Current management of diverticular disease complications

Fistulating diverticulitis: a distinct clinical entity?

Introduction

Diverticular disease (DD) of the colon has a number of phenotypes, including asymptomatic diverticulosis and complicated diverticulitis with bowel perforation or bleeding. The factor that affects the phenotype of this condition and leads to a wide range of clinical presentations is unknown. The formation of fistulas associated with diverticulitis has long been recognized, and they are treated according to ad hoc indications. We hypothesized that the formation of fistulas in diverticular disease exhibits such a wide range of variable anatomic features that it may be considered a distinct form of the condition, fistulating diverticulitis (FD).

Methods

We conducted a narrative review based on 50 years of publications covering a wide range of diverticulitis-associated fistulas, both common and uncommon.

Results

While there is abundant literature on common fistulas, such as colovesical and colovaginal fistulas, little is known about rarer fistulas, such as coloenteric fistulas, colocutaneous fistulas, and genitourinary tract fistulas. The majority of these fistulas are treated surgically, which is in contrast to the trend toward conservative management that is predominant in acute or chronic diverticulitis.

Discussion

Epidemiological and histological evidence support the hypothesis that FD may be a feature of chronic DD that requires individual management. Histopathology shows similarities with Crohn's disease. It remains unknown which underlying immune or genetic factors may be affecting the clinical presentation of these patients, leading to fistulation. We contend that there is adequate published evidence to characterize a distinct phenotype of FD that can involve the entire GI tract and other organs. Surgical guidelines may need to be modified to treat this small but important group, which predominantly requires surgical treatment.

Colonic diverticular disease revisited

INTRODUCTION

Diverticular disease, including diverticulosis and diverticulitis, presents a significant health concern globally, with increasing prevalence in Western societies and emerging trends in Asia. The incidence of diverticulitis, is on the rise, leading to significant morbidity and healthcare costs.

AREAS COVERED

A literature search was conducted using the PubMed database, and studies published between 1995 and 2024 were selected based on their relevance to the overall understanding of disease. This review investigates the clinical spectrum, classification, and management strategies of diverticular disease, focusing particularly on evolving trends in diagnosis and treatment. Discussions regarding the prevalence of diverticulosis, the identification of risk factors associated with disease progression, recent advancements in research, and the utilization of biomarkers in disease monitoring and treatment decision-making are considered in detail.

EXPERT OPINION

The discourse on diverticular disease underscores the pressing need for tailored management strategies and innovative treatments. Understanding the intricacies of the disease's pathophysiology is paramount for effective intervention. Recent advances in diagnostic imaging and biomarker identification are promising, yet more research is imperative to further refine patient care. Advances in these areas hold the potential for significantly improving outcomes in disease management.

Defining diverticular fistula through inpatient admissions: a population study

BACKGROUND

Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level.

METHODS

A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed.

RESULTS

A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2 years, p < .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p < .0001), to be admitted electively (44.7% v 12.0%, p < .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20 days, p < .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p < .0001), and to have longer LOS (mean 8.74 v 6.81 days, p < .0001) than those who received medical treatment alone.

CONCLUSION

Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of < 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States.

Bowel obstruction: a narrative review for all physicians

Small and large bowel obstructions are responsible for approximately 15% of hospital admissions for acute abdominal pain in the USA and ~ 20% of cases needing acute surgical care. Starting from the analysis of a common clinical problem, we want to guide primary care physicians in the initial management of a patient presenting with acute abdominal pain associated with intestinal obstruction.