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Garfinkle R, Boutros M. Current Management of Diverticulitis. Adv Surg 2024; 58:87-106. [PMID: 39089789 DOI: 10.1016/j.yasu.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Over the last few decades, our understanding of the pathophysiology and natural history of sigmoid diverticulitis has greatly improved. This knowledge has challenged many of the traditional principles in the management for diverticulitis, such as routine antibiotic administration in all cases, number-based recommendations for elective surgery, and the necessity for an end colostomy in emergency surgery. This review will cover the breadth of management for sigmoid diverticulitis, covering both uncomplicated and complicated disease as well as elective and emergent disease presentations. New and emerging concepts in management will be highlighted with a particular focus on level-1 data, when available.
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Affiliation(s)
- Richard Garfinkle
- Division of Mayo Clinic Colon and Rectal Surgery, 200 First Street, SW, Rochester, MN 55905, USA; Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marylise Boutros
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Department of Colorectal Surgery, Cleveland Clinic Florida, Ellen Leifer Shulman and Steven Shulman Digestive Disease Institute, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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2
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Quigley EMM. Can diet change the natural history of gastrointestinal diseases? JGH Open 2024; 8:e13063. [PMID: 38770354 PMCID: PMC11103768 DOI: 10.1002/jgh3.13063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 03/27/2024] [Indexed: 05/22/2024]
Abstract
Belatedly, gastroenterologists have begun to pay attention to the role of diet in the exacerbation of gastrointestinal symptoms in many digestive disorders-a recognition that has spurred both high-quality clinical trials and translational research into this area. It has become clear that multiple mechanisms acting either in isolation or together can induce gut symptoms and that appropriate interventions can lead to significant relief. What this review will explore is not the role of diet in the production of certain symptoms or symptom clusters, but rather whether a dietary intervention can beneficially alter the natural history of a gastrointestinal disease-a much more demanding expectation. Yet there are examples of where a diet, if sustained, can have a long-term impact on at least some of those affected by conditions such as eosinophilic esophagitis, celiac disease, food allergy, and constipation.
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Affiliation(s)
- Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive DisordersHouston Methodist Hospital and Weill Cornell Medical CollegeHoustonTexasUSA
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3
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Marasco G, Buttitta F, Cremon C, Barbaro MR, Stanghellini V, Barbara G. The role of microbiota and its modulation in colonic diverticular disease. Neurogastroenterol Motil 2023; 35:e14615. [PMID: 37243442 DOI: 10.1111/nmo.14615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/06/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Diverticular disease (DD) is a common condition in Western countries. The role of microbiota in the pathogenesis of DD and its related symptoms has been frequently postulated since most complications of this disease are bacteria-driven and most therapies rely on microbiota modulation. Preliminary data showed fecal microbial imbalance in patients with DD, particularly when symptomatic, with an increase of pro-inflammatory and potentially pathogenetic bacteria. In addition, bacterial metabolic markers can mirror specific pathways of the disease and may be even used for monitoring treatment effects. All treatments currently suggested for DD can affect microbiota structure and metabolome compositions. PURPOSE Sparse evidence is available linking gut microbiota perturbations, diverticular disease pathophysiology, and symptom development. We aimed to summarize the available knowledge on gut microbiota evaluation in diverticular disease, with a focus on symptomatic uncomplicated DD, and the relative treatment strategies.
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Affiliation(s)
- Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Francesco Buttitta
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
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4
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Kruis W, Germer C, Böhm S, Dumoulin FL, Frieling T, Hampe J, Keller J, Kreis ME, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer AG, Leifeld L. German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management. United European Gastroenterol J 2022; 10:940-957. [PMID: 36459576 PMCID: PMC9731665 DOI: 10.1002/ueg2.12313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/11/2022] [Indexed: 12/03/2022] Open
Abstract
Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.
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Affiliation(s)
- Wolfgang Kruis
- Apl Professor der MedizinischenFakultätUniversität KölnCologneGermany
| | - Christoph‐Thomas Germer
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | | | | | | | - Jochen Hampe
- Medizinische Klinik IUniversitätsklinikumTU DresdenDresdenGermany
| | - Jutta Keller
- Medizinische KlinikIsraelitisches KrankenhausHamburgGermany
| | - Martin E. Kreis
- Klinik für Allgemein‐, Viszeral‐ und GefäßchirurgieCharité ‐ Universitätsmedizin BerlinCampus Benjamin FranklinBerlinGermany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2Zentrum für Innere Medizin (ZIM)Universitätsklinikum WürzburgWürzburgGermany
| | - Joachim Labenz
- Abteilung für Innere MedizinEvang. Jung‐Stilling‐Krankenhaus, SiegenSiegenGermany
| | - Johann F. Lock
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | - Jörg Peter Ritz
- Klinik für Allgemein‐ und ViszeralchirurgieHelios Klinikum SchwerinSchwerinGermany
| | - Andreas G. Schreyer
- Institut für diagnostische und interventionelle RadiologieMedizinische Hochschule Brandenburg Theodor Fontane Klinikum BrandenburgBrandenburgGermany
| | - Ludger Leifeld
- Medizinische Klinik 3 – Gastroenterologie und Allgemeine Innere MedizinSt. Bernward KrankenhausHildesheimGermany
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Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
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6
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Carabotti M, Falangone F, Cuomo R, Annibale B. Role of Dietary Habits in the Prevention of Diverticular Disease Complications: A Systematic Review. Nutrients 2021; 13:nu13041288. [PMID: 33919755 PMCID: PMC8070710 DOI: 10.3390/nu13041288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/02/2021] [Accepted: 04/12/2021] [Indexed: 02/05/2023] Open
Abstract
Recent evidence showed that dietary habits play a role as risk factors for the development of diverticular complications. This systematic review aims to assess the effect of dietary habits in the prevention of diverticula complications (i.e., acute diverticulitis and diverticula bleeding) in patients with diverticula disease. PubMed and Scopus databases were searched up to 19 January 2021, 330 records were identified, and 8 articles met the eligibility criteria and were subjected to data extraction. The quality of the studies was evaluated by the Newcastle-Ottawa quality assessment form. No study meets the criteria for being a high-quality study. A high intake of fiber was associated to a decreased risk of diverticulitis or hospitalization due to diverticular disease, with a protective effect for fruits and cereal fiber, but not for vegetable fiber; whereas, a high red meat consumption and a generally Western dietary pattern were associated with an increased risk of diverticulitis. Alcohol use seemed to be associated to diverticular bleeding, but not to recurrent diverticulitis or diverticular complications. Further high-quality studies are needed to better define these associations. It is mandatory to ascertain the role of dietary habits for the development of recurrent acute diverticulitis and diverticular bleeding.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00189 Rome, Italy; (M.C.); (F.F.)
| | - Francesca Falangone
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00189 Rome, Italy; (M.C.); (F.F.)
| | - Rosario Cuomo
- Gastroenterology and Endoscopy Unit, “Sant’Anna e San Sebastiano” Hospital Caserta, 81100 Caserta, Italy;
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, 00189 Rome, Italy; (M.C.); (F.F.)
- Correspondence: ; Tel.: +39-06-33775695
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7
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Garfinkle R, Boutros M. Elective surgery for diverticulitis – What does the surgeon need to consider? SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Langenfeld SJ. Evaluation and Medical Management of Uncomplicated Diverticulitis. Clin Colon Rectal Surg 2021; 34:86-90. [PMID: 33642947 DOI: 10.1055/s-0040-1716699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Uncomplicated diverticulitis is common, and its evaluation and treatment have evolved over time. Most patients present in a nontoxic manner with localized pain, leukocytosis, and reliable findings on computed tomography (CT). Healthy and stable patients are typically treated in the outpatient setting with very high rates of success. Recently, the necessity of antibiotic therapy has come into question, and several alternative agents have emerged, with the jury still out on their relative roles in diverticular disease. Currently, colonoscopy is still recommended after the resolution of an index episode of uncomplicated diverticulitis, and recurrence rates remain low. Several diet and lifestyle modifications have been shown to impact the rates of diverticulitis recurrence.
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Affiliation(s)
- Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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9
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Frieling T. [Diverticula in the gastrointestinal tract]. Internist (Berl) 2021; 62:277-287. [PMID: 33560449 DOI: 10.1007/s00108-021-00942-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
The prevalence of diverticula varies depending on the location within the gastrointestinal tract. Diverticula of the esophagus, stomach and small intestine are rare, more frequent are peripapillary diverticula and colonic diverticula. Meckel diverticula can also be of relevance in adults. Diverticula have to be differentiated from intramural pseudodiverticulosis of the esophagus and bile duct cysts. An endoscopic and radiological diagnostic work-up is only necessary for symptomatic diverticula or complications. In some cases additional functional diagnostic tests, such as high-resolution esophageal manometry to detect underlying motility disorders (Zenker's diverticulum, epiphrenic diverticulum) or the hydrogen breath test to detect bacterial overgrowth in the small intestine (diverticula of the small intestine) are mandatory. Effective treatment requires the close interdisciplinary cooperation between different specialist disciplines. Therapeutic modalities include pharmacotherapy, endoscopy and surgical methods.
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Affiliation(s)
- Thomas Frieling
- Medizinische Klinik II, Klinik für Innere Medizin mit Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Gastrointestinaler Onkologie, Hämatoonkologie und Palliativmedizin, Helios Klinikum Krefeld, Lutherplatz 40, 47805, Krefeld, Deutschland.
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10
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Abstract
Epidemiological studies have consistently demonstrated the benefits of dietary fibre on gastrointestinal health through consumption of unrefined whole foods, such as wholegrains, legumes, vegetables and fruits. Mechanistic studies and clinical trials on isolated and extracted fibres have demonstrated promising regulatory effects on the gut (for example, digestion and absorption, transit time, stool formation) and microbial effects (changes in gut microbiota composition and fermentation metabolites) that have important implications for gastrointestinal disorders. In this Review, we detail the major physicochemical properties and functional characteristics of dietary fibres, the importance of dietary fibres and current evidence for their use in the management of gastrointestinal disorders. It is now well-established that the physicochemical properties of different dietary fibres (such as solubility, viscosity and fermentability) vary greatly depending on their origin and processing and are important determinants of their functional characteristics and clinical utility. Although progress in understanding these relationships has uncovered potential therapeutic opportunities for dietary fibres, many clinical questions remain unanswered such as clarity on the optimal dose, type and source of fibre required in both the management of clinical symptoms and the prevention of gastrointestinal disorders. The use of novel fibres and/or the co-administration of fibres is an additional therapeutic approach yet to be extensively investigated.
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11
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Piscopo N, Ellul P. Diverticular Disease: A Review on Pathophysiology and Recent Evidence. THE ULSTER MEDICAL JOURNAL 2020; 89:83-88. [PMID: 33093692 PMCID: PMC7576390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Diverticular disease is common condition globally, especially in Western countries. Diverticulitis, Symptomatic uncomplicated Diverticular disease and Segmental Colitis associated with diverticula constitute diverticular disease. Although most patients with diverticula are asymptomatic, around 25% of patients will experience symptoms whilst 5% of patients have an episode of acute diverticulitis. The prevalence increases with age with more than one theory being put forward to explain its pathogenesis. Faecolith entrapment in diverticula results in colonic mucosal damage and oedema, bacterial proliferation and toxin accumulation leading to perforation. This mechanism may explain diverticulitis in elderly patients with multiple, larger diverticula. Ischaemic damage could be the cause of acute diverticulitis in younger patients with sparse diverticula where more frequent and forceful muscular contractions in response to colonic stimuli occlude the vasculature leading to ischaemia and microperforation. Chronic colonic active inflammation in the presence of diverticular disease is termed Segmental colitis associated with diverticulosis. Its pathophysiology is still indeterminate but together with its clinical picture, may mimic Inflammatory Bowel Disease. Treatment includes a high fibre diet together with antibiotics and/or salicylates with surgery in severe cases. Indications for elective surgery in diverticular disease have changed over the past decades as this may not suggest a reduction in morbidity and mortality. Prophylaxis with probiotics, laxatives, anti-spasmotics, anticholinergic drugs and salicylates are at the centre of recent studies. Studies are also challenging previously believed facts regarding dietary fibre, nuts and seeds whilst emphasizing the effect of healthy lifestyle and smoking on the increasing incidence of DD.
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12
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Computational analysis of mechanical stress in colonic diverticulosis. Sci Rep 2020; 10:6014. [PMID: 32265489 PMCID: PMC7138845 DOI: 10.1038/s41598-020-63049-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 03/18/2020] [Indexed: 12/15/2022] Open
Abstract
Diverticulosis results from the development of pouch-like structures, called diverticula, over the colon. The etiology of the disease is poorly understood resulting in a lack of effective treatment approaches. It is well known that mechanical stress plays a major role in tissue remodeling, yet its role in diverticulosis has not been studied. Here, we used computational mechanics to investigate changes in stress distribution engendered over the colon tissue by the presence of a pouch-like structure. The objectives of the study were twofold: (1) observe how stress distribution changes around a single pouch and (2) evaluate how stress elevation correlates with the size of the pouch. Results showed that high stresses are concentrated around the neck of a pouch, and their values and propagation increase with the size of the pouch neck rather than the pouch surface area. These findings suggest that stress distribution may change in diverticulosis and a vicious cycle may occur where pouch size increases due to stress elevation, which in turn elevates stress further and so on. Significant luminal pressure reduction would be necessary to maintain stress at normal level according to our results and therapeutic approaches aimed directly at reducing stress should rather be sought after.
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13
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Prolonged Recurrent Abdominal Pain is Associated With Ongoing Underlying Mucosal Inflammation in Patients who had an Episode of Acute Complicated Diverticulitis. J Clin Gastroenterol 2019; 53:e178-e185. [PMID: 29356787 DOI: 10.1097/mcg.0000000000000980] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent data suggest continuous chronic inflammation in patients after an acute diverticulitis (AD) episode. GOALS The aim of this article was to compare clinical parameters, inflammatory cytokine expression, and immune-cell infiltrates between patients after severe versus nonsevere AD, as defined by radiology examination during the acute episode. STUDY Sixteen patients, after suffering an episode of AD, were included, and, of them, 8 had severe disease. Demographic data, disease characteristics, and inflammatory markers were collected. Tissue samples from diverticular and unaffected tissue were obtained during colonoscopy. Mucosal inflammation was assessed histologically and by measuring inflammatory cytokine mRNA expression. RESULTS Clinically, continued nonspecific abdominal symptoms were significantly more prevalent among patients after severe AD compared with patients after nonsevere AD (P=0.0002). Patients after severe AD also had significantly higher C reactive protein levels (9.85±7.5 vs. 3±2.1 mg/dL; P=0.027) and tendency for higher calprotectin levels (115.7±85 vs. 35±8.7 mg/g; P=0.08). Reverse transcription polymerase chain reaction-determined cytokines levels were 5.4±4.4, 5.14±10, and 0.8±0.82 for tumor necrosis factor alpha, interleukin-6, and interleukin-1β, respectively, in affected mucosa compared with 1.06±1.57, 1.56±2.1, and 0.35±0.5, respectively, in nonaffected mucosa (P=0.01, 0.05, 0.14, respectively). Cytokine expression in patients after nonsevere AD did not differ significantly between affected and nonaffected mucosa. Histologic scores for crypt distortion, lymphoid aggregates, and lymphocyte infiltration were all significantly higher in patients after severe AD compared with patients after nonsevere AD (P<0.05 for all comparisons). CONCLUSIONS Patients after severe AD have more prolonged chronic symptoms, higher inflammatory markers, higher tissue inflammatory cytokine levels, and more inflammatory infiltrates in diverticular colonic tissue than patients after nonsevere AD. These results may contribute to patients' risk stratification and guide therapeutic decisions.
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14
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche J, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres J, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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15
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche JM, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres JI, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:220-240. [PMID: 31014749 DOI: 10.1016/j.rgmx.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
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Affiliation(s)
| | - N Salgado-Nesme
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - R Carmona-Sánchez
- Unidad de Médica Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México.
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - J Aguilera-Carrera
- Hospital de Especialidades Médicas de la Salud, San Luis Potosí, S.L.P., México
| | | | - C Arnaud-Carreño
- Departamento de Cirugía, Hospital General «Dr. Aurelio Valdivieso», Secretaría de Salud del Estado de Oaxaca, Oaxaca, Oaxaca, México
| | | | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | | | - F Esquivel-Ayanegui
- Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - F Roesch-Dietlen
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A López-Colombo
- Direccción de Educación e Investigación, UMAE Hospital de Especialidades CMN Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - J I Muñoz-Torres
- Facultad de Medicina, Universidad Autónoma de Baja California, Mexicali, BC, México
| | | | | | - J Suazo-Barahona
- Centro de Enfermedades Digestivas, Hospital del Valle, San Pedro Sula, Honduras
| | - M Stoopen-Rometti
- Departamento de Radiología e Imagen, CT Scanner Lomas Altas, Ciudad de México, México
| | - E Torres-Flores
- Hospital General de Zona # 1, Instituto Mexicano del Seguro Social, Pachuca, Hidalgo, México
| | | | - O Vergara-Fernández
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
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16
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O'Grady J, O'Connor EM, Shanahan F. Review article: dietary fibre in the era of microbiome science. Aliment Pharmacol Ther 2019; 49:506-515. [PMID: 30746776 DOI: 10.1111/apt.15129] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/27/2018] [Accepted: 12/14/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Explanations for the health benefits of dietary fibre have, in the past, been inconsistent and studies of the physiological effects of dietary fibre were, perhaps, directed at the wrong read-outs. Confounding factors included a failure to appreciate the molecular diversity and varied properties of fibre-types and the role of fibre as a substrate for microbial metabolism in the gut. AIM To present a modern perspective on fibre science and to encourage clinicians to re-consider the health impact of dietary fibre and how best to approach adjustments in dietary consumption. METHODS This perspective is drawn selectively from recent microbiome science; no attempt was made to perform an exhaustive review of all articles related to every aspect of dietary fibre. RESULTS Advances in microbiome science have revealed not only the functional impact of dietary fibre on the composition and function of the microbiota but have also demonstrated the physiologic responses to microbial-derived metabolites from fibre digestion. Moreover, studies have shown the personalised nature of host responses to dietary fibre intervention, with outcomes being dependent on individual pre-treatment gut ecology. CONCLUSIONS The physical properties of dietary fibres are important for homeostasis within the gut, but the predominant health benefits extend beyond the gut to enhanced metabolic welfare, including protection against obesity and related metabolic diseases. Fibre is a form of functional food joining a growing list of examples of diet-microbe-host interactions which link microbe-host metabolic and immune cascades.
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Affiliation(s)
- John O'Grady
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland.,Department of Medicine, University College Cork, National University of Ireland, Cork, Ireland
| | - Eibhlís M O'Connor
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland.,Department of Biological Sciences and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Fergus Shanahan
- APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland.,Department of Medicine, University College Cork, National University of Ireland, Cork, Ireland
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Cuomo R, Cargiolli M, Cassarano S, Carabotti M, Annibale B. Treatment of diverticular disease, targeting symptoms or underlying mechanisms. Curr Opin Pharmacol 2018; 43:124-131. [PMID: 30291995 DOI: 10.1016/j.coph.2018.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/12/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
Abstract
Diverticular disease (DD) is a highly prevalent disease in western industrialized countries that encompasses a complex set of disorders. Because of its complexity and heterogeneity, both from a pathogenic and a clinical point of view, the management of this disease represent a challenge in clinical practice. This review aims to analyze and summarize the most recent evidence on the medical strategies for DD, considering separately the different stages of the disease, from prevention of diverticula formation to treatment of acute diverticulitis and prevention of recurrences. Based on some evidence, dietary fiber is useful to prevent diverticula formation and in diverticulosis, with no pharmacological treatment in these settings. Treatment of symptomatic uncomplicated diverticular disease as well as primary prevention of acute diverticulitis is based on probiotics, fibres, mesalazine and rifaximin, individually or as combination therapy, although a standard approach has not yet been defined. On the contrary, in acute diverticulitis (AD) recent acquisitions have clarified and standardized the role of systemic antibiotics, reserving its use only to complicated forms and in selected cases of uncomplicated disease. Secondary prevention of AD is essentially based on mesalazine and rifaximin but, despite promising results, no strong evidence have been produced. To date, grey areas remain in the medical management of DD.
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Affiliation(s)
- Rosario Cuomo
- Gastroenterology Department of Clinical Medicine and Surgery, School of Medicine "Federico II", Naples, Italy.
| | - Martina Cargiolli
- Gastroenterology Department of Clinical Medicine and Surgery, School of Medicine "Federico II", Naples, Italy
| | - Sara Cassarano
- Gastroenterology Department of Clinical Medicine and Surgery, School of Medicine "Federico II", Naples, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy
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18
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Affiliation(s)
- John O'Grady
- Department of Medicine and APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland.
| | - Fergus Shanahan
- Department of Medicine and APC Microbiome Ireland, University College Cork, National University of Ireland, Cork, Ireland
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20
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Meyer R, Werthmann PG, Kienle GS. Reduction of the frequency of recurrent diverticulitis episodes under treatment with the integrative medicine therapies Carpellum Mali comp. and Kalium aceticum comp.-A case report. Complement Ther Med 2018; 40:203-206. [PMID: 30219450 DOI: 10.1016/j.ctim.2018.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/12/2018] [Accepted: 03/31/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Colonic diverticula develop in at least 60% of elderly patients. Less than 25% of these develop diverticulitis. Recurrent episodes are experienced by about 13% of the symptomatic patients. The effect on prevention of recurrent diverticulitis of currently used therapies is controversial. Surgical colon resection is used in some patients in emergency or to prevent future episodes and complications. Carpellum Mali comp. (Juglans regia, Testa; Pirus malus, Carpellum) and Kalium aceticum comp. (Kalium carbonicum, Acetum vini destillatum, Antimonit, Crocus sativus, Spiritus e vino, Corallium rubrum) - preparations of Integrative Anthroposophic Medicine - have been used for at least 60 years to improve chronic abdominal pain and to treat obstipation, irritable bowel syndrome and colitis. CASE PRESENTATION A 72-year-old retired physician presented in 2013 with a 7-year history of recurrent diverticulitis. During the first 6 years, three to four episodes each year required antibiotic therapy. In 2013 the episodes became more frequent, occurring approximately every 2 months. The patient was concerned about risks from repeated antibiotic treatment and the potential need for surgery. Oral Carpellum Mali comp. and subcutaneous Kalium aceticum comp. treatments were added to the therapy in March. The patient experienced improvement over 4 months without any symptoms. In the following 28 months she had 4 minor diverticulitis episodes, followed by 11-months without any flares; she reported no side effects in the 41-month follow-up period. CONCLUSION Carpellum Mali comp. and Kalium aceticum comp. seem to have been helpful in the case presented here. Experiences with theses remedies in recurrent diverticulitis should be collected to determine whether it would be meaningful to carry out further investigations.
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Affiliation(s)
- Renee Meyer
- Primula Internal Medicine, Meggett, SC, United States
| | - Paul G Werthmann
- Institute for Applied Epistemology and Medical Methodology (IFAEMM) at the University of Witten Herdecke, Zechenweg 6, 79111 Freiburg i. Brsg., Germany.
| | - Gunver S Kienle
- Institute for Applied Epistemology and Medical Methodology (IFAEMM) at the University of Witten Herdecke, Zechenweg 6, 79111 Freiburg i. Brsg., Germany; Center for Complementary Medicine, Institute for Infection Prevention and Hospital Epidemiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany, Breisacher Str. 115B, 79106 Freiburg, Germany
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21
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Carrott P, Pearlman M, Allen K, Suwanabol P. Disease-Specific Diets in Surgical Diseases. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0214-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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22
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Lanas A, Abad-Baroja D, Lanas-Gimeno A. Progress and challenges in the management of diverticular disease: which treatment? Therap Adv Gastroenterol 2018; 11:1756284818789055. [PMID: 30046356 PMCID: PMC6056793 DOI: 10.1177/1756284818789055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/11/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico
Universitario Lozano Blesa, C/ San Juan Bosco 15, Zaragoza, 50009, Spain.
University of Zaragoza. IIS Aragón. CIBERehs
| | - Daniel Abad-Baroja
- Servicio de Aparato Digestivo University Clinic
Hospital Lozano Blesa, Spain
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23
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Abstract
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.
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Affiliation(s)
- Kathleen M Schieffer
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Bryan P Kline
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Gregory S Yochum
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA.,b Department of Biochemistry & Molecular Biology , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Walter A Koltun
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
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24
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Dahl C, Crichton M, Jenkins J, Nucera R, Mahoney S, Marx W, Marshall S. Evidence for Dietary Fibre Modification in the Recovery and Prevention of Reoccurrence of Acute, Uncomplicated Diverticulitis: A Systematic Literature Review. Nutrients 2018; 10:nu10020137. [PMID: 29382074 PMCID: PMC5852713 DOI: 10.3390/nu10020137] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022] Open
Abstract
In practice, nutrition recommendations vary widely for inpatient and discharge management of acute, uncomplicated diverticulitis. This systematic review aims to review the evidence and develop recommendations for dietary fibre modifications, either alone or alongside probiotics or antibiotics, versus any comparator in adults in any setting with or recently recovered from acute, uncomplicated diverticulitis. Intervention and observational studies in any language were located using four databases until March 2017. The Cochrane Risk of Bias tool and GRADE were used to evaluate the overall quality of the evidence and to develop recommendations. Eight studies were included. There was "very low" quality evidence for comparing a liberalised and restricted fibre diet for inpatient management to improve hospital length of stay, recovery, gastrointestinal symptoms and reoccurrence. There was "very low" quality of evidence for using a high dietary fibre diet as opposed to a standard or low dietary fibre diet following resolution of an acute episode, to improve reoccurrence and gastrointestinal symptoms. The results of this systematic review and GRADE assessment conditionally recommend the use of liberalised diets as opposed to dietary restrictions for adults with acute, uncomplicated diverticulitis. It also strongly recommends a high dietary fibre diet aligning with dietary guidelines, with or without dietary fibre supplementation, after the acute episode has resolved.
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Affiliation(s)
- Camilla Dahl
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Megan Crichton
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Julie Jenkins
- Department of Nutrition and Dietetics, Robina Hospital, Robina, QLD 4226, Australia.
| | - Romina Nucera
- Department of Nutrition and Dietetics, Robina Hospital, Robina, QLD 4226, Australia.
| | - Sophie Mahoney
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
| | - Wolfgang Marx
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
- School of Allied Health, La Trobe University, Melbourne, VIC 3086, Australia.
| | - Skye Marshall
- Faculty of Health Sciences & Medicine, Bond University, Robina, QLD 4226, Australia.
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25
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Carabotti M, Annibale B. Treatment of diverticular disease: an update on latest evidence and clinical implications. Drugs Context 2018; 7:212526. [PMID: 29623099 PMCID: PMC5866096 DOI: 10.7573/dic.212526] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, Sapienza, Rome
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, Sapienza, Rome
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26
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Bartels LE, Jepsen P, Tøttrup A, Vilstrup H, Dahlerup JF. Helicobacter pylori infection is associated with reduced prevalence of colonic diverticular disease. Helicobacter 2017; 22. [PMID: 28299869 DOI: 10.1111/hel.12384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Lars Erik Bartels
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus C, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus C, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Anders Tøttrup
- Department of Surgery, Aarhus University Hospital, Aarhus C, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus C, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus C, Denmark
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27
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Carabotti M, Annibale B, Severi C, Lahner E. Role of Fiber in Symptomatic Uncomplicated Diverticular Disease: A Systematic Review. Nutrients 2017; 9:nu9020161. [PMID: 28230737 PMCID: PMC5331592 DOI: 10.3390/nu9020161] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/03/2017] [Accepted: 02/14/2017] [Indexed: 02/05/2023] Open
Abstract
Symptomatic uncomplicated diverticular disease (SUDD) is a syndrome characterized by recurrent abdominal symptoms in patients with colonic diverticula. There is some evidence that a high-fiber diet or supplemental fibers may reduce symptoms in SUDD patients and a high-fiber diet is commonly suggested for these patients. This systematic review aims to update the evidence on the efficacy of fiber treatment in SUDD, in terms of a reduction in symptoms and the prevention of acute diverticulitis. According to PRISMA, we identified studies on SUDD patients treated with fibers (PubMed and Scopus). The quality of these studies was evaluated by the Jadad scale. The main outcome measures were a reduction of abdominal symptoms and the prevention of acute diverticulitis. Nineteen studies were included, nine with dietary fiber and 10 with supplemental fiber, with a high heterogeneity concerning the quantity and quality of fibers employed. Single studies suggest that fibers, both dietary and supplemental, could be beneficial in SUDD, even if the quality is very low, with just one study yielding an optimal score. The presence of substantial methodological limitations, the heterogeneity of the therapeutic regimens employed, and the lack of ad hoc designed studies, did not permit a summary of the outcome measure. Thus, the benefit of dietary or supplemental fiber in SUDD patients still needs to be established.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
- Department of Internal Medicine and Medical Specialties, University Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
| | - Carola Severi
- Department of Internal Medicine and Medical Specialties, University Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
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Dahl WJ, Agro NC, Eliasson ÅM, Mialki KL, Olivera JD, Rusch CT, Young CN. Health Benefits of Fiber Fermentation. J Am Coll Nutr 2017; 36:127-136. [PMID: 28067588 DOI: 10.1080/07315724.2016.1188737] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Although fiber is well recognized for its effect on laxation, increasing evidence supports the role of fiber in the prevention and treatment of chronic disease. The aim of this review is to provide an overview of the health benefits of fiber and its fermentation, and describe how the products of fermentation may influence disease risk and treatment. Higher fiber intakes are associated with decreased risk of cardiovascular disease, type 2 diabetes, and some forms of cancer. Fiber may also have a role in lowering blood pressure and in preventing obesity by limiting weight gain. Fiber is effective in managing blood glucose in type 2 diabetes, useful for weight loss, and may provide therapeutic adjunctive roles in kidney and liver disease. In addition, higher fiber diets are not contraindicated in inflammatory bowel disease or irritable bowel syndrome and may provide some benefit. Common to the associations with disease reduction is fermentation of fiber and its potential to modulate microbiota and its activities and inflammation, specifically the production of anti-inflammatory short chain fatty acids, primarily from saccharolytic fermentation, versus the deleterious products of proteolytic activity. Because fiber intake is inversely associated with all-cause mortality, mechanisms by which fiber may reduce chronic disease risk and provide therapeutic benefit to those with chronic disease need further elucidation and large, randomized controlled trials are needed to confirm causality.Teaching Points• Strong evidence supports the association between higher fiber diets and reduced risk of cardiovascular disease, type 2 diabetes, and some forms of cancer.• Higher fiber intakes are associated with lower body weight and body mass index, and some types of fiber may facilitate weight loss.• Fiber is recommended as an adjunctive medical nutritional therapy for type 2 diabetes, chronic kidney disease, and certain liver diseases.• Fermentation and the resulting shifts in microbiota composition and its activity may be a common means by which fiber impacts disease risk and management.
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Affiliation(s)
- Wendy J Dahl
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
| | - Nicole C Agro
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
| | - Åsa M Eliasson
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
| | - Kaley L Mialki
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
| | - Joseph D Olivera
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
| | - Carley T Rusch
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
| | - Carly N Young
- a Food Science and Human Nutrition Department , University of Florida/IFAS , Gainesville , Florida
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Jamal Talabani A, Lydersen S, Ness-Jensen E, Endreseth BH, Edna TH. Risk factors of admission for acute colonic diverticulitis in a population-based cohort study: The North Trondelag Health Study, Norway. World J Gastroenterol 2016; 22:10663-10672. [PMID: 28082819 PMCID: PMC5192278 DOI: 10.3748/wjg.v22.i48.10663] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/20/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess risk factors of hospital admission for acute colonic diverticulitis.
METHODS The study was conducted as part of the second wave of the population-based North Trondelag Health Study (HUNT2), performed in North Trondelag County, Norway, 1995 to 1997. The study consisted of 42570 participants (65.1% from HUNT2) who were followed up from 1998 to 2012. Of these, 22436 (52.7%) were females. The cases were defined as those 358 participants admitted with acute colonic diverticulitis during follow-up. The remaining participants were used as controls. Univariable and multivariable Cox regression analyses was used for each sex separately after multiple imputation to calculate HR.
RESULTS Multivariable Cox regression analyses showed that increasing age increased the risk of admission for acute colonic diverticulitis: Comparing with ages < 50 years, females with age 50-70 years had HR = 3.42, P < 0.001 and age > 70 years, HR = 6.19, P < 0.001. In males the corresponding values were HR = 1.85, P = 0.004 and 2.56, P < 0.001. In patients with obesity (body mass index ≥ 30) the HR = 2.06, P < 0.001 in females and HR = 2.58, P < 0.001 in males. In females, present (HR = 2.11, P < 0.001) or previous (HR = 1.65, P = 0.007) cigarette smoking increased the risk of admission. In males, breathlessness (HR = 2.57, P < 0.001) and living in rural areas (HR = 1.74, P = 0.007) increased the risk. Level of education, physical activity, constipation and type of bread eaten showed no association with admission for acute colonic diverticulitis.
CONCLUSION The risk of hospital admission for acute colonic diverticulitis increased with increasing age, in obese individuals, in ever cigarette smoking females and in males living in rural areas.
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30
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Uno Y, van Velkinburgh JC. Logical hypothesis: Low FODMAP diet to prevent diverticulitis. World J Gastrointest Pharmacol Ther 2016; 7:503-512. [PMID: 27867683 PMCID: PMC5095569 DOI: 10.4292/wjgpt.v7.i4.503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/04/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
Despite little evidence for the therapeutic benefits of a high-fiber diet for diverticulitis, it is commonly recommended as part of the clinical management. The ongoing uncertainty of the cause(s) of diverticulitis confounds attempts to determine the validity of this therapy. However, the features of a high-fiber diet represent a logical contradiction for colon diverticulitis. Considering that Bernoulli’s principle, by which enlarged diameter of the lumen leads to increased pressure and decreased fluid velocity, might contribute to development of the diverticulum. Thus, theoretically, prevention of high pressure in the colon would be important and adoption of a low FODMAP diet (consisting of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help prevent recurrence of diverticulitis.
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Mesalazine for the Treatment of Symptomatic Uncomplicated Diverticular Disease of the Colon and for Primary Prevention of Diverticulitis: A Systematic Review of Randomized Clinical Trials. J Clin Gastroenterol 2016; 50 Suppl 1:S64-9. [PMID: 27622370 DOI: 10.1097/mcg.0000000000000669] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Symptomatic uncomplicated diverticular disease (SUDD) is a common gastrointestinal disease, because it affects about one fourth of the patient harboring colonic diverticula. GOAL To assess the effectiveness of mesalazine in improving symptoms (namely abdominal pain) and in preventing diverticulitis occurrence in patients with SUDD. STUDY Only randomized clinical trials (irrespective of language, blinding, or publication status) that compared mesalazine with placebo or any other therapy in SUDD were evaluated. The selected endpoints were symptom relief and diverticulitis occurrence at maximal follow-up. Absolute risk reduction (ARR, with 95% confidence interval) and the number needed to treat were used as measures of the therapeutic effect. RESULTS Six randomized clinical trials enrolled 1021 patients: 526 patients were treated with mesalazine and 495 with placebo or other therapies. Symptom relief with mesalazine was always larger than that with placebo and other therapies. However, absolute risk reduction was significant only when mesalazine was compared with placebo, a high-fiber diet, and low-dose rifaximin. The incidence of diverticulitis with mesalazine was lower than that observed with placebo and other treatments, being significant only when compared with placebo. CONCLUSIONS Mesalazine is effective in achieving symptom relief and primary prevention of diverticulitis in patients with SUDD.
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Greenwood-Ericksen MB, Havens JM, Ma J, Weissman JS, Schuur JD. Trends in Hospital Admission and Surgical Procedures Following ED visits for Diverticulitis. West J Emerg Med 2016; 17:409-17. [PMID: 27429691 PMCID: PMC4944797 DOI: 10.5811/westjem.2016.4.29757] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/28/2016] [Accepted: 04/07/2016] [Indexed: 01/26/2023] Open
Abstract
Introduction Diverticulitis is a common diagnosis in the emergency department (ED). Outpatient management of diverticulitis is safe in selected patients, yet the rates of admission and surgical procedures following ED visits for diverticulitis are unknown, as are the predictive patient characteristics. Our goal is to describe trends in admission and surgical procedures following ED visits for diverticulitis, and to determine which patient characteristics predict admission. Methods : We performed a cross-sectional descriptive analysis using data on ED visits from 2006–2011 to determine change in admission and surgical patterns over time. The Nationwide Emergency Department Sample database, a nationally representative administrative claims dataset, was used to analyze ED visits for diverticulitis. We included patients with a principal diagnosis of diverticulitis (ICD-9 codes 562.11, 562.13). We analyzed the rate of admission and surgery in all admitted patients and in low-risk patients, defined as age <50 with no comorbidities (Elixhauser). We used hierarchical multivariate logistic regression to identify patient characteristics associated with admission for diverticulitis. Results Fryom 2006 to 2011 ED visits for diverticulitis increased by 21.3% from 238,248 to 302,612, while the admission rate decreased from 55.7% to 48.5% (−7.2%, 95% CI [−7.78 to −6.62]; p<0.001 for trend). The admission rate among low-risk patients decreased from 35.2% in 2006 to 26.8% in 2011 (−8.4%, 95% CI [−9.6 to −7.2]; p<0.001 for trend). Admission for diverticulitis was independently associated with male gender, comorbid illnesses, higher income and commercial health insurance. The surgical rate decreased from 6.5% in 2006 to 4.7% in 2011 (−1.8%, 95% CI [−2.1 to −1.5]; p<0.001 for trend), and among low-risk patients decreased from 4.0% to 2.2% (−1.8%, 95% CI [−4.5 to −1.7]; p<0.001 for trend). Conclusion From 2006 to 2011 ED visits for diverticulitis increased, while ED admission rates and surgical rates declined, with comorbidity, sociodemographic factors predicting hospitalization. Future work should focus on determining if these differences reflect increased disease prevalence, increased diagnosis, or changes in management.
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Affiliation(s)
- Margaret B Greenwood-Ericksen
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts; Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Joaquim M Havens
- Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Center for Surgery and Public Health, Department of Surgery, Boston, Massachusetts; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, Massachusetts
| | - Jiemin Ma
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, Georgia
| | - Joel S Weissman
- Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Center for Surgery and Public Health, Department of Surgery, Boston, Massachusetts
| | - Jeremiah D Schuur
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Pathophysiology and Therapeutic Strategies for Symptomatic Uncomplicated Diverticular Disease of the Colon. Dig Dis Sci 2016; 61:673-83. [PMID: 26458921 DOI: 10.1007/s10620-015-3925-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/05/2015] [Indexed: 12/12/2022]
Abstract
Colonic diverticulosis imposes a significant burden on industrialized societies. The current accepted causes of diverticula formation include low fiber content in the western diet with decreased intestinal content and size of the lumen, leading to the transmission of muscular contraction pressure to the wall of the colon, inducing the formation of diverticula usually at the weakest point of the wall where penetration of the blood vessels occurs. Approximately 20 % of the patients with colonic diverticulosis develop abdominal symptoms (i.e., abdominal pain and discomfort, bloating, constipation, and diarrhea), a condition which is defined as symptomatic uncomplicated diverticular disease (SUDD). The pathogenesis of SUDD symptoms remains uncertain and even less is known about how to adequately manage bowel symptoms. Recently, low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to symptom development, thus changing and improving the therapeutic approach. In this review, a comprehensive search of the literature regarding on SUDD pathogenetic hypotheses and pharmacological strategies was carried out. The pathogenesis of SUDD, although not completely clarified, seems to be related to an interaction between colonic microbiota alterations, and immune, enteric nerve, and muscular system dysfunction (Cuomo et al. in United Eur Gastroenterol J 2:413-442, 2014). Greater understanding of the inflammatory pathways and gut microbiota composition in subjects affected by SUDD has increased therapeutic options, including the use of gut-directed antibiotics, mesalazine, and probiotics (Bianchi et al. in Aliment Pharmacol Ther 33:902-910, 2011; Comparato et al. in Dig Dis Sci 52:2934-2941, 2007; Tursi et al. in Aliment Pharmacol Ther 38:741-751, 2013); however, more research is necessary to validate the safety, effectiveness, and cost-effectiveness of these interventions.
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Luz AC, Oliveira MG, Noblat L. Cross-cultural adaptation and content validation of START. SAO PAULO MED J 2016; 134:20-7. [PMID: 26786612 PMCID: PMC10496579 DOI: 10.1590/1516-3180.2014.00303101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 11/17/2014] [Accepted: 01/31/2015] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Non-treatment of diseases or clinical conditions has been considered to constitute omission of care in several countries. The aim of the present study was to develop a transcultural adaptation of the Screening Tool to Alert Doctors to the Right Treatment (START) to Brazilian Portuguese and to validate the tool's content. DESIGN AND SETTING Cultural adaptation and validation of the START criteria using the Delphi consensus technique. METHOD START was translated from its original language into Brazilian Portuguese, followed by back-translation and validation by means of the modified Delphi technique. For this, an electronic form was developed and sent to 20 experts, who were asked to use a Likert scale to assess the statements included in START, in relation to their pertinence to Brazilian realities. All of the statements that exhibited mean scores greater than 4.0 were considered to have attained consensus. The experts' identities were kept confidential throughout the validation process. RESULTS In the first phase of the validation process, 63.6% (14/22) of the statements in START attained consensus. The remaining statements were returned to the experts so that they could have the opportunity to review their comments and statements and to assess them again, based on the Likert scale used earlier. In this phase, 100% of the START instrument attained consensus. CONCLUSION The content of START was entirely validated for Brazil, with all of the original criteria maintained.
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Affiliation(s)
- Aline Cristina Luz
- BPharm. Clinical Pharmacist, Cardiopulmonary Institute, Salvador, Bahia, Brazil.
| | - Márcio Galvão Oliveira
- BPharm, PhD. Adjunct Professor of Clinical Pharmacy, Multidisciplinary Health Institute, Universidade Federal da Bahia (UFBA), Vitória da Conquista, Bahia, Brazil.
| | - Lúcia Noblat
- BPharm, PhD. Associate Professor of Clinical Pharmacy, School of Pharmacy, Universidade Federal da Bahia (UFBA), Salvador, Bahia, Brazil.
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Elisei W, Tursi A. Recent advances in the treatment of colonic diverticular disease and prevention of acute diverticulitis. Ann Gastroenterol 2016; 29:24-32. [PMID: 26752946 PMCID: PMC4700842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
The incidence of diverticulosis and diverticular disease of the colon is increasing worldwide. Although the majority of patients remains asymptomatic long-life, the prevalence of diverticular disease of the colon, including acute diverticulitis, is substantial and is becoming a significant burden on National Health Systems in terms of direct and indirect costs. Focus is now being drawn on identifying the correct therapeutic approach by testing various treatments. Fiber, non-absorbable antibiotics and probiotics seem to be effective in treating symptomatic and uncomplicated patients, and 5-aminosalicylic acid might help prevent acute diverticulitis. Unfortunately, robust evidence on the effectiveness of a medical strategy to prevent acute diverticulitis recurrence is still lacking. We herein provide a concise review on the effectiveness and future perspectives of these treatments.
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Affiliation(s)
- Walter Elisei
- Division of Gastroenterology, ASL Roma H, Albano Laziale, Rome (Walter Elisei)
| | - Antonio Tursi
- Gastroenterology Service, ASL BAT, Andria (Antonio Tursi), Italy,
Correspondence to: Antonio Tursi, MD, Via Torino 49, 76123 Andria, BT, Italy, Tel.: +39 0883 551094, Fax: +39 0883 1978210, e-mail:
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Gargallo Puyuelo CJ, Sopeña F, Lanas Arbeloa A. Colonic diverticular disease. Treatment and prevention. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:590-9. [DOI: 10.1016/j.gastrohep.2015.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 03/06/2015] [Accepted: 03/11/2015] [Indexed: 02/07/2023]
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Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute Technical Review on the Management of Acute Diverticulitis. Gastroenterology 2015; 149:1950-1976.e12. [PMID: 26453776 DOI: 10.1053/j.gastro.2015.10.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lisa L Strate
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Anne F Peery
- Division of Gastroenterology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ignacio Neumann
- Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 2015; 19:615-26. [PMID: 26377584 DOI: 10.1007/s10151-015-1370-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.
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Affiliation(s)
- G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
| | - R Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - A Laghi
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - A Serventi
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - D Bellini
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - P Gervaz
- Coloproctology Unit, La Colline Clinic, Geneva, Switzerland
| | - B Annibale
- Division of Gastroenterology, Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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[Treatment of the acute diverticulitis: A systematic review]. Presse Med 2015; 44:1113-25. [PMID: 26358668 DOI: 10.1016/j.lpm.2015.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/23/2015] [Accepted: 08/03/2015] [Indexed: 01/04/2023] Open
Abstract
Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis.
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Tursi A, Papa A, Danese S. Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon. Aliment Pharmacol Ther 2015. [PMID: 26202723 DOI: 10.1111/apt.13322] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The incidence of diverticulosis and diverticular disease of the colon, including diverticulitis, is increasing worldwide, and becoming a significant burden on national health systems. Treatment of patients with diverticulosis and DD is generally based on high-fibre diet and antibiotics, respectively. However, new pathophysiological knowledge suggests that further treatment may be useful. AIM To review the current treatment of diverticulosis and diverticular disease. METHODS A search of PubMed and Medline databases was performed to identify articles relevant to the management of diverticulosis and diverticular disease. Major international conferences were also reviewed. RESULTS Two randomised controlled trials (RCT) found the role of antibiotics in managing acute diverticulitis to be questionable, particularly in patients with no complicating comorbidities. One RCT found mesalazine to be effective in preventing acute diverticulitis in patients with symptomatic uncomplicated diverticular disease. The role of rifaximin or mesalazine in preventing diverticulitis recurrence, based on the results of 1 and 4 RCTs, respectively, remains unclear. RCTs found rifaximin and mesalazine to be effective in treating symptomatic uncomplicated diverticular disease. The use of probiotics in diverticular disease and in preventing acute diverticulitis occurrence/recurrence appears promising but unconclusive. Finally, the role of fibre in treating diverticulosis remains unclear. CONCLUSIONS Available evidence suggests that antibiotics have a role only in the treatment of complicated diverticulitis. It appears to be some evidence for a role for rifaximin and mesalazine in treating symptomatic uncomplicated diverticular disease. Finally, there is not currently adequate evidence to recommend any medical treatment for the prevention of diverticulitis recurrence.
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Affiliation(s)
- A Tursi
- Gastroenterology Service, ASL BAT, Andria, BT, Italy
| | - A Papa
- Division of Internal Medicine and Gastroenterology, Complesso Integrato "Columbus", Catholic University, Rome, Italy
| | - S Danese
- IBD Unit, IRCCS "Humanitas", Rozzano, MI, Italy
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Pustovit RV, Furness JB, Rivera LR. A ghrelin receptor agonist is an effective colokinetic in rats with diet-induced constipation. Neurogastroenterol Motil 2015; 27:610-7. [PMID: 25616061 DOI: 10.1111/nmo.12517] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/24/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Despite constipation being a common problem, the treatments that are available have side effects and are only partly effective. Recent studies show that centrally penetrant ghrelin receptor agonists cause defecation in humans and other species. Here, we describe some features of a rat model of low fiber-induced constipation, and investigate the effectiveness of the ghrelin agonist, capromorelin. METHODS Rats were given low-fiber diets for 5 weeks. Their colorectal responsiveness to distension and to a behavioral test, water avoidance and colon histology were compared to those of rats on a standard diet. KEY RESULTS After the low-fiber diet, distension of the colon produced fewer propulsive contractions, behaviorally induced defecation was reduced, and the lining of the colorectum was inflamed. However, capromorelin was similarly effective in causing defecation in constipated and non-constipated rats. CONCLUSIONS & INFERENCES Low-fiber diet in rats produces a constipation phenotype, characterized by reduced responsiveness of the colorectum to distension and to a behavioral stimulus of defecation, water avoidance. The effectiveness of capromorelin suggests that centrally penetrant ghrelin receptor stimulants may be effective in treating constipation.
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Affiliation(s)
- R V Pustovit
- Department of Anatomy & Neuroscience, University of Melbourne, Parkville, VIC, Australia
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Böhm SK. Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking. VISZERALMEDIZIN 2015; 31:84-94. [PMID: 26989377 PMCID: PMC4789955 DOI: 10.1159/000381867] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding. Methods A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed. Results Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities. Conclusion Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.
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Affiliation(s)
- Stephan K Böhm
- Medizinische Universitätsklinik, Kantonsspital Baselland, Bruderholz, Switzerland
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Diverticular disease as a chronic gastrointestinal condition: experience from a specialist clinic. Eur J Gastroenterol Hepatol 2015; 27:442-8. [PMID: 25874519 DOI: 10.1097/meg.0000000000000304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Although diverticular disease is a prevalent condition and a significant burden on the healthcare system, care is devolved across gastrointestinal, GP, and colorectal surgery clinics. We created a specialist Diverticular Disease Clinic to streamline care, enhance evidence-based practice and provide a base for research. The aim of this study was to assess patient referral sources, predictors of persistent disease and surgical outcomes. METHODS We retrospectively reviewed all patients attending our clinic. Patients younger than 50 years of age on initial presentation were considered 'younger' patients. Persistent symptoms lasted for at least 3 months. RESULTS Overall, 177 patients had confirmed diverticular disease. Patients were referred following hospital admission (82 patients, 46.3%) or from the community (95 patients, 53.7%). Ninety-five patients (53.7%) had persistent symptoms. Patients with more than two episodes of diverticulitis were more likely to have persistent symptoms (P<0.0001).Following hospitalization, younger patients were 3.98 times more likely to develop persistent symptoms (P=0.04). This was independent of the severity of the original infection, as a low peak C-reactive protein level of less than 50 mg/L was associated with persistent symptoms (odds ratio=3.62, P=0.03). Over the study period, 12 patients (6.9%) had elective surgery. CONCLUSION There is demand for dedicated care for patients with persistent symptoms from diverticular disease. Specialized clinics are a model for this care, provided by either gastroenterologists or surgeons, in centres with adequate demand. Our findings reinforce the hypotheses that chronic abdominal pain in diverticular disease may be related to sensation abnormalities similar to postinfective irritable bowel syndrome.
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Bugiantella W, Rondelli F, Longaroni M, Mariani E, Sanguinetti A, Avenia N. Left colon acute diverticulitis: an update on diagnosis, treatment and prevention. Int J Surg 2014; 13:157-164. [PMID: 25497007 DOI: 10.1016/j.ijsu.2014.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy.
| | - Maurizio Longaroni
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
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Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis. Dis Colon Rectum 2014; 57:1397-405. [PMID: 25380006 DOI: 10.1097/dcr.0000000000000224] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis. OBJECTIVE The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes. DESIGN This is a population-based retrospective cohort study using administrative discharge data. SETTING This study was conducted in Ontario, Canada. PATIENTS All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012). MAIN OUTCOME MEASURES Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics. RESULTS There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001). LIMITATIONS There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data. CONCLUSIONS There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.
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Tursi A, Danese S. Preventing diverticulitis recurrence by selecting the right therapy for a complex disease. Gastroenterology 2014; 147:733-6. [PMID: 25167986 DOI: 10.1053/j.gastro.2014.08.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Antonio Tursi
- Servizio di Gastroenterologia Territoriale, ASL BAT, Andria, Italy.
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Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014; 2:413-42. [PMID: 25360320 PMCID: PMC4212498 DOI: 10.1177/2050640614547068] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
- Rosario Cuomo, Department of Clinical Medicine and Surgery, Federico II University Hospital School of Medicine via S. Pansini 5, 80131 Napoli, Italy.
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, AOU Careggi, Florence, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Fiocca
- Pathology Unit, IRCCS San Martino-IST University Hospital, Genoa, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, La ‘Sapienza' University, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, L. Sacco University Hospital, Milan, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Parma, Italy
| | | | - Bruno Annibale
- Medical-Surgical and Translational Medicine Department, La Sapienza University, Rome, Italy
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Raskin JB, Kamm MA, Jamal MM, Márquez J, Melzer E, Schoen RE, Szalóki T, Barrett K, Streck P. Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials. Gastroenterology 2014; 147:793-802. [PMID: 25038431 DOI: 10.1053/j.gastro.2014.07.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 07/10/2014] [Accepted: 07/11/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS No therapy has been proven to prevent the recurrence of diverticulitis. Mesalamine has shown efficacy in preventing relapse in inflammatory bowel disease, and there is preliminary evidence that it might be effective for diverticular disease. We investigated the efficacy of mesalamine in preventing recurrence of diverticulitis in 2 identical but separate phase 3, randomized, double-blind, placebo-controlled, multicenter trials (identical confirmatory trials were conducted for regulatory reasons). METHODS We evaluated the efficacy and safety of multimatrix mesalamine vs placebo in the prevention of recurrent diverticulitis in 590 (PREVENT1) and 592 (PREVENT2) adult patients with ≥1 episodes of acute diverticulitis in the previous 24 months that resolved without surgery. Patients received mesalamine (1.2 g, 2.4 g, or 4.8 g) or placebo once daily for 104 weeks. The primary end point was the proportion of recurrence-free patients at week 104. Diverticulitis recurrence was defined as surgical intervention at any time for diverticular disease or presence of computed tomography scan results demonstrating bowel wall thickening (>5 mm) and/or fat stranding consistent with diverticulitis. For a portion of the study, recurrence also required the presence of abdominal pain and an increase in white blood cells. RESULTS Mesalamine did not reduce the rate of diverticulitis recurrence at week 104. Among patients in PREVENT1, 53%-63% did not have disease recurrence, compared with 65% of those given placebo. Among patients in PREVENT2, 59%-69% of patients did not have disease recurrence, compared with 68% of those given placebo. Mesalamine did not reduce time to recurrence, and the proportions of patients requiring surgery were comparable among treatment groups. No new adverse events were identified with mesalamine administration. CONCLUSIONS Mesalamine was not superior to placebo in preventing recurrent diverticulitis. Mesalamine is not recommended for this indication. ClinicalTrials.gov ID: NCT00545740 and NCT00545103.
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Affiliation(s)
| | - Michael A Kamm
- St Vincent's Hospital and University of Melbourne, Melbourne, Australia; Imperial College, London, UK
| | - M Mazen Jamal
- VA Long Beach Healthcare System, Long Beach, California
| | | | - Ehud Melzer
- Department of Gastroenterology and Liver Disease, Kaplan Medical Center, Rehovot, Israel
| | - Robert E Schoen
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tibor Szalóki
- Department of Gastroenterology, Ödön Jávorszky Hospital, Vác, Hungary
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Tomita R. Are there any functional differences of the enteric nervous system between the right-sided diverticular colon and the left-sided diverticular colon? An in vitro study. Int J Colorectal Dis 2014; 29:571-7. [PMID: 24562545 DOI: 10.1007/s00384-014-1837-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate functional differences of the enteric nervous system (ENS) in patients between right-side colonic diverticula (RCD) and left-sided colonic diverticula (LCD), the author compared the ENS responses between RCD and LCD. METHODS Ten specimens were obtained from 10 patients with RCD, and 16 specimens were taken from 16 LCD. As a control, twenty-two specimens of right-sided normal colon (RNC) were obtained from 22 colonic cancers. Twenty-four specimens of left sided normal colon (LNC) were obtained from 24 colonic cancers. A mechanography was used to evaluate in vitro muscle responses to electrical field stimulation (EFS) before and after treatment with various autonomic nerve blockers. RESULTS Before blockade of the adrenergic and cholinergic nerves, the incidences of contraction via cholinergic nerve in the colons with diverticula were significantly greater than those in the normal colons (right-sided colon; p = 0.0022, left-sided colon; p < 0.0001). There were no significant differences between RNC and LNC (p = 0.3606), and between RCD and LCD (p = 0.7684). After the blockade of adrenergic and cholinergic nerves, the incidence of relaxation via non-adrenergic non-cholinergic inhibitory (NANC) nerve in the normal colons was significantly greater than that in the diverticular colons (right-sided colon; p = 0.0435, left-sided colon; p = 0.0034). There were no significant differences between RNC and LNC (p = 0.2909) and between RCD and LCD (p = 0.9464). CONCLUSION Cholinergic nerves were dominant in bilateral diverticular colon compared with bilateral normal colon. NANC inhibitory nerves were dominant in bilateral normal colon compared with bilateral diverticular colon. There were also no functional differences of the ENS between RCD and LCD.
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Affiliation(s)
- Ryouichi Tomita
- Department of Surgery, School of Life Dentistry, Nippon Dental University, 2-3-16 Fujimi, Chiyoda-ku, Tokyo, 102-8158, Japan,
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Tursi A. Efficacy, safety, and applicability of outpatient treatment for diverticulitis. DRUG HEALTHCARE AND PATIENT SAFETY 2014; 6:29-36. [PMID: 24729730 PMCID: PMC3976207 DOI: 10.2147/dhps.s61277] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute diverticulitis of the colon represents a significant burden for national health systems, in terms of direct and indirect costs. Although current guidelines recommend use of antibiotics for the outpatient treatment of acute uncomplicated diverticulitis, evidence for this is still lacking. Hence, significant effort is now being made to identify the appropriate therapeutic approach to treat and prevent relapses of diverticulitis. Outpatient treatment has been identified as a safe and effective therapeutic approach in up to 90% of patients with uncomplicated diverticulitis. It allows important costs saving to health systems without a negative influence on quality of life for patients with uncomplicated diverticulitis, and reduces health care costs by more than 60%.
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