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Pallotta L, Vona R, Maselli MA, Cicenia A, Bella A, Ignazzi A, Carabotti M, Cappelletti M, Gioia A, Tarallo M, Tellan G, Fiori E, Pezzolla F, Matarrese P, Severi C. Oxidative imbalance and muscular alterations in diverticular disease. Dig Liver Dis 2022; 54:1186-1194. [PMID: 35232677 DOI: 10.1016/j.dld.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/20/2021] [Accepted: 02/02/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is still a matter of debate if neuromuscular alterations reflect a primary event in diverticular disease (DD). AIMS This study aimed to assess colonic wall layers from both stenotic and non-stenotic complicated DD, bio-phenotypic alterations, inflammatory and oxidative status. METHODS A systematic analysis of colonic specimens obtained from stenotic and non-stenotic DD specimens was conducted and compared with controls. Biological activity and qPCR analysis were performed on longitudinal and circular muscles. Western blot analysis was performed throughout colonic wall layers to quantify oxidative and inflammatory markers. RESULTS A homogenous increase in oxidative stress was observed through all the layers, which were more sharpened in the longitudinal muscle for a loss in antioxidant defenses. In both stenotic and non-stenotic colon, the longitudinal muscle presented an impaired relaxation and a cellular phenotypic switch driven by transforming growth factor-β with an increase in mRNA expression of collagen Iα and a decrease in myosin heavy chain. The circular muscle, as the mucosa, was less affected by molecular alterations. No peculiar increase in inflammatory markers was observed. CONCLUSION A longitudinal colonic myopathy is present in DD, independently from the disease stage associated with an oxidative imbalance that could suggest new therapeutic strategies.
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Affiliation(s)
- Lucia Pallotta
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy.
| | - Rosa Vona
- Center for Gender-Specific Medicine, Italian National Institute of Health, Rome, Italy
| | - Maria Antonietta Maselli
- Experimental Pharmacology Laboratory, National Institute of Gastroenterology "S. de Bellis", Research Hospital, Castellana Grotte, BA, USA
| | - Alessia Cicenia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Antonino Bella
- Department of Infectious Diseases, Italian National Institute of Health, Rome, Italy
| | - Antonia Ignazzi
- Experimental Pharmacology Laboratory, National Institute of Gastroenterology "S. de Bellis", Research Hospital, Castellana Grotte, BA, USA
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, Sapienza University of Rome, Italy
| | - Martina Cappelletti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Alessia Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Mariarita Tarallo
- Department of Surgery "P. Valdoni", Sapienza University of Rome, Italy
| | - Guglielmo Tellan
- Department of Internistic, Anaesthetic and Cardiovascular Clinical Sciences, Sapienza University of Rome, Italy
| | - Enrico Fiori
- Department of Surgery "P. Valdoni", Sapienza University of Rome, Italy
| | - Francesco Pezzolla
- Experimental Pharmacology Laboratory, National Institute of Gastroenterology "S. de Bellis", Research Hospital, Castellana Grotte, BA, USA
| | - Paola Matarrese
- Center for Gender-Specific Medicine, Italian National Institute of Health, Rome, Italy
| | - Carola Severi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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Pathophysiology of Diverticular Disease: From Diverticula Formation to Symptom Generation. Int J Mol Sci 2022; 23:ijms23126698. [PMID: 35743141 PMCID: PMC9223421 DOI: 10.3390/ijms23126698] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 01/04/2023] Open
Abstract
Diverticular disease is a common clinical problem, particularly in industrialized countries. In most cases, colonic diverticula remain asymptomatic throughout life and sometimes are found incidentally during colonic imaging in colorectal cancer screening programs in otherwise healthy subjects. Nonetheless, roughly 25% of patients bearing colonic diverticula develop clinical manifestations. Abdominal symptoms associated with diverticula in the absence of inflammation or complications are termed symptomatic uncomplicated diverticular disease (SUDD). The pathophysiology of diverticular disease as well as the mechanisms involved in the shift from an asymptomatic condition to a symptomatic one is still poorly understood. It is accepted that both genetic factors and environment, as well as intestinal microenvironment alterations, have a role in diverticula development and in the different phenotypic expressions of diverticular disease. In the present review, we will summarize the up-to-date knowledge on the pathophysiology of diverticula and their different clinical setting, including diverticulosis and SUDD.
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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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Barrenschee M, Cossais F, Böttner M, Egberts JH, Becker T, Wedel T. Impaired Expression of Neuregulin 1 and Nicotinic Acetylcholine Receptor β4 Subunit in Diverticular Disease. Front Cell Neurosci 2019; 13:563. [PMID: 31920561 PMCID: PMC6930903 DOI: 10.3389/fncel.2019.00563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/05/2019] [Indexed: 12/15/2022] Open
Abstract
Neuregulin 1 (NRG1) regulates the expression of the nicotinic acetylcholine receptor (nAChR) and is suggested to promote the survival and maintenance of the enteric nervous system (ENS), since deficiency of its corresponding receptor complex ErbB2/ErbB3 leads to postnatal colonic aganglionosis. As diverticular disease (DD) is associated with intestinal hypoganglionosis, the NRG1-ErbB2/ErbB3 system and the nAChR were studied in patients with DD and controls. Samples of tunica muscularis of the sigmoid colon from patients with DD (n = 8) and controls (n = 11) were assessed for mRNA expression of NRG1, ErbB2, and ErbB3 and the nAChR subunits α3, α5, α7, β2, and β4. Site-specific gene expression levels of the NRG1-ErbB2/3 system were determined in myenteric ganglia harvested by laser microdissection (LMD). Localization studies were performed by immunohistochemistry for the NRG1-ErbB2/3 system and nAChR subunit β4. Rat enteric nerve cell cultures were stimulated with NRG1 or glial-cell line derived neurotrophic factor (GDNF) for 6 days and mRNA expression of the aforementioned nAchR was measured. NRG1, ErbB3, and nAChR subunit β4 expression was significantly down-regulated in both the tunica muscularis and myenteric ganglia of patients with DD compared to controls, whereas mRNA expression of ErbB3 and nAChR subunits β2, α3, α5, and α7 remained unaltered. NRG1, ErbB3, and nAChR subunit β4 immunoreactive signals were reduced in neuronal somata and the neuropil of myenteric ganglia from patients with DD compared to control. nAChR subunit β4 exhibited also weaker immunoreactive signals in the tunica muscularis of patients with DD. NRG1 treatment but not GDNF treatment of enteric nerve cell cultures significantly enhanced mRNA expression of nAchR β4. The down-regulation of NRG1 and ErbB3 in myenteric ganglia of patients with DD supports the hypothesis that intestinal hypoganglionosis observed in DD may be attributed to a lack of neurotrophic factors. Regulation of nAChR subunit β4 by NRG1 and decreased nAChR β4 in patients with DD provide evidence that a lack of NRG1 may affect the composition of enteric neurotransmitter receptor subunits thus contributing to the intestinal motility disorders previously reported in DD.
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Affiliation(s)
- Martina Barrenschee
- Neurogastroenterology, Institute of Anatomy, Christian-Albrechts University of Kiel, Kiel, Germany
| | - François Cossais
- Neurogastroenterology, Institute of Anatomy, Christian-Albrechts University of Kiel, Kiel, Germany
| | - Martina Böttner
- Neurogastroenterology, Institute of Anatomy, Christian-Albrechts University of Kiel, Kiel, Germany
| | - Jan-Hendrik Egberts
- Department of General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thilo Wedel
- Neurogastroenterology, Institute of Anatomy, Christian-Albrechts University of Kiel, Kiel, Germany
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Barbaro MR, Cremon C, Fuschi D, Scaioli E, Veneziano A, Marasco G, Festi D, Stanghellini V, Barbara G. Nerve fiber overgrowth in patients with symptomatic diverticular disease. Neurogastroenterol Motil 2019; 31:e13575. [PMID: 30838745 DOI: 10.1111/nmo.13575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/10/2019] [Accepted: 02/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonic diverticulosis is a common condition in industrialized countries. Up to 25% of patients with diverticula develop symptoms, a condition termed symptomatic uncomplicated diverticular disease (SUDD). The aim of the present study was to characterize neuroimmune interactions and nerve fiber plasticity in the colonic mucosa of patients with diverticula. METHODS Controls, patients with diverticulosis and with SUDD were enrolled in the study. Mucosal biopsies were obtained close to diverticula (diverticular region) and in a normal mucosa (distant site), corresponding to sigmoid and descending colon in the controls. Quantitative immunohistochemistry was used to assess mast cells, T cells, macrophages, nerve fibers, and neuronal outgrowth (growth-associated protein 43, GAP43+fibers). KEY RESULTS No difference emerged in mast cells and T cells among the three groups. Macrophages were increased in patients with SUDD and diverticulosis as compared to controls. Nerve fibers were enhanced in patients with SUDD and diverticulosis in comparison with controls in the diverticular region. GAP43+ fibers were increased only in patients with SUDD as compared to controls and to patients with diverticulosis in the diverticular region. In patients with SUDD, GAP43 density was increased in the diverticular region compared to distant site. Macrophages close to GAP43+ fibers were increased in the diverticular region of patients with SUDD. Significant correlations were found between GAP43+ fibers and immune cells. CONCLUSIONS AND INFERENCES Patients with diverticula are characterized by increased macrophage counts, while nerve fiber sprouting is increased only in the diverticular region of patients with SUDD suggesting a role in symptom generation.
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Affiliation(s)
- Maria Raffaella Barbaro
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Cesare Cremon
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Daniele Fuschi
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Eleonora Scaioli
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Alberto Veneziano
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Vincenzo Stanghellini
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences and Center for Applied Biomedical Research (CRBA), Alma Mater Studiorum - University of Bologna and S. Orsola-Malpighi Hospital, Bologna, Italy
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Alaburda P, Lukosiene JI, Pauza AG, Rysevaite-Kyguoliene K, Kupcinskas J, Saladzinskas Z, Tamelis A, Pauziene N. Ultrastructural changes of the human enteric nervous system and interstitial cells of Cajal in diverticular disease. Histol Histopathol 2019; 35:147-157. [PMID: 31187871 DOI: 10.14670/hh-18-136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In spite of numerous advances in understanding diverticular disease, its pathogenesis remains one of the main problems to be solved. We aimed to investigate the ultrastructural changes of the enteric nervous system in unaffected individuals, in asymptomatic patients with diverticulosis and in patients with diverticular disease. METHODS Transmission electron microscopy was used to analyse samples of the myenteric, outer submucosal and inner submucosal plexuses from patients without diverticula (n=9), asymptomatic patients with diverticulosis (n=7) and in patients with complicated diverticular disease (n=9). We described the structure of ganglia, interstitial cells of Cajal and enteric nerves, as well as their relationship with each other. The distribution and size of nerve processes were analysed quantitatively. RESULTS In complicated diverticular disease, neurons exhibited larger lipofuscin-like inclusions, their membranous organelles had larger cisterns and the nucleus showed deeper indentations. Nerve remodeling occurred in every plexus, characterised by an increased percentage of swollen and fine neurites. Interstitial cells of Cajal had looser contacts with the surrounding cells and showed cytoplasmic depletion and proliferation of the rough endoplasmic reticulum. In asymptomatic patients with diverticulosis, alterations of enteric nerves and ICC were less pronounced. CONCLUSIONS In conclusion, the present findings suggest that most ultrastructural changes of the enteric nervous system occur in complicated diverticular disease. The changes are compatible with damage to the enteric nervous system and reactive remodeling of enteric ganglia, nerves and interstitial cells of Cajal. Disrupted architecture of enteric plexuses might explain clinical and pathophysiological changes associated with diverticular disease.
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Affiliation(s)
- Paulius Alaburda
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jaune I Lukosiene
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audrys G Pauza
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Present address: Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol, United Kingdom
| | | | - Juozas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Algimantas Tamelis
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Neringa Pauziene
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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Severi C, Carabotti M, Cicenia A, Pallotta L, Annibale B. Recent advances in understanding and managing diverticulitis. F1000Res 2018; 7:F1000 Faculty Rev-971. [PMID: 30026920 PMCID: PMC6039950 DOI: 10.12688/f1000research.14299.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 02/05/2023] Open
Abstract
In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single 'causa prima' will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies.
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Affiliation(s)
- Carola Severi
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Alessia Cicenia
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Lucia Pallotta
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
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Barrenschee M, Wedel T, Lange C, Hohmeier I, Cossais F, Ebsen M, Vogel I, Böttner M. No neuronal loss, but alterations of the GDNF system in asymptomatic diverticulosis. PLoS One 2017; 12:e0171416. [PMID: 28152033 PMCID: PMC5289619 DOI: 10.1371/journal.pone.0171416] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/20/2017] [Indexed: 12/15/2022] Open
Abstract
Background Glial cell line-derived neurotrophic factor (GDNF) is a potent neurotrophic factor known to promote the survival and maintenance of neurons not only in the developing but also in the adult enteric nervous system. As diverticular disease (DD) is associated with reduced myenteric neurons, alterations of the GDNF system were studied in asymptomatic diverticulosis (diverticulosis) and DD. Methods Morphometric analysis for quantifying myenteric ganglia and neurons were assessed in colonic full-thickness sections of patients with diverticulosis and controls. Samples of tunica muscularis (TM) and laser-microdissected myenteric ganglia from patients with diverticulosis, DD and controls were analyzed for mRNA expression levels of GDNF, GFRA1, and RET by RT-qPCR. Myenteric protein expression of both receptors was quantified by fluorescence-immunohistochemistry of patients with diverticulosis, DD, and controls. Results Although no myenteric morphometric alterations were found in patients with diverticulosis, GDNF, GFRA1 and RET mRNA expression was down-regulated in the TM of patients with diverticulosis as well as DD. Furthermore GFRA1 and RET myenteric plexus mRNA expression of patients with diverticulosis and DD was down-regulated, whereas GDNF remained unaltered. Myenteric immunoreactivity of the receptors GFRα1 and RET was decreased in both asymptomatic diverticulosis and DD patients. Conclusion Our data provide evidence for an impaired GDNF system at gene and protein level not only in DD but also during early stages of diverticula formation. Thus, the results strengthen the idea of a disturbed GDNF-responsiveness as contributive factor for a primary enteric neuropathy involved in the pathogenesis and disturbed intestinal motility observed in DD.
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Affiliation(s)
| | - Thilo Wedel
- Institute of Anatomy, Kiel University, Kiel, Germany
| | | | - Ines Hohmeier
- Institute of Anatomy, Kiel University, Kiel, Germany
| | | | - Michael Ebsen
- Department of Pathology, Städtisches Krankenhaus Kiel, Kiel, Germany
| | - Ilka Vogel
- Department of Surgery, Städtisches Krankenhaus Kiel, Kiel, Germany
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Wedel T, Barrenschee M, Lange C, Cossais F, Böttner M. Morphologic Basis for Developing Diverticular Disease, Diverticulitis, and Diverticular Bleeding. VISZERALMEDIZIN 2015; 31:76-82. [PMID: 26989376 PMCID: PMC4789973 DOI: 10.1159/000381431] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Diverticula of the colon are pseudodiverticula defined by multiple outpouchings of the mucosal and submucosal layers penetrating through weak spots of the muscle coat along intramural blood vessels. A complete prolapse consists of a diverticular opening, a narrowed neck, and a thinned diverticular dome underneath the serosal covering. The susceptibility of diverticula to inflammation is explained by local ischemia, translocation of pathogens due to retained stool, stercoral trauma by fecaliths, and microperforations. Local inflammation may lead to phlegmonous diverticulitis, paracolic/mesocolic abscess, bowel perforation, peritonitis, fistula formation, and stenotic strictures. Diverticular bleeding is due to an asymmetric rupture of distended vasa recta at the diverticular dome and not primarily linked to inflammation. Structural and functional changes of the bowel wall in diverticular disease comprise: i) Altered amount, composition, and metabolism of connective tissue; ii) Enteric myopathy with muscular thickening, deranged architecture, and altered myofilament composition; iii) Enteric neuropathy with hypoganglionosis, neurotransmitter imbalance, deficiency of neurotrophic factors and nerve fiber remodeling; and iv) Disturbed intestinal motility both in vivo (increased intraluminal pressure, motility index, high-amplitude propagated contractions) and in vitro (altered spontaneous and pharmacologically triggered contractility). Besides established etiologic factors, recent studies suggest that novel pathophysiologic concepts should be considered in the pathogenesis of diverticular disease.
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Affiliation(s)
- Thilo Wedel
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
| | | | - Christina Lange
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - François Cossais
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Martina Böttner
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
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Abstract
BACKGROUND Although diverticular disease is one of the most frequent gastrointestinal disorders the pathogenesis is not yet sufficiently clarified. OBJECTIVES The aim is to define the anatomy and pathogenesis of diverticular disease considering the risk factors and description of structural and functional alterations of the bowel wall. METHODS This article gives an appraisal of the literature, presentation and evaluation of classical etiological factors, analysis and discussion of novel pathogenetic concepts. RESULTS Colonic diverticulosis is defined as an acquired out-pouching of multiple and initially asymptomatic pseudodiverticula through muscular gaps in the colon wall. Diverticular disease is characterized by diverticular bleeding and/or inflammatory processes (diverticulitis) with corresponding complications (e.g. abscess formation, fistula, covered and open perforation, peritonitis and stenosis). Risk factors for diverticular disease include increasing age, genetic predisposition, congenital connective tissue diseases, low fiber diet, high meat consumption and pronounced overweight. Alterations of connective tissue cause a weakening of preformed exit sites of diverticula and rigidity of the bowel wall with reduced flexibility. It is assumed that intestinal innervation disorders and structural alterations of the musculature induce abnormal contractile patterns with increased intraluminal pressure, thereby promoting the development of diverticula. Moreover, an increased release of pain-mediating neurotransmitters is considered to be responsible for persistent pain in chronic diverticular disease. CONCLUSIONS According to the present data the pathogenesis of diverticular disease cannot be attributed to a single factor but should be considered as a multifactorial event.
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Alterations of the enteric smooth musculature in diverticular disease. J Gastroenterol 2014; 49:1241-52. [PMID: 24113817 DOI: 10.1007/s00535-013-0886-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 08/06/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The pathogenesis of diverticular disease (DD) is considered to be multifactorial and involves intestinal motor disturbances and an underlying enteric neuromuscular pathology. While an enteric neuropathy has been well documented, actual studies on concomitant alterations of the enteric musculature are limited. This study is aimed at reassessing the smooth muscle tissue by histological, ultrastructural and molecular-biological approaches. METHODS Full-thickness sigmoid specimens were obtained from patients with DD (n = 20) and controls (n = 19). Morphometric analysis was performed to evaluate the thickness and connective tissue index of the circular and longitudinal muscle layers as well as the myenteric plexus. Structural alterations were determined by light and transmission electron microscopy. mRNA profiles of components of the contractile smooth muscle apparatus including smooth muscle α-actin, smoothelin, histone deacetylase 8, and smooth muscle myosin heavy chain (SMMHC) were assessed by qPCR. Altered gene expression levels were confirmed at protein level by immunohistochemistry. RESULTS Compared to controls, patients with DD showed (1) increased thickness of the circular and longitudinal muscle layers, (2) architectural alterations of smooth muscle cells, (3) increased connective tissue index of the longitudinal muscle layer, (4) focally reduced density of myofilaments at ultrastructural level, (5) specific down-regulation of SMMHC mRNA levels, (6) decreased immunoreactivity of SMMHC, (7) oligo-neuronal hypoganglionosis. CONCLUSIONS DD is associated with distinct structural and functional alterations of the enteric musculature. The enteric myopathy is characterized by disturbed muscular architecture, connective tissue replacement and loss of specific myofilaments and thus may contribute to the pathogenesis and progression of DD.
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Sanger GJ, Broad J, Kung V, Knowles CH. Translational neuropharmacology: the use of human isolated gastrointestinal tissues. Br J Pharmacol 2014; 168:28-43. [PMID: 22946540 DOI: 10.1111/j.1476-5381.2012.02198.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 08/08/2012] [Accepted: 08/23/2012] [Indexed: 12/22/2022] Open
Abstract
Translational sciences increasingly emphasize the measurement of functions in native human tissues. However, such studies must confront variations in patient age, gender, genetic background and disease. Here, these are discussed with reference to neuromuscular and neurosecretory functions of the human gastrointestinal (GI) tract. Tissues are obtained after informed consent, in collaboration with surgeons (surgical techniques help minimize variables) and pathologists. Given the difficulties of directly recording from human myenteric neurones (embedded between muscle layers), enteric motor nerve functions are studied by measuring muscle contractions/relaxations evoked by electrical stimulation of intrinsic nerves; responses are regionally dependent, often involving cholinergic and nitrergic phenotypes. Enteric sensory functions can be studied by evoking the peristaltic reflex, involving enteric sensory and motor nerves, but this has rarely been achieved. As submucosal neurones are more accessible (after removing the mucosa), direct neuronal recordings are possible. Neurosecretory functions are studied by measuring changes in short-circuit current across the mucosa. For all experiments, basic questions must be addressed. Because tissues are from patients, what are the controls and the influence of disease? How long does it take before function fully recovers? What is the impact of age- and gender-related differences? What is the optimal sample size? Addressing these and other questions minimizes variability and raises the scientific credibility of human tissue research. Such studies also reduce animal use. Further, the many differences between animal and human GI functions also means that human tissue research must question the ethical validity of using strains of animals with unproved translational significance.
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Affiliation(s)
- G J Sanger
- Neurogastroenterology Group, Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, UK.
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Böttner M, Barrenschee M, Hellwig I, Harde J, Egberts JH, Becker T, Zorenkov D, Wedel T. The enteric serotonergic system is altered in patients with diverticular disease. Gut 2013; 62:1753-62. [PMID: 23144076 DOI: 10.1136/gutjnl-2012-302660] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Disturbances of the enteric serotonergic system have been implicated in several intestinal motility disorders. Patients with diverticular disease (DD) have been reported to exhibit abnormal intestinal motility and innervation patterns. Gene expression profiles of the serotonergic system and distribution of the serotonin type 4 receptor (5HT-4R) were thus studied in patients with DD. DESIGN Colonic specimens from patients with DD and controls were subjected to quantitative PCR for serotonin receptors 2B, 3A, 4, serotonin transporter and synthesising enzyme tryptophan hydroxylase. Localisation of 5HT-4R was determined by dual-label immunocytochemistry using smooth muscle actin (α-SMA) and pan-neuronal markers (PGP 9.5) and quantitative analysis was carried out. Site-specific gene expression analysis of 5HT-4R was assessed within myenteric ganglia and muscle layers. Correlation of 5HT-4R with muscarinic receptors 2 and 3 (M2R, M3R) messenger RNA expression was determined. RESULTS 5HT-4R mRNA expression was downregulated in the tunica muscularis and upregulated in the mucosa of patients with DD, whereas the other components of the serotonergic system remained unchanged. 5HT-4R was detected in ganglia and muscle layers, but was decreased in the circular muscle layer and myenteric ganglia of patients with DD. 5HT-4R mRNA expression correlated with M2R/M3R mRNA expression in controls, but not in patients with DD. CONCLUSIONS The serotonergic system is compromised in DD. Altered expression of 5HT-4R at mRNA and protein levels may contribute to intestinal motor disturbances reported in patients with DD. The findings support the hypothesis that DD is associated and possibly promoted by an enteric neuromuscular pathology.
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MESH Headings
- Aged
- Case-Control Studies
- Colon, Sigmoid/metabolism
- Colon, Sigmoid/physiopathology
- Diverticulum, Colon/metabolism
- Diverticulum, Colon/physiopathology
- Enteric Nervous System/metabolism
- Enteric Nervous System/physiopathology
- Female
- Humans
- Male
- Middle Aged
- Polymerase Chain Reaction
- Receptors, Serotonin, 5-HT2/metabolism
- Receptors, Serotonin, 5-HT2/physiology
- Receptors, Serotonin, 5-HT3/metabolism
- Receptors, Serotonin, 5-HT3/physiology
- Receptors, Serotonin, 5-HT4/metabolism
- Receptors, Serotonin, 5-HT4/physiology
- Serotonergic Neurons/metabolism
- Serotonergic Neurons/physiology
- Serotonin Plasma Membrane Transport Proteins/metabolism
- Serotonin Plasma Membrane Transport Proteins/physiology
- Transcriptome/physiology
- Tryptophan Hydroxylase/metabolism
- Tryptophan Hydroxylase/physiology
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Affiliation(s)
- Martina Böttner
- Institute of Anatomy, Christian-Albrechts-University of Kiel, , Kiel, Germany
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In vitro motor patterns and electrophysiological changes in patients with colonic diverticular disease. Int J Colorectal Dis 2013; 28:1413-22. [PMID: 23702821 DOI: 10.1007/s00384-013-1716-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The underlying mechanism responsible for motility changes in colonic diverticular disease (DD) is still unknown. In the present study, our aim was to investigate the structural and in vitro motor changes in the sigmoid colon of patients with DD. METHODS Muscle bath, microelectrodes and immunohistochemical techniques were performed with samples obtained from the left and sigmoid colon of patients with DD and compared with those of patients without DD. RESULTS The amplitude and area under the curve of the spontaneous rhythmic phasic contractions were greatly reduced in patients with DD whereas their frequency and tone remained unaltered. Electrical field stimulation induced a neurally mediated, enhanced ON-contraction (amplitude) in patients with DD and increased the duration of latency of OFF-contractions. The resting membrane potential of smooth muscle cells was hyperpolarized and the amplitude of the inhibitory junction potential was increased in patients with DD. In contrast, no significant histological differences were observed in patients with DD as smooth muscle (circular and longitudinal layers), interstitial cells of Cajal, glial cells and myenteric neurons densities remained unaltered. CONCLUSIONS Sigmoid strips from patients with asymptomatic DD showed an altered motor pattern with reduced spontaneous motility and enhanced neurally mediated colonic responses involving both excitatory and inhibitory motor pathways. No major neural and muscular structural elements were detected at this stage of the disease. These findings could be valuable in understanding the pathophysiology of this prevalent digestive disease.
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Böttner M, Barrenschee M, Hellwig I, Harde J, Egberts JH, Becker T, Zorenkov D, Schäfer KH, Wedel T. The GDNF System Is Altered in Diverticular Disease - Implications for Pathogenesis. PLoS One 2013; 8:e66290. [PMID: 23805210 PMCID: PMC3689736 DOI: 10.1371/journal.pone.0066290] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 05/07/2013] [Indexed: 01/19/2023] Open
Abstract
Background & Aims Absence of glial cell line-derived neurotrophic factor (GDNF) leads to intestinal aganglionosis. We recently demonstrated that patients with diverticular disease (DD) exhibit hypoganglionosis suggesting neurotrophic factor deprivation. Thus, we screened mRNA expression pattern of the GDNF system in DD and examined the effects of GDNF on cultured enteric neurons. Methods Colonic specimens obtained from patients with DD (n = 21) and controls (n = 20) were assessed for mRNA expression levels of the GDNF system (GDNF, GDNF receptors GFRα1 and RET). To identify the tissue source of GDNF and its receptors, laser-microdissected (LMD) samples of human myenteric ganglia and intestinal muscle layers were analyzed separately by qPCR. Furthermore, the effects of GDNF treatment on cultured enteric neurons (receptor expression, neuronal differentiation and plasticity) were monitored. Results mRNA expression of GDNF and its receptors was significantly down-regulated in the muscularis propria of patients with DD. LMD samples revealed high expression of GDNF in circular and longitudinal muscle layers, whereas GDNF receptors were also expressed in myenteric ganglia. GDNF treatment of cultured enteric neurons increased mRNA expression of its receptors and promoted neuronal differentiation and plasticity revealed by synaptophysin mRNA and protein expression. Conclusions Our results suggest that the GDNF system is compromised in DD. In vitro studies demonstrate that GDNF enhances expression of its receptors and promotes enteric neuronal differentiation and plasticity. Since patients with DD exhibit hypoganglionosis, we propose that the observed enteric neuronal loss in DD may be due to lacking neurotrophic support mediated by the GDNF system.
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Affiliation(s)
- Martina Böttner
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
- * E-mail:
| | | | - Ines Hellwig
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Jonas Harde
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Jan-Hendrik Egberts
- Department of General and Thoracic Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Thomas Becker
- Department of General and Thoracic Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Dimitri Zorenkov
- Department of Neurology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Karl-Herbert Schäfer
- Department of Informatics and Microsystems Technics, University of Applied Sciences, Kaiserslautern, Germany
| | - Thilo Wedel
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
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Abstract
Although diverticular disease of the colon (diverticulosis) is a frequent finding in Western countries, its pathophysiologic grounds are still only partially understood. Traditionally considered as an age-related condition, colonic diverticulosis is probably the final result of several factors concurring together to determine the anatomo-functional abnormalities eventually causing outpouching of the viscus' mucosa. Among these factors, a relevant role seems to be played by an abnormal neuromuscular function of the large bowel, as shown by abnormal myoelectrical and motor function repeatedly described in these patients, as well as by altered visceral perception. These anomalies might be related to the recent demonstration of derangement of enteric innervation (especially involving interstitial cells of Cajal and enteric glial cells), mucosal neuropeptides, and mucosal inflammation. The latter may have a role of paramount importance in the development of visceral hypersensitivity, responsible for abdominal pain in a subset of patients.
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Affiliation(s)
- Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
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Abstract
The pathogenesis of diverticular disease is still poorly understood and considered to be multifactorial. Whereas classical pathogenetic concepts have focused on risk factors including increasing age, low-fiber diet and connective tissue disorders, novel concepts take into account that patients with diverticular disease exhibit disturbed intestinal motility patterns (that may result in functional obstruction and painful sensations) therefore postulating an underlying enteric neuro-/myopathy. Recent studies including quantitative evaluations of the enteric nervous system (ENS) in diverticular disease yielded hypoganglionic conditions of both myenteric and submucosal plexus as well as a nerve tissue remodeling in chronic diverticular disease. The disturbed neuromuscular communication was proven by demonstrating alterations in several enteric neurotransmitter systems, exemplified for the cholinergic, serotonergic, nitrergic system as well as for vasointestinal peptide, galanin and tachykinins. Novel lines of evidence have added the involvement of neurotrophic factors such as glial cell line-derived neurotrophic factor which is supposed to regulate ENS development and maintenance and which is downregulated in patients with diverticular disease. Consistent with the hypothesis of an enteric myopathy, deficits in smooth muscle integrity and composition such as hypertrophy, fibrotic transformation and gene expression deficits could be delineated. Taken together, the structural and functional findings on alterations of the ENS and the enteric musculature in diverticular disease provide evidence to strengthen the hypothesis that an enteric neuro-/myopathy may contribute to the development of colonic diverticula and the generation of symptoms in the course of the disease.
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Affiliation(s)
- Martina Böttner
- Department of Anatomy, Christian-Albrechts University of Kiel, Kiel, Germany.
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Wedel T, Barrenschee M, Hellwig I, Harde J, Böttner M. Pathogenese der Divertikulose und Divertikelkrankheit des Kolons. VISZERALMEDIZIN 2012. [DOI: 10.1159/000339349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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