Recent advances in diverticular disease

Randomized control trial on the efficacy of Limosilactobacillus reuteri ATCC PTA 4659 in reducing inflammatory markers in acute uncomplicated diverticulitis

INTRODUCTION

Recent guidelines suggest treating acute uncomplicated diverticulitis (AUD) without antibiotics. We tested the efficacy of Limosilactobacillus reuteri ATCC PTA 4659 in AUD. Primary outcome was the reduction of abdominal pain and inflammatory markers [C-reactive protein (C-RP) and calprotectin]. Secondary outcome was the reduction of hours of hospitalization.

PATIENTS AND METHODS

A double-blind, randomized controlled trial was conducted in 119 patients with AUD. The probiotic group (61 patients) was treated with fluids, bowel rest and L. reuteri/b.i.d. for 10 days. The placebo group (58 patients) was treated with the same therapy and placebo/b.i.d. for 10 days. All patients completed a daily visual analogue scale (VAS) for abdominal pain.

RESULTS

Both groups showed a mean VAS score of 7 at enrolment and a reduction of 4 points after 3 days. C-RP value, after 72 h, decreased by 58.8% in the probiotic group and by only 40% in the placebo group (P < 0.05). Calprotectin levels, after 72 h, decreased by 17% in the probiotic group and by only 10.6% in the control group (P < 0.05). In the probiotic group, the hospitalization was done for 75.5 h compared to 83.5 in the placebo group.

CONCLUSIONS

The supplementation with L. reuteri 4659 together with bowel rest and fluids significantly reduced both blood and faecal inflammatory markers compared to the placebo group.

Systematic review: outpatient management of acute uncomplicated diverticulitis

PURPOSE OF REVIEW

Acute uncomplicated diverticulitis is traditionally managed by inpatient admission for bowel rest, intravenous fluids and intravenous antibiotics. In recent years, an increasing number of publications have sought to determine whether care might instead be conducted in the community, with earlier enteral feeding and oral antibiotics. This systematic review evaluates the safety and efficacy of such an ambulatory approach.

METHODS

Medline, Embase and Cochrane Library databases were searched. All peer-reviewed studies that investigated the role of ambulatory treatment protocols for acute uncomplicated diverticulitis, either directly or indirectly, were eligible for inclusion.

RESULTS

Nine studies were identified as being suitable for inclusion, including one randomised controlled trial, seven prospective cohort studies and one retrospective cohort study. All, except one, employed imaging as part of their diagnostic criteria. There was inconsistency between studies with regards to whether patients with significant co-morbidities were eligible for ambulatory care and whether bowel rest therapy was employed. Neither of these variables influenced outcome. Across all studies, 403 out of a total of 415 (97 %) participants were successfully treated for an episode of acute uncomplicated diverticulitis using an outpatient-type approach. Cost savings ranged from 35.0 to 83.0 %.

CONCLUSION

Current evidence suggests that a more progressive, ambulatory-based approach to the majority of cases of acute uncomplicated diverticulitis is justified. Based on this evidence, the authors present a possible outpatient-based treatment algorithm. An appropriately powered randomised controlled trial is now required to determine its safety and efficacy compared to traditional inpatient management.

Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis

OBJECTIVE

Despite the high prevalence of hospitalization for left iliac fossa tenderness, there is a striking lack of randomized data available to guide therapy. The authors hypothesize that an oral antibiotic and fluids are not inferior to intravenous (IV) antibiotics and 'bowel rest' in clinically diagnosed acute uncomplicated diverticulitis.

METHOD

A randomized controlled trial was constructed in two District General Hospitals. All clinically diagnosed patients presenting with acute uncomplicated diverticulitis were eligible for the study. Oral and IV regimens utilizing ciprofloxacin and metronidazole were compared. The primary outcomes studied were surrogates for resolution of symptoms (including tenderness on day 3 and length of stay) and failure of oral therapy. Secondary endpoints studied were serial constitutional and biomarker trends.

RESULTS

There were 41 patients in the oral arm and 38 in the IV arm (n = 79). No patient had to be converted to IV antibiotics from the oral group. There was a complete resolution of symptoms in both groups. Tenderness was equivalent in both groups on day 3. Among secondary endpoints, a serial decrease in C reactive protein was the best serological predictor of resolution for both groups.

CONCLUSION

Oral antibiotics are not inferior to intravenous antibiotics in achieving resolution of clinically diagnosed diverticulitis.

Diverticulosis and colorectal cancer: between lights and shadows

The prevalence of diverticulosis and colorectal cancer (CRC) is markedly increased in the last century. Both diseases are highly frequent in Western countries and in aged people. Western diet--low in fiber and rich in dietary fat--has been largely regarded to play a major role in the pathogenesis of both conditions. A causal relationship between diverticulosis and CRC has been suggested in different studies. Epidemiologic series found a more frequent rectosigmoid localization of neoplastic lesions (advanced adenoma and CRC) in patients with diverticulosis as compared with controls, particularly in those with a previous diverticulitis episode or with an extensive disease. However, data are still controversial, with other studies failing to confirm this observation. Such discrepancy could be referred to the highly heterogeneous study design and setting in the different epidemiologic series. Pathologic studies showed that either macroscopic and microscopic chronic inflammation--which is regarded as risk factor for CRC development--is present in the colonic mucosa of some patients with diverticula. Moreover, alterations in the extracellular matrix, also involved in colorectal carcinogenesis, have been depicted in diverticulosis. In addition, an upward shifting of cell proliferation occurs in diverticular mucosa, and in nondiverticular patients with advanced adenomas. Finally, aberrant crypt foci--which are considered potential markers of CRC risk in ulcerative colitis--have been detected in colonic mucosa of patients with diverticulosis. Despite this substantial amount of evidence, however, the available data are not yet strong enough to suggest a more aggressive CRC prevention in diverticular as compared with nondiverticular subjects.