Clinical features and differential diagnosis of diverticular disease

Source of dietary fibre and diverticular disease incidence: a prospective study of UK women

BACKGROUND

Previous prospective studies have found the incidence of intestinal diverticular disease decreased with increasing intakes of dietary fibre, but associations by the fibre source are less well characterised. We assessed these associations in a large UK prospective study of middle-aged women.

METHODS AND FINDINGS

During 6 (SD 1) years follow-up of 690 075 women without known diverticular disease who had not changed their diet in the last 5 years, 17 325 were admitted to hospital or died with diverticular disease. Dietary fibre intake was assessed using a validated 40-item food questionnaire and remeasured 1 year later in 4265 randomly-selected women. Mean total dietary fibre intake at baseline was 13.8 (SD 5.0) g/day, of which 42% came from cereals, 22% from fruits, 19% from vegetables (not potatoes) and 15% from potatoes. The relative risk (95% CI) for diverticular disease per 5 g/day fibre intake was 0.86 (0.84 to 0.88). There was significant heterogeneity by the four main sources of fibre (p<0.0001), with relative risks, adjusted for each of the other sources of dietary fibre of 0.84 (0.81 to 0.88) per 5 g/day for cereal, 0.81 (0.77 to 0.86) per 5 g/day for fruit, 1.03 (0.93 to 1.14) per 5 g/day for vegetable and 1.04 (1.02 to 1.07) per 1 g/day for potato fibre.

CONCLUSIONS

A higher intake of dietary fibre is associated with a reduced risk of diverticular disease. The associations with diverticular disease appear to vary by fibre source, and the reasons for this variation are unclear.

Colonic diverticular: disease diagnosis and therapy

Colonic diverticular disease is one of the most common gastrointestinal disorders in the Western world, affecting approximately 50% of the population above the age of 70 years. Symptoms develop only in about one quarter of the affected individuals with complications in one-third of the symptomatic patients. Diagnosis is mostly confirmed by colonoscopy. Abdominal CT is the most sensitive for the diagnosis of complicated severe diverticulitis, while colonoscopy or in severe cases angiography may be performed in bleeding patients. Initial therapy of non-complicated symptomatic diverticulitis includes antibiotics and more recently non-absorbable antibiotics. In complicated cases should be treated with broad spectrum i.v. antibiotics, however surgery may became necessary in a minority of the cases. The proportion of patients needing acute surgical intervention has decreased in the last decades with the advancement of conservative management including medical therapy, endoscopy and imaging techniques and the indication of elective was also changed. Orv. Hetil., 2012, 153, 205–213.

Diverticular disease and the risk of colon cancer - a population-based case-control study

BACKGROUND

Colon cancer and diverticular disease are most common in the Western world and their incidences tend to increase with advancing age. The association between the diseases remains unclear.

AIM

To analyse the risk of colon cancer after hospitalisation for diverticular disease.

METHODS

Nationwide case-control study. A total of 41,037 patients with colon cancer during 1992-2006, identified from the Swedish Cancer Register were included. Each case was matched with two control subjects. From the Swedish Inpatient Register, cases and control subjects hospitalised for diverticular disease were identified. Odds ratios (OR) and confidence intervals for receiving a diagnosis of colon cancer after hospital discharge for diverticular disease were calculated. Colon cancer mortality was compared between patients with or without diverticular disease.

RESULTS

Within 6months after an admission due to diverticular disease, OR of having a colon cancer diagnosis were up to 31.49 (19.00-52.21). After 12 months, there was no increased risk. The number of discharges for diverticular disease did not affect the risk. Colon cancer mortality did not differ between patients with and without diverticular disease.

CONCLUSIONS

Diverticular disease does not increase the risk of colon cancer in the long term, and a history of diverticular disease does not affect colon cancer mortality. The increased risk of colon cancer within the first 12months after diagnosing diverticular disease is most likely due to surveillance and misclassification. Examination of the colon should be recommended after a primary episode of symptomatic diverticular disease.

Association between colonic polyps and diverticular disease

AIM: To evaluate the association between colonic polyps and diverticular disease in Japan.

METHODS: We retrospectively reviewed the medical records of 672 consecutive patients who underwent total colonoscopy between August 2006 and April 2007 at Nishinjo Hospital, Okinawa, Japan. Patients with a history of any of the following were excluded from the study: previous polypectomy, colonic resection, and inflammatory bowel diseases. The association between colonic polyps and diverticular disease was analyzed by logistic regression analysis, adjusted for age and sex.

RESULTS: Prevalence of colonic polyps in all patients with diverticular disease was significantly higher than that in those without diverticular disease (adjusted odds ratio 1.7).

CONCLUSION: Our data showed that patients with diverticular disease have a higher risk of colonic polyps compared to those without.

Diagnostic yield of colonoscopy based on symptoms

OBJECTIVE

There are only a few data on the diagnostic yield of colonoscopy in different symptoms. The aim of this study was to assess the outcome of colonoscopy in patients with various gastrointestinal symptoms and to estimate the relation between the findings and the presenting symptoms.

MATERIAL AND METHODS

1121 consecutive colonoscopies were registered during 1 year. Asymptomatic subjects and patients with known inflammatory bowel disease (IBD) were excluded, leaving 767 eligible for the study. Symptoms, findings and clinical judgement about their relation were recorded.

RESULTS

In patients with bleeding symptoms (n=405), serious colonic pathology--cancers and adenomas >1 cm, IBD and angiodysplasia--was found in 54 (13.3%), 83 (20.5%) and 20 (4.9%) patients, respectively; 162 (40%) patients had findings that could be related to the symptom. In 173 subjects with non-bloody diarrhoea, the diagnostic yield was 31.2%, i.e. mostly IBD and microscopic colitis. In 189 subjects with other gastrointestinal symptoms, the diagnostic yield was 13.2%. Serious colonic pathology was found in 8 of 362 (2.2%) subjects examined because of non-bleeding symptoms.

CONCLUSION

The diagnostic yield of colonoscopy is high in patients with bleeding symptoms or diarrhoea, while the prevalence of significant findings is equal to a screening population in patients with other symptoms.

Prospective, five-year follow-up study of patients with symptomatic uncomplicated diverticular disease

PURPOSE

The natural history of diverticular disease is largely unknown. Most studies are retrospective and treatment recommendations are derived from outdated literature. This study was a prospective, long-term assessment of the development of complications in patients with symptomatic diverticular disease.

METHODS

All patients with a confirmed diagnosis of symptomatic diverticular disease between August 1999 and April 2001 were followed up prospectively for an average of five years. Hospital computerized discharges were assessed for any subsequent elective or emergency admission for diverticular disease-related complications, including surgical intervention. A telephone questionnaire was conducted on all patients and/or their family physician looking specifically for symptoms, complications, and surgical intervention.

RESULTS

A total of 163 patients (106 females) were identified (median age, 74 (interquartile range, 64-80) years). The diagnosis was confirmed through colonoscopy (n = 106), flexible sigmoidoscopy (n = 57), and barium enema (n = 31). Nineteen were lost to follow-up and a further 19 died from unrelated causes. Twenty-five were excluded. After the initial diagnosis, two patients (1.7 percent) subsequently presented with an episode of diverticulitis, which was treated conservatively. A single patient (0.8 percent) required surgery for chronic symptoms. One hundred sixteen patients (97 percent) had no or mild symptoms after a median follow-up of 66 months.

CONCLUSIONS

In this prospective long-term study, symptomatic uncomplicated diverticular disease seems to run a long-term benign course with a very low incidence of subsequent complications. Symptomatic disease, acute diverticulitis, and complicated diverticular disease seem to constitute distinct clinical entities with little crossover between groups.

Epidemiology and management of diverticular disease of the colon

The aim of this review is mainly to show the high prevalence of diverticulosis and the clinical relevance of uncomplicated and complicated diverticular disease worldwide. The prevalence of diverticular disease is directly related to the aging of the population and in western countries is diagnosed in approximately 50–65% of adult subjects. The often more frequent adoption of an incorrect dietary style, such as a low-fiber diet, and the progressive increase in the average age of western populations will increase the prevalence of this pathology and the economic burden for health systems even more so. Furthermore, the management of uncomplicated diverticular disease, segmental colitis associated to diverticula and diverticulitis, which represent the different manifestations of the symptomatic spectrum of colonic diverticulosis, are reported.

The pathology of diverticulosis: classical concepts and mucosal changes in diverticula

Left-sided diverticular disease affects upwards of 50% of the population over the age of 60 years in western countries and is becoming more common as the population ages. Studies from the 1960s to 1980s related its occurrence to the use of low fiber diets, and to the prolonged colonic transit time and increased intraluminal pressure associated with low-volume stools. Pulsion diverticula (pseudodiverticula) emerge through the muscularis propria of the left colon at points of penetration of the vasa recta that supply the submucosa and mucosa. Cardinal features of the sigmoid colon in diverticular disease are abnormalities of the muscularis propria, including thickening and elastosis of the teniae, shortening of the bowel, and thickening and folding of the circular muscle with the development of transverse semilunar ridges between the mesenteric and antimesenteric teniae. Complications of diverticular disease such as hemorrhage, diverticulitis, peridiverticular abscess, fistula, and perforation are well recognized.

Review article: uncomplicated diverticular disease of the colon

Diverticular disease of the colon is the fifth most important gastrointestinal disease in terms of direct and indirect health care costs in western countries. Uncomplicated diverticular disease is defined as the presence of diverticula in the absence of complications such as perforation, fistula, obstruction and/or bleeding. The distribution of diverticula along the colon varies worldwide being almost always left-sided and directly related to age in western countries and right-sided where diet is rich in fibre. The pathophysiology of diverticular disease is complex and relates to abnormal colonic motility, changes in the colonic wall, chronic mucosal low-grade inflammation, imbalance in colonic microflora and visceral hypersensitivity. Moreover, there can be genetic factors involved in the development of colonic diverticula. The use of non-absorbable antibiotics is the mainstay of therapy in patients with mild to moderate symptoms, and the effect of fibre-supplementation alone does not appear to be significantly different from placebo, although no definite data are available. More recently, alternative treatments have been reported. Mesalazine acts as a local mucosal immunomodulator and has been shown to improve symptoms and prevent recurrence of diverticulitis. In addition, probiotics have also been shown to be beneficial by re-establishing a normal gut microflora. In this study, the current literature on uncomplicated diverticular disease of the colon is reviewed.

Diverticulosis coli: update on a "Western" disease

Diverticular disease affects upwards of 50% of the population over the age of 60 years in Western countries and is becoming more common as the population ages. Studies from the 1970s and 1980s related its occurrence to the use of low-fiber diets and to the prolonged colonic transit time and increased intraluminal pressure associated with low-volume stools. Pulsion diverticula (pseudodiverticula) emerge through the thickened circular layer of the muscularis propria of the left colon at points of penetration of the vasa recta that supply the submucosa and mucosa. Complications of diverticular disease such as hemorrhage, diverticulitis, peridiverticular abscess, fistula, and perforation are well recognized. More recently, attention has been drawn to the polypoid prolapsing mucosal folds that may develop as the affected segment of bowel (usually the sigmoid) becomes shorter and to changes in the mucosa surrounding the diverticula and in the bowel wall that may result in confusion with ulcerative colitis or Crohn disease (sigmoid colitis-associated diverticulosis [SCAD]). Distinguishing SCAD from these entities is extremely important, and pathologists should be aware of the possibility of overdiagnosing chronic inflammatory bowel disease in biopsies or resection specimens of sigmoid colon with diverticular disease.

Diverticulosis and Diverticulitis

Diverticulosis and diverticulitis are common disorders in modern society and represent different places on the spectrum of diverticular disease. Often called a problem of western civilization, diverticular disease is rare in developing countries. This article provides an overview of the epidemiology of diverticular disease, risk factors, and clinical presentation in varying phases. Differential diagnostic testing and comprehensive management from the medical, surgical, and wound, ostomy, and continence nursing perspectives are also addressed. Nurses play a key role in supporting people with diverticular disease and referring them for appropriate assessment, treatment, and support.

Boswell Award of the SAVA: 1991. Dr. D. G. Catton

Colonic diverticula are protrusions of the mucosa through the outer muscular layers, which are usually abnormally thickened, to form narrow necked pouches. Diverticular disease of the colon covers a wide clinical spectrum: from an incidental finding to symptomatic uncomplicated disease to diverticulitis. A quarter of patients with diverticulitis will develop potentially life-threatening complications including perforation, fistulae, obstruction or stricture. In Western countries diverticular disease predominantly affects the left colon, its prevalence increases with age and its causation has been linked to a low dietary fibre intake. Right-sided diverticular disease is more commonly seen in Asian populations and affects younger patients. Its pathogenesis and relationship to left-sided diverticular disease remains unclear. Diverticular disease of the colon is a significant cause of morbidity and mortality in the Western world and its frequency has increased throughout the whole of the 20th century. Since it is a disease of the elderly, and with an aging population, it can be expected to occupy an increasing portion of the surgical and gastroenterological workload. It is uncertain what symptoms uncomplicated diverticular disease gives rise to: there is an overlap with irritable bowel syndrome. Diagnosis is primarily by barium enema and colonoscopy, but more sophisticated imaging procedures such as computed tomography (CT) are increasingly being used to assess and treat complications such as abscess or fistula, or to provide alternative diagnoses if diverticulosis is not confirmed. Initial therapy for uncomplicated diverticulitis is supportive, including monitoring, bowel rest and antibacterials. CT is used to guide percutaneous drainage of abscesses to avoid surgery or allow it to be performed as an elective procedure. Surgery is indicated for complications of acute diverticulitis, including failure of medical treatment, gross perforation, and abscess formation that cannot be resolved by percutaneous drainage. Complications of chronic diverticulitis (fistula formation, stricture and obstruction) are also usually treated surgically. However, the indications for, and the timing and staging of operations for diverticular disease are often difficult decisions requiring sound clinical judgement. Factors such as the number of episodes of inflammation, the age of the patient, and his/her overall medical condition play a role in determining whether or not a patient should undergo surgical resection. Laparoscopic surgery may be associated with less pain, less morbidity and shorter hospital stays, but its exact role is yet to be defined. Diverticular disease of the colon is the most common cause of acute lower gastrointestinal haemorrhage, which can be massive. Although the majority of patients stop bleeding spontaneously, angiographic and surgical treatment may be required, while the place of endoscopic haemostasis remains to be established.