Diverticulosis of the colon in Israel

Predictors of Clinical Course and Outcomes of Acute Diverticulitis: The Role of Age and Ethnicity

Background and Objectives: Acute diverticulitis (AD) is the leading and most burdensome complication of colonic diverticulosis. However, risk factors for its development and predictors of its course are still poorly defined. In this regard, the association of a young age with a complicated course and worse outcome are still controversial. Moreover, little research has addressed the effect of ethnicity on the course of AD. The current study aimed to evaluate the impact of these variables on AD’s course and outcome in the diverse and unique ethnic landscape of Israel. Materials and Methods: We performed a retrospective review of the charts of patients with a radiologically confirmed diagnosis of AD. Patients’ outcomes and disease course, including hospitalization duration, complications, and recurrent episodes, were documented and compared among different age and ethnic groups. Multivariate analysis was performed to identify predictors of complicated AD. Results: Overall, 637 patients with AD were included, the majority (95%) had distal colon AD, and almost one quarter of them were aged less than 50 years. The majority of patients in the young age (<50) group were males (69.7%). Nonetheless, the rate of recurrent episodes (35.3% vs. 37.3%, p = 0.19), hospitalization duration (5 ± 4.7 vs. 6 ± 3.2, p = 0.09) and complications rate (17.3% vs. 13.7%; p = 0.16) were similar for both age groups. In the ethnicity group analysis, Arab minority patients had a first episode of AD at a significantly younger age compared to their Jewish counterparts (51.8 vs. 59.4 years, p < 0.001). However, factors such as a complicated course (16% vs. 15%; p = 0.08) and relapsing episode rates (33% vs. 38%; p = 0.36) did not differ significantly between groups. None of the variables, including young age and ethnic group, were predictors of complicated AD course in the multivariate analysis. Conclusion: AD is increasingly encountered in young patients, especially in ethnic minority groups, but neither ethnicity nor young age was associated with worse outcomes.

Israeli Arabs develop diverticulitis at a younger age and are more likely to require surgery than Jews

BACKGROUND

Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis.

AIM

To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery.

METHODS

Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012.

RESULTS

Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis.

CONCLUSIONS

Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis.

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.

Diverticular disease and migration--the influence of acculturation to a Western lifestyle on diverticular disease

BACKGROUND

Diverticular disease of the colon is more common in the Western world, compared with non-Western countries.

AIM

To investigate the risk of diverticular disease in immigrants of diverse ethnicity and in different phases of acculturation.

METHODS

Socio-demographic indicators and the risk of diverticular disease were investigated. The study population was a prospectively followed national cohort of 4 million residents born between 1925 and 1965. Risk ratios (RRs) of hospital admissions and deaths because of diverticular disease and acute diverticulitis from 1991 through 2000 were calculated.

RESULTS

The risk of hospital admission because of diverticular disease, after adjustment for age, sex and socio-economic indicators, was lower in non-Western immigrants (RRs = 0.5-0.7) compared with natives and the risk increased with time after the settlement. Women of all origins had a higher risk compared with men (RR = 1.5). This sex-difference increased with age (P < 0.001). Socio-economic status, residency or housing situation were not risk factors.

CONCLUSION

This population-based study found that immigrants from non-Westernized countries had lower relative risks for hospitalization because of diverticular disease than natives, but the risk increased during a relatively short period of time after settlement. Diverticular disease of the colon appears to be an acquired disorder and acculturation to a Western lifestyle has an impact on the risk.

Colonic diverticular disease in a multiracial Asian patient population has an ethnic predilection

BACKGROUND

Traditionally, diverticular disease of the colon has been attributed to ageing, low dietary fibre and a high intraluminal pressure. Recently, genetic and racial factors have also been implicated.

METHODS

Four-hundred and ten consecutive multiracial Asian patients undergoing colonoscopy for a variety of bowel symptoms in a private endoscopy unit were studied for differing frequencies (if any) in colonic diverticular disease and concomitant abnormalities.

RESULTS

Forty-one patients (10%) had diverticular disease. Diverticula were present in 22/147 Chinese (15%), 14/153 Indians (9%) and 5/110 Malays (4.5%). The mean age of patients with diverticular disease was 55 years as compared with 51.3 years in those without (P = 0.12) and there was no gender difference. Thirty-six patients (88%) had diverticula in the right colon only, four patients (10%) exclusively in the left hemicolon, and one patient (2%) had bilateral involvement. Using regression analysis, Chinese ethnicity [odds ratio (OR)=2.11; 95% confidence interval (CI), 1.09-4.09; P = 0.027), constipation (OR = 2.65; 95% CI, 1.23-5.42; P = 0.007) and colorectal adenomas (OR = 2.65; 95% CI, 1.08-6.46; P = 0.033) were independently associated with diverticular disease.

CONCLUSIONS

Colonic diverticular disease in a multiracial Asian patient population has an ethnic predilection and is predominantly right-sided.

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.

Epidemiological evaluation of colonic diverticulosis and dietary fiber in Japan

The incidence of colonic diverticulosis was examined in 5 hospitals geographically isolated from each other in Japan during the period between mid '70s and 1986. The incidence rapidly increased in all hospitals from 3.5-9.0% in mid '70s and 8.4-23.2% in 1986. The ratio of right-sided type colonic diverticulosis was approximately 70-80% in each hospital and the ratio did not fluctuate significantly during the period. Birth cohort analysis revealed that although the incidence of right-sided diverticula had increased with aging, in groups born in more recent decades right-sided diverticula appeared in younger age than other groups. It was suggested that environmental factors rather than congenital factors may cause the increase of the incidence of right-sided colon diverticula.

Diverticular disease

Although most often clinically silent, colonic diverticula are responsible for a large number of gastrointestinal illnesses in our society. Complications of diverticular disease, including perforation and hemorrhage, may occur in 15% to 20% of patients with diverticula during their lifetime, and although often mild and self-limiting diseases, they too frequently cause life-threatening problems that require prompt surgical intervention. Despite a cadre of sophisticated laboratory and radiologic tests that have been developed to aid in the diagnosis of complicated diverticular disease, the diagnosis and treatment of diverticulitis still relies heavily on patient history, physical examination, physician judgment, and the patient's clinical response to treatment. Thus it is important for the managing physician to fully understand the pathogenesis of diverticula, the clinical consequences and modes of presentation of complicated diverticular disease, and the array of interventions available for treatment of these problems. This monograph summarizes our knowledge of diverticular disease to date and tries to give specific guidelines for the treatment of patients with complicated diverticulitis. However, it must be understood that the presentation and severity of these complications vary widely from patient to patient. Thus one cannot take a single approach toward a patient who has diverticulitis or diverticular bleeding. Rather, successful outcomes depend on an individual approach to each patient while maintaining certain generally accepted principles of treatment.

The changing epidemiology of diverticular disease in Israel

In a retrospective evaluation of 1244 consecutive barium enemas performed at two hospitals over a five-year period (1979 to 1984), colonic diverticula were found in 177 (14.2 percent). The prevalence among the Ashkenazi Jews was 19.7 percent, among the Sephardi and Oriental Jews, 16 percent, and among the Arabs, 9.5 percent. Comparing these figures with the results of a similar study performed ten years ago, it becomes obvious that the prevalence of diverticular disease in the Ashkenazi group remained the same, while there was a three-fold increase among Sephardi and Oriental Jews, and a seven-fold increase among Arabs. It is postulated that, in less than one generation, diverticular disease will be equally frequent among all ethnic groups in Israel.

Diverticular disease of the colon in Japan. A review of 615 cases

Of 615 patients with diverticular disease of the colon, 429 had diverticula in the cecum and ascending colon, 98 in the sigmoid and descending colon and 88 in both the right- and left-side colon. The right-sided type was more common in younger people and more predominant in men, whereas the left-sided type was more common in the elderly and showed no difference in numbers between men and women. More than 50 per cent of patients were asymptomatic and 25 per cent complained of disturbed bowel function. The frequency of diverticulitis was not related to location, but to the number of diverticula. Seventy-seven were complicated by acute inflammation (right-sided diverticulitis, 61, and left-sided diverticulitis, 16). Many patients with right-sided diverticulitis improved with medical treatment and the operative procedure of choice was drainage of the inflamed area with supplemental appendectomy.

Diverticular disease of the colon in Jordan

In a case review over a nine-year period, 35 patients were referred to the University Hospital with a variety of abdominal symptoms related to the gastrointestinal tract, were found to have diverticular disease of the colon. In a retrospective evaluation of 274 consecutive barium enemas performed at the same institute in patients aged 20 to 85 years, in a three-year period (1979 to 1981), colonic diverticula were found in 11 patients, giving incidence of 4 per cent; all positive enemas for diverticulosis in this group occurred in patients over the age of 40 years.

Prevalence of colonic diverticular disease in southern Iran

Five hundred fifty-six barium enema examinations performed in male and female patients (aged 20--70+ years) were studied retrospectively to estimate the prevalence of colonic diverticulosis in southern Iran. The frequency of diverticulosis in all subjects above the age of 20 years was 1.6 per cent, in persons above the age of 50 years, 2.4 per cent, and in persons below the age of 50 years, 1.2 per cent. This is in marked contrast to the high prevalence of the disease in Western countries, e.g., the 20 per cent overall prevalence in the United States. The high dietary fiber intake of the Iranian people may explain the rarity of the disease in Iran.

Diverticular disease of the large intestine in Northern Norway

In 280 unselected necropsies on patients over 20 years of age in Northern Norway, diverticular disease was present in 25% of the males and 43% of the females. The frequency of diverticular disease increased in both sexes by age. Both the frequency of diverticular disease and the average number of diverticula per case with diverticular disease were higher in females than in males in all age groups. The sigmoid was the most frequent site of diverticula in both sexes and for all ages, and the average number of diverticula per diverticulum-bearing segment was also highest in the sigmoid for all ages and in both sexes. The average number of diverticula in the sigmoid of affected individuals increased with age and with the number of segments involved. Diverticular disease was not associated with adenomas of the large intestine or with malignant or benign neoplasms elsewhere in the body or with any of the common diseases thought to be related to a Western type of diet, except with cerebrovascular disease.