarily affected by antibiotic treatment when compared with placebo (P < 0.001).

CONCLUSION

Rifaximin appears to be of some advantage in obtaining symptomatic relief in diverticular disease of the colon when compared with fibre supplementation alone.

Age and sex: underestimated selection criteria for referral to x-ray examination of the colon?

An analysis was made of 2416 consecutive patients who underwent a double-contrast barium enema at the Central Roentgen Institute in Oslo. Age, sex, and radiological findings were registered. The age and sex distribution among patients consulting in general practice and in our study was surprisingly similar. This suggests that age as a risk factor for colorectal neoplasms did not play a prominent role among the referring doctors. Colorectal cancer was more frequent in males (4%) than females (2%) (p = 0.03). Odds ratio adjusted for age was 2.1 (1.3-3.8). This may be due to few examinations performed in old age, and different patient behaviour when experiencing colorectal symptoms. The overall polyp frequency was 11%. The frequency increased significantly from the age group 40-49.

Identity cards for patients infected with HIV?

Dr A C Srivastava has written to us to describe a case that raises the suggestion that people infected with the human immuno-deficiency virus (HIV) should carry identity cards. We asked two physicians, a general practitioner working with patients with the acquired immune deficiency syndrome (AIDS), and a general practitioner with a special interest in medical ethics to respond to the broad issues raised by Dr Srivastava's letter.

Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece

A case control study exploring the role of diet and other biosocial factors in the aetiology of diverticulosis was undertaken in Athens, Greece, in 1981-1982. One hundred consecutive cases with radiologically confirmed diverticulosis and 110 control patients with fractures or other orthopaedic disorders were submitted to a structured interview, including frequency of consumption of about 80 food items. The main positive findings were, (i) the cases reported significantly less frequent consumption of vegetables, brown bread and, to a lesser extent, potatoes and fruits, and (ii) the cases reported significantly more frequent consumption of meat and, to a lesser extent, milk, and milk products. The difference in risk between those people who frequently consume vegetables but rarely consume meat, and those who rarely consume vegetables and frequently consume meat, was almost 50-fold.