Tumour necrosis factor alpha in segmental colitis associated with diverticula

Prevalence and Natural History of Segmental Colitis Associated With Diverticulosis

INTRODUCTION

We assessed the prevalence and clinical outcomes of segmental colitis associated with diverticulosis (SCAD) in patients with newly diagnosed diverticulosis.

METHODS

A 3-year international, multicenter, prospective cohort study was conducted involving 2,215 patients.

RESULTS

SCAD diagnosis was posed in 44 patients (30 male patients; median age: 64.5 years; prevalence of 1.99%, 95% confidence interval, 1.45%-2.66%). Patients with SCAD types D and B showed worse symptoms, higher fecal calprotectin values, needed more steroids, and reached less likely complete remission.

DISCUSSION

Although SCAD generally had a benign outcome, types B and D were associated with more severe symptoms and worse clinical course.

Common Diagnostic Challenges and Pitfalls in Segmental Colitis Associated with Diverticulosis (SCAD)

Segmental colitis associated with diverticulosis (SCAD) is characterized by inflammation involving the sigmoid inter-diverticular mucosa, sparing the proximal colon and rectum. Due to the heterogeneity of clinical manifestations and endoscopic and histological findings, SCAD diagnosis might be challenging in clinical practice. This narrative review aimed to report the SCAD diagnostic criteria adopted in different studies, highlighting the current challenges and main pitfalls in its diagnosis. We analysed fourteen studies, mainly prospective observational studies. Haematochezia and rectal bleeding were the main complaints leading to diagnosis, followed by diarrhoea. An accurate endoscopic description was performed in 86% of studies, while a standardised biopsy sampling protocol (sigma, proximal colon and rectum) was scarcely adopted, being complete only in 28.5% of studies. The evaluation of concomitant drugs potentially inducing colitis was carried out in only 57% of studies. Great heterogeneity in sigmoid endoscopic (edema, erythema, erosions, ulcers, mucosal friability) and histological findings (chronic and/or acute inflammatory infiltrate) was observed. We showed that SCAD diagnosis is often based on not fully adequate macroscopic colonic description and scant biopsy protocol sampling. An accurate clinical and endoscopic evaluation, with an adequate sampling biopsy protocol, with attention to differential diagnosis, seemed to be crucial for a prompt SCAD diagnosis.

Do Colonic Mucosal Tumor Necrosis Factor Alpha Levels Play a Role in Diverticular Disease? A Systematic Review and Meta-Analysis

Diverticular disease (DD) is the most frequent condition in the Western world that affects the colon. Although chronic mild inflammatory processes have recently been proposed as a central factor in DD, limited information is currently available regarding the role of inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-α). Therefore, we conducted a systematic review and meta-analysis aiming to assess the mucosal TNF-α levels in DD. We conducted a systematic literature search using PubMed, Embase, and Scopus to identify observational studies assessing the TNF-α levels in DD. Full-text articles that satisfied our inclusion and exclusion criteria were included, and a quality assessment was performed using the Newcastle-Ottawa Scale (NOS). The principal summary outcome was the mean difference (MD). The results were reported as MD (95% confidence interval (CI)). A total of 12 articles involving 883 subjects were included in the qualitative synthesis, out of which 6 studies were included in our quantitative synthesis. We did not observe statistical significance related to the mucosal TNF-α levels in symptomatic uncomplicated diverticular disease (SUDD) vs. the controls (0.517 (95% CI -1.148-2.182)), and symptomatic vs. asymptomatic DD patients (0.657 (95% CI -0.883-2.196)). However, the TNF-α levels were found to be significantly increased in DD compared to irritable bowel disease (IBS) patients (27.368 (95% CI 23.744-30.992)), and segmental colitis associated with diverticulosis (SCAD) vs. IBS patients (25.303 (95% CI 19.823-30.784)). Between SUDD and the controls, as well as symptomatic and asymptomatic DD, there were no significant differences in the mucosal TNF-α levels. However, the TNF-α levels were considerably higher in DD and SCAD patients than IBS patients. Our findings suggest that TNF-α may play a key role in the pathogenesis of DD in specific subgroups and could potentially be a target for future therapies.

Segmental Colitis Associated with Diverticulosis (SCAD)

PURPOSE OF REVIEW

A distinctive, possibly "novel" form of a segmental inflammatory colonic disease process associated with diverticular disease (so-called SCAD or segmental-colitis-associated-diverticulosis) is reviewed.

RECENT FINDINGS

Although this phenotype of inflammatory colonic disease was initially recognized decades ago, mainly in the elderly, recent evidence from long term natural history studies along with meta-analyses confirms that its clinical course is usually benign and drug-responsive. Interestingly, its appearance in some treated with monoclonal agents (eg., ipilimumab associated colitis) or infected with coronavirus-19 may have critical implications for its pathogenesis. This review further explores the implications of recognition of this pattern of colonic inflammatory disease, with relevance for physicians involved in both clinical practice and clinical trials of newer therapeutic agents.

Paradigm shift: the Copernican revolution in diverticular disease

Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.

Considerations and Changes in the Evaluation, Management, and Outcomes in the Management of Diverticular Disease: The Diagnosis, Pathology, and Treatment of Diverticular Colitis

Diverticular colitis, also known as segmental colitis associated with diverticulosis, is a colonic inflammatory disorder on the spectrum of inflammatory bowel disease (IBD). The disease consists of macroscopic and microscopic inflammation affecting inter-diverticular mucosa, sparing peri-diverticular mucosa, with inflammation confined to the descending and sigmoid colon. The disease likely arises from the altered immune response of an individual, genetically susceptible to the IBD spectrum of diseases. Patients with segmental colitis associated with diverticulosis (SCAD) are typically older, and likely represent a subgroup of IBD-susceptible patients who lacked an environmental trigger until that point in their life. Most patients remain in remission with initial treatments of mesalamine or topical steroids, and maintenance mesalamine afterwards. Only the most severe form of the disease necessitates immunomodulatory therapy and the consideration of surgery.

Segmental colitis associated with diverticulosis: is it the coexistence of colonic diverticulosis and inflammatory bowel disease?

Segmental colitis associated with diverticulosis (SCAD) is an inflammatory process that affects colonic luminal mucosa in segments that are also affected by diverticulosis. Its prevalence varies between 1.15% and 11.4% amongst those suffering from diverticular disease (DD). Being closely associated with DD, it is slightly commoner in males and usually presents in the sixth decade of life. Although the exact pathogenesis of SCAD is unknown, it is probably heterogeneous and includes mechanisms that also play a part in inflammatory bowel disease (IBD). The clinical presentation is non-specific and similar to that of other pathologies involving the sigmoid colon, and its diagnosis is based on endoscopic findings in correlation with histology. Currently, there are no guidelines for its management, which is usually based on the administration of salicylates and antibiotics, with surgery being reserved for refractory cases. The rarity of SCAD may be multifactorial: whereas milder forms go undiagnosed or are attributed to DD, more severe forms can be misdiagnosed as IBD. This latter distinction is an important one to make, since SCAD and IBD differ as regards their natural history and prognosis, while very often no long-term medications are required in SCAD.

How to Differentiate Segmental Colitis Associated With Diverticulosis and Inflammatory Bowel Diseases

The segmental colitis associated with diverticulosis," better known by its acronym "SCAD," is a chronic inflammatory process localized in the colonic area presenting diverticulosis, and therefore mainly in the sigmoid colon. By definition, both the rectum and the right colon are spared from any inflammation both endoscopically and from a histologic point of view. Recent data have hypothesized that SCAD may be an independent clinical entity within the inflammatory bowel disease set of diseases. Compared with inflammatory bowel disease, SCAD seems to have a more benign outcome, with low rate of complications.

Segmental colitis associated diverticulosis syndrome

Segmental colitis associated diverticulosis (SCAD) has become increasingly appreciated as a form of inflammatory disease of the colon. Several features suggest that SCAD is a distinct disorder. SCAD tends to develop almost exclusively in older adults, predominately, but not exclusively, males. The inflammatory process occurs mainly in the sigmoid colon, and usually remains localized to this region of the colon alone. SCAD most often presents with rectal bleeding and subsequent endoscopic visualization reveals a well localized process with non-specific histopathologic inflammatory changes. Granulomas are not seen, and if present, may be helpful in definition of other disorders such as Crohn’s disease of the colon, an entity often confused with SCAD. Bacteriologic and parasitic studies for an infectious agent are negative. Normal rectal mucosa (i.e., “rectal sparing”) is present and can be confirmed with normal rectal biopsies. SCAD often resolves spontaneously without treatment, or completely after a limited course of therapy with only a 5-aminosalicylate. Recurrent episodes may occur, but most often, patients with this disorder have an entirely self-limited clinical course. Occasionally, treatment with other agents, including corticosteroids, or surgical resection has been required.

A case of diverticular colitis with lesions resembling ulcerative colitis and correlation of tumor necrosis factor-alpha staining with clinical manifestations

A 45-year-old male with a 3-month history of abdominal pain and melena underwent colonoscopy (CS) at our hospital in May 2009. He was diagnosed with diverticular colitis based on findings of redness around diverticula in the sigmoid colon and biopsy findings of non-specific inflammation. The second CS, which was performed in July 2009 to investigate relapse, showed diffuse redness around diverticula in the sigmoid colon. As seen in active ulcerative colitis (UC), the formation of crypt abscesses was observed in the biopsy. Although the patient was making satisfactory progress after administration of oral mesalazine, CS was performed again in September 2011 because of recurrence of melena, which revealed redness and erosion around diverticula in the ascending and sigmoid colon. Biopsy findings were similar to those of active UC. Immunohistochemical staining of the biopsy specimen with anti-tumor necrosis factor (TNF)-a antibody showed 80 % of lymphocytes were positive for TNF-a compared with 20 % at the first biopsy. The patient’s symptoms subsided with an increase in the dose of mesalazine and concurrent administration of prednisolone at 10 mg. He has remained on oral mesalazine and is currently asymptomatic. The findings of this study suggested a correlation between clinical manifestations and the proportion of TNF-a-positive lymphocytes.

Musosal tumour necrosis factor α in diverticular disease of the colon is overexpressed with disease severity

AIM

Inflammation occurs in diverticular disease (DD), but there is little information on inflammatory cytokines such as tumour necrosis factor α (TNF-α). The aim of this study was to assess TNF-α expression in DD and to see whether it is related to the severity of the disease.

METHOD

Twenty-four patients with symptomatic DD were divided into those with acute uncomplicated diverticulitis (AUD) (12 patients) and those with symptomatic uncomplicated diverticular disease (SUDD) (12 patients). Twelve further patients with asymptomatic diverticulosis (AD), six with segmental colitis associated with diverticulosis (SCAD), with ulcerative colitis (UC) and six healthy individuals (HC) were enrolled as controls. TNF-α expression in the colonic mucosa was assessed by the amount of mRNA codifying for the synthesis of TNF-α.

RESULTS

TNF-α expression was significantly higher in AUD than in HC (P=0.0007), in AD (P=0.0001) and in SUDD (P=0.0179). It was significantly higher also in SUDD than in HC (P=0.0007) and in AD (P=0.0001). TNF-α expression in AUD did not differ significantly from that in UC (P=0.0678) and SCAD (P=0.0610). It was significantly higher in UC, SCAD and AUD than in SUDD (P=0.0007, P=0.0001, P=0.0179).

CONCLUSION

TNF-α expression in DD seems to be related to the severity of the disease. In particular, it appears to be overexpressed in DD with inflammation (AUD and SUDD) compared with DD without (AD).

Tumour necrosis factor-alpha expression in segmental colitis associated with diverticulosis is related to the severity of the endoscopic damage

BACKGROUND

Tumour necrosis factor-α expression may be increased in segmental colitis associated with diverticulosis.

AIMS

To assess tumour necrosis factor-α expression in segmental colitis associated with diverticulosis in relation with the severity of the endoscopic damage.

METHODS

21 patients affected by segmental colitis associated with diverticulosis were studied (15 M, 6 F, mean age 58.87 years, range 43-85 years). Segmental colitis associated with diverticulosis was graduated as mild-moderate (patterns A and C) and severe (patterns B and D). Ten patients with moderate-to-severe ulcerative colitis, 10 patients with moderate-to-severe Crohn's disease, and 10 patients with irritable bowel syndrome served as control groups.

RESULTS

Tumour necrosis factor-α expression was significantly higher in segmental colitis associated with diverticulosis B (42.7%) and segmental colitis associated with diverticulosis D (40%) than in segmental colitis associated with diverticulosis A (19.1%) and segmental colitis associated with diverticulosis C (21.1%).Tumour necrosis factor-α expression was lower in segmental colitis associated with diverticulosis A and C than in ulcerative colitis and Crohn's disease, whilst no different tumour necrosis factor-α expression was found between segmental colitis associated with diverticulosis B and D and both ulcerative colitis and Crohn's disease.Finally, tumour necrosis factor-α expression was significantly lower in irritable bowel syndrome (8%±4) than in every type of segmental colitis associated with diverticulosis.

CONCLUSIONS

Tumour necrosis factor-α expression in segmental colitis associated with diverticulosis seems to be related to the severity of the endoscopic damage. This behaviour, similar to that of the inflammatory bowel diseases (IBD), confirms that this disease should be considered as a subtype of IBD.

Segmental colitis associated with diverticulosis: complication of diverticular disease or autonomous entity?

Segmental colitis associated with diverticulosis (SCAD) is a disease that affects colon harboring diverticula, mostly located in the sigmoid region. It has been considered a rare disease for many years, but new studies may contribute to easier recognition. Although its pathogenesis is not yet well defined, in the past SCAD has been considered a complication of diverticular disease, whilst new endoscopic, histological, and clinical data have encouraged the concept that SCAD includes pathogenetic and therapeutic aspects peculiar to inflammatory bowel diseases. We therefore describe herein current knowledge about this disease, and why it can be considered a truly autonomous entity instead of a complication of diverticular disease.

Features and management of colonic diverticular disease

Diverticular disease is one of the most prevalent gastrointestinal conditions to afflict Western populations. Although the majority of patients with diverticulosis remain asymptomatic, about one third will develop symptoms at some point in their lives. Symptomatic diverticular disease can range from chronic mild gastrointestinal distress to acute bouts of diverticulitis complicated by abscess or frank colonic perforation. The mainstay of treatment of symptomatic diverticular disease has long been bowel rest, antibiotics, and pain control, reserving surgery for those with complicated disease. This review discusses the epidemiology, pathophysiology, clinical presentation, and management of the spectrum of diverticular disease, including recent advances in the treatment of chronic diverticular disease.

Segmental colitis associated with diverticula: a rare clinical entity and a new challenge for the gastroenterologist

BACKGROUND AND AIM

Segmental colitis associated with diverticula (SCAD) has recently drawn a particular attention in the field of rare forms of colitis because of some peculiarities suggesting both its autonomy as a clinical entity and a resemblance with the most relevant forms of inflammatory bowel diseases (IBD). Aim of this review was to report the state of art on this topic.

METHODS

Epidemiological, clinical, endoscopic/histological and diagnostic features are described. Moreover, from both the pathogenetic and therapeutic point of view, new relevant information is highlighted regarding the possible role of tumour necrosis factor alpha (TNF-alpha) in mucosal inflammation.

RESULTS

SCAD would appear as a rare autonomous clinical entity distinctive of old age, although it is still not well defined. It is likely that prevalence of SCAD could have been underestimated in the past since its main clinical presentation (namely bleeding without pain) is often found in elderly patients with diverticula. Endoscopy and histology could be helpful to discriminate it from infectious diverticulitis. Increasing evidence encourages the concept that SCAD includes pathogenetic and therapeutic aspects peculiar of IBD. This could be relevant for clinical management of SCAD. Indeed, the resolution of a severe, refractory case of SCAD has been recently reported with biological drugs used for IBD therapy. This observation could encourage, in the near future, the use of biological therapy in severe forms of SCAD as an alternative to surgery.