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Domas E, Starks K, Kanneganti S. Current Management of Diverticulitis. Surg Clin North Am 2024; 104:529-543. [PMID: 38677818 DOI: 10.1016/j.suc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Diverticulosis and diverticulitis remain common diagnoses in western countries, and the incidence continues to rise. Diverticulitis accounts for roughly one-third of admissions to acute care hospitals annually, with even more patients being treated as outpatients due to improved understanding of risk stratification and the natural history of disease progression. Thus, having a thorough understanding of the etiology of the disease in conjunction with computed tomography findings and patient presentation can help dictate the appropriate treatment.
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Affiliation(s)
- Erik Domas
- Virginia Mason Franciscan Health, St. Joseph Medical Center General Surgery Residency, 1708 South Yakima Avenue, Suite 115, Tacoma, WA 98405, USA
| | - Kiefer Starks
- Virginia Mason Franciscan Health, St. Joseph Medical Center General Surgery Residency, 1708 South Yakima Avenue, Suite 115, Tacoma, WA 98405, USA
| | - Shalini Kanneganti
- Department of Colon and Rectal Surgery, Virginia Mason Franciscan Health, Franciscan Surgical Associates at St. Joseph, 1708 South Yakima Avenue, Suite 105 & 112, Tacoma, WA 98405, USA.
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2
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Williams S, Bjarnason I, Hayee B, Haji A. Diverticular disease: update on pathophysiology, classification and management. Frontline Gastroenterol 2024; 15:50-58. [PMID: 38487561 PMCID: PMC10935533 DOI: 10.1136/flgastro-2022-102361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/19/2023] [Indexed: 03/17/2024] Open
Abstract
Colonic diverticulosis is prevalent, affecting approximately 70% of the western population by 80 years of age. Incidence is rapidly increasing in younger age groups. Between 10% and 25% of those with diverticular disease (DD) will experience acute diverticulitis. A further 15% will develop complications including abscess, bleeding and perforation. Such complications are associated with significant morbidity and mortality and constitute a worldwide health burden. Furthermore, chronic symptoms associated with DD are difficult to manage and present a further significant healthcare burden. The pathophysiology of DD is complex due to multifactorial contributing factors. These include diet, colonic wall structure, intestinal motility and genetic predispositions. Thus, targeted preventative measures have proved difficult to establish. Recently, commonly held conceptions on DD have been challenged. This review explores the latest understanding on pathophysiology, risk factors, classification and treatment options.
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Affiliation(s)
- Sophie Williams
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - Ingvar Bjarnason
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, London, UK
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3
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Marasco G, Buttitta F, Cremon C, Barbaro MR, Stanghellini V, Barbara G. The role of microbiota and its modulation in colonic diverticular disease. Neurogastroenterol Motil 2023; 35:e14615. [PMID: 37243442 DOI: 10.1111/nmo.14615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/06/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Diverticular disease (DD) is a common condition in Western countries. The role of microbiota in the pathogenesis of DD and its related symptoms has been frequently postulated since most complications of this disease are bacteria-driven and most therapies rely on microbiota modulation. Preliminary data showed fecal microbial imbalance in patients with DD, particularly when symptomatic, with an increase of pro-inflammatory and potentially pathogenetic bacteria. In addition, bacterial metabolic markers can mirror specific pathways of the disease and may be even used for monitoring treatment effects. All treatments currently suggested for DD can affect microbiota structure and metabolome compositions. PURPOSE Sparse evidence is available linking gut microbiota perturbations, diverticular disease pathophysiology, and symptom development. We aimed to summarize the available knowledge on gut microbiota evaluation in diverticular disease, with a focus on symptomatic uncomplicated DD, and the relative treatment strategies.
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Affiliation(s)
- Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Francesco Buttitta
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
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4
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Drapkina OM, Lazebnik LB, Bakulin IG, Skazyvaeva EV, Bakulina NV, Sitkin SI, Skalinskaya MI, Zhuravleva MS, Avalueva EB, Livzan MA, Bordin DS, Khavkin AI. Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:33-69. [DOI: 10.31146/1682-8658-ecg-210-2-33-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine Russian Federation
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | - M. I. Skalinskaya
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. B. Avalueva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | | | - D. S. Bordin
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation; Moscow Clinical Scientific Center named after Loginov
| | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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5
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Drapkina OM, Lazebnik LB, Bakulin IG, Skazyvaeva EV, Bakulina NV, Sitkin SI, Skalinskaya MI, Zhuravleva MS, Avalueva EB, Livzan MA, Bordin DS, Khavkin AI. Colonic diverticular disease: clinical presentation, diagnosis, treatment, and prevention Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientific Society of Russia, and the North- West Society of Gastroenterologists and Hepatologists. EXPERIMENTAL AND CLINICAL GASTROENTEROLOGY 2023:33-69. [DOI: https:/doi.org/10.31146/1682-8658-ecg-210-2-33-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Clinical guidelines are intended for gastroenterologists, internists, and general practitioners and focus primarily on the management of patients with symptomatic uncomplicated diverticular disease, as well as on the primary and secondary prevention of acute diverticulitis and other complications of diverticular disease. Clinical guidelines were developed by the Russian Scientific Medical Society of Internal Medicine, the Gastroenterological Scientifi c Society of Russia, and the North-West Society of Gastroenterologists and Hepatologists. One of the reasons for creating new clinical guidelines is that the current guidelines on diverticular disease (2021) pay much more attention to complications of diverticular disease and surgical treatment of acute and chronic complications of the disease.
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Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine Russian Federation
| | - L. B. Lazebnik
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation
| | - I. G. Bakulin
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. V. Skazyvaeva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - N. V. Bakulina
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - S. I. Sitkin
- North-Western state medical University named after I. I. Mechnikov; Almazov National Medical Research Centre
| | - M. I. Skalinskaya
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - M. S. Zhuravleva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | - E. B. Avalueva
- North-Western state medical University named after I. I. Mechnikov Russian Federation
| | | | - D. S. Bordin
- A. I. Yevdokimov Moscow State University of Medicine and Dentistry Russian Federation; Moscow Clinical Scientific Center named after Loginov
| | - A. I. Khavkin
- Veltischev Research and Clinical Institute for Pediatrics and Pediatric Surgery, Pirogov Russian National Research Medical University
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Nardone OM, Marasco G, Lopetuso LR, Mocci G, Pastorelli L, Petruzzellis C, Scaldaferri F. Insights into Mesalazine Use in Clinical Practice of Young Gastroenterologists. J Clin Med 2023; 12:jcm12052005. [PMID: 36902792 PMCID: PMC10004260 DOI: 10.3390/jcm12052005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Mesalazine is among the medications most prescribed by gastroenterologists, with variable and controversial use in different settings. We aimed to explore the use of mesalazine in the clinical practice of young gastroenterologists. METHODS A web-based electronic survey was distributed to all participants of the National Meeting of the Italian Young Gastroenterologist and Endoscopist Association. RESULTS A total of 101 participants took part in the survey, with a majority (54.4%) being aged >30 years, 63.4% of whom were trainees in academic hospitals, and 69.3% of whom were involved in the clinical management of inflammatory bowel disease (IBD). While both non-dedicated and IBD physicians generally agreed on the appropriate dose of mesalazine for mild ulcerative colitis (UC), significant differences were observed between the two groups for moderate-severe ulcerative colitis (UC). Additionally, in IBD patients who were starting immuno-modulators and/or biologics, 80% of IBD-dedicated physicians continued to prescribe mesalazine, compared to 45.2% of non-dedicated physicians (p = 0.002). Indeed, 48.4% of non-dedicated IBD physicians did not acknowledge mesalazine for colorectal cancer chemoprevention. With regards to Crohn's disease, it is mainly used by 30.1% of IBD physicians for preventing postoperative recurrence of Crohn's disease. Finally, 57.4% used mesalazine for symptomatic uncomplicated diverticular disease, and 84.2% did not recommend its use for irritable bowel syndrome. CONCLUSIONS This survey showed heterogeneous behaviors in the daily use of mesalazine, mainly in the management of IBD. Educational programs and novel studies are needed to clarify its use.
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Affiliation(s)
- Olga Maria Nardone
- Gastroenterology, Department of Public Health, University Federico II of Naples, 80131 Naples, Italy
| | - Giovanni Marasco
- Division of Internal Medicine and Digestive Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel./Fax: +39-0512145265
| | - Loris Riccardo Lopetuso
- CEMAD—IBD UNIT—Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Giammarco Mocci
- Division of Gastroenterology, “Brotzu” Hospital, 09124 Cagliari, Italy
| | - Luca Pastorelli
- Gastroenterology and Hepatology Unit, ASST Santi Paolo e Carlo, 20142 Milan, Italy
- Department of Health Sciences, University of Milan, 20142 Milan, Italy
| | - Carlo Petruzzellis
- Gastroenterology Unit, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi, 95123 Catania, Italy
| | - Franco Scaldaferri
- CEMAD—IBD UNIT—Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
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Piccin A, Gulotta M, di Bella S, Martingano P, Crocè LS, Giuffrè M. Diverticular Disease and Rifaximin: An Evidence-Based Review. Antibiotics (Basel) 2023; 12:antibiotics12030443. [PMID: 36978310 PMCID: PMC10044695 DOI: 10.3390/antibiotics12030443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.
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Affiliation(s)
- Anna Piccin
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Marco Gulotta
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Stefano di Bella
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Infectious Disease Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Paola Martingano
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Lory Saveria Crocè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Liver Clinic, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06510, USA
- Correspondence:
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Kruis W, Germer C, Böhm S, Dumoulin FL, Frieling T, Hampe J, Keller J, Kreis ME, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer AG, Leifeld L. German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management. United European Gastroenterol J 2022; 10:940-957. [PMID: 36459576 PMCID: PMC9731665 DOI: 10.1002/ueg2.12313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/11/2022] [Indexed: 12/03/2022] Open
Abstract
Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.
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Affiliation(s)
- Wolfgang Kruis
- Apl Professor der MedizinischenFakultätUniversität KölnCologneGermany
| | - Christoph‐Thomas Germer
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | | | | | | | - Jochen Hampe
- Medizinische Klinik IUniversitätsklinikumTU DresdenDresdenGermany
| | - Jutta Keller
- Medizinische KlinikIsraelitisches KrankenhausHamburgGermany
| | - Martin E. Kreis
- Klinik für Allgemein‐, Viszeral‐ und GefäßchirurgieCharité ‐ Universitätsmedizin BerlinCampus Benjamin FranklinBerlinGermany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2Zentrum für Innere Medizin (ZIM)Universitätsklinikum WürzburgWürzburgGermany
| | - Joachim Labenz
- Abteilung für Innere MedizinEvang. Jung‐Stilling‐Krankenhaus, SiegenSiegenGermany
| | - Johann F. Lock
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | - Jörg Peter Ritz
- Klinik für Allgemein‐ und ViszeralchirurgieHelios Klinikum SchwerinSchwerinGermany
| | - Andreas G. Schreyer
- Institut für diagnostische und interventionelle RadiologieMedizinische Hochschule Brandenburg Theodor Fontane Klinikum BrandenburgBrandenburgGermany
| | - Ludger Leifeld
- Medizinische Klinik 3 – Gastroenterologie und Allgemeine Innere MedizinSt. Bernward KrankenhausHildesheimGermany
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9
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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: 8] [Impact Index Per Article: 4.0] [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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10
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Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: https:/doi.org/10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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11
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Koprowski MA, Affleck A, Tsikitis VL. Emerging evidence and recent controversies in diverticulitis: a 5-year review. Ann Gastroenterol 2022; 35:8-16. [PMID: 34987283 PMCID: PMC8713340 DOI: 10.20524/aog.2021.0677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022] Open
Abstract
Diverticulitis is a common gastrointestinal disease that still garners significant attention and study because of its heterogeneity in presentation and outcome. We provide a review of the newest and most controversial topics in diverticulitis. Recent discoveries on the influence of diet and other environmental risk factors are discussed, showing how the epidemiology of the disease process is shifting away from what was previously felt to be a disorder primarily limited to older western populations. Interestingly, as has long been suspected, genetic mutations and variations associated with the development of diverticulitis are being discovered and are summarized here. The data for non-operative and outpatient management of diverticulitis are reviewed, as are pharmacologic agents studied for use in the secondary prevention of diverticulitis. Lastly, we present controversies in the surgical treatment of diverticulitis. This review will provide a synopsis of the last 5 years of literature relating to diverticulitis.
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Affiliation(s)
| | - Arthur Affleck
- Department of Surgery (Marina Affi Koprowski, Arthur Affleck)
| | - Vassiliki Liana Tsikitis
- Division of Gastrointestinal Surgery, Department of Surgery (Vassiliki Liana Tsikitis), Oregon Health and Science University, Portland, OR, USA
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12
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Affiliation(s)
- Matthew Symer
- Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, PO Box 172, New York, NY 10065, USA
| | - Heather L Yeo
- Department of Healthcare Policy and Research, New York-Presbyterian, Weill Cornell Medicine, 525 East 68th Street, PO Box 172, New York, NY 10065, USA.
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13
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Garfinkle R, Boutros M. Elective surgery for diverticulitis – What does the surgeon need to consider? SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2020.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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14
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Saavedra-Perez D, Curbelo-Peña Y, Sampson-Davila J, Albertos S, Serrano A, Ibañez L, Errando X, Perez X. Management of symptomatic uncomplicated diverticular colon disease: A systematic review of diagnosis and treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 44:497-518. [PMID: 33647346 DOI: 10.1016/j.gastrohep.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/28/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
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Affiliation(s)
- David Saavedra-Perez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España.
| | - Yuhamy Curbelo-Peña
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Jaime Sampson-Davila
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Sonia Albertos
- Servicio de Digestología, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Alejandro Serrano
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Luis Ibañez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Xavier Errando
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Xavier Perez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
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Langenfeld SJ. Evaluation and Medical Management of Uncomplicated Diverticulitis. Clin Colon Rectal Surg 2021; 34:86-90. [PMID: 33642947 DOI: 10.1055/s-0040-1716699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Uncomplicated diverticulitis is common, and its evaluation and treatment have evolved over time. Most patients present in a nontoxic manner with localized pain, leukocytosis, and reliable findings on computed tomography (CT). Healthy and stable patients are typically treated in the outpatient setting with very high rates of success. Recently, the necessity of antibiotic therapy has come into question, and several alternative agents have emerged, with the jury still out on their relative roles in diverticular disease. Currently, colonoscopy is still recommended after the resolution of an index episode of uncomplicated diverticulitis, and recurrence rates remain low. Several diet and lifestyle modifications have been shown to impact the rates of diverticulitis recurrence.
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Affiliation(s)
- Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Lock JF, Galata C, Reißfelder C, Ritz JP, Schiedeck T, Germer CT. The Indications for and Timing of Surgery for Diverticular Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 117:591-596. [PMID: 33161943 DOI: 10.3238/arztebl.2020.0591] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 11/14/2019] [Accepted: 05/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diverticular disease is one of the more common abdominal disorders. In 2016, approximately 130 000 patients received inpatient treatment for diverticular disease in Germany. The disease has a number of subtypes, each of which has an appropriate treatment. In this article, we present the current surgical indications and optimal timing of surgery for diverticular disease. METHODS This review is based on publications that were retrieved by an extensive, selective search in Medline and the Cochrane Library (1998-2018) for studies and guidelines with information on the indications for surgery in diverticular disease. RESULTS Studies of evidence grades 2 to 4 were available. Patients receiving a diagnosis of freely perforated diverticulitis and peritonitis (Classification of Diverticular Disease [CDD] type 2c) should be operated on at once. Covered perforated diverticulitis with a macroabscess (>1 cm, CDD type 2b) may be an indication for elective surgery after successful conservative treatment. New evidence from a randomized, controlled trial suggests that elective surgery should also be considered for patients with chronic recurrent diverticulitis (CDD type 3b). The decisive factor in such cases is the impairment of the quality of life for the individual patient. Elective surgery is indicated in chronic recurrent diverticulitis with complications (fistulae, stenoses). Asymptomatic diverticulosis (CDD type 0) and uncomplicated diverticulitis (CDD type 1) are not surgical indications. Likewise, in diverticular hemorrhage (CDD type 4), surgery is only indicated in exceptional cases, when conservative treatment fails. CONCLUSION The surgical indication and the proper timing of surgery depend on the type of disease that is present. Future studies should more thoroughly investigate the effect of surgery on the quality of life in patients with the various types of diverticular disease.
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Affiliation(s)
- Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Christian Galata
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reißfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jörg-Peter Ritz
- Department of General and Visceral Surgery, Helios Klinikum Schwerin, Schwerin, Germany
| | - Thomas Schiedeck
- Department of General, Visceral, Thoracic and Pediatric Surgery, Klinikum Ludwigsburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
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Giacosa A, Riva A, Petrangolini G, Allegrini P, Fazia T, Bernardinelli L, Gasparri C, Faliva MA, Peroni G, Perna S, Rondanelli M. Symptomatic uncomplicated diverticular disease management: an innovative food-grade formulation of Curcuma longa and Boswellia serrata extracts. Drugs Context 2021; 9:dic-2020-9-2. [PMID: 33408751 PMCID: PMC7747791 DOI: 10.7573/dic.2020-9-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background The treatment of symptomatic uncomplicated colonic diverticular disease (SUDD) is still under debate, and new data show a pathogenic role of dysbiosis and low-grade inflammation in intestinal mucosa. Recent research has highlighted the anti-inflammatory effects of botanical extracts such as Curcuma longa L. and Boswellia serrata Roxb. ex Colebr. The aim of this work is to investigate the potential role of a new delivery formulation of the association of curcumin and boswellia phytosome extracts (CBP) in SUDD. Methods In a 30-day one-group longitudinal explanatory study, patients (men and women) were treated with an innovative association of CBP standardized extracts, 500 mg bid. Results Treatment of SUDD with the association of CBP was followed by a significant decrease in abdominal pain (p<0.0001). The study group showed that CBP supplementation was efficacious within 10 days and that efficacy was maintained almost constant until the 30th day of intervention. Conclusion A phytosome of curcumin and boswellia extracts may be useful for the relief of SUDD pain. However, controlled studies should be performed for final conclusions to be drawn.
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Affiliation(s)
- Attilio Giacosa
- Gastroenterology Unit, Policlinico di Monza, Monza, 20900 Italy.,CDI (Centro Diagnostico Italiano), Milan, 20147 Italy
| | - Antonella Riva
- Research and Development Unit, Indena SpA, Milan, 20139 Italy
| | | | | | - Teresa Fazia
- Department of Brain and Behavioral Science, University of Pavia, Pavia, 27100 Italy
| | - Luisa Bernardinelli
- Department of Brain and Behavioral Science, University of Pavia, Pavia, 27100 Italy
| | - Clara Gasparri
- Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona "Istituto Santa Margherita", University of Pavia, Pavia, 27100 Italy
| | - Milena Anna Faliva
- Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona "Istituto Santa Margherita", University of Pavia, Pavia, 27100 Italy
| | - Gabriella Peroni
- Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona "Istituto Santa Margherita", University of Pavia, Pavia, 27100 Italy
| | - Simone Perna
- Department of Biology, University of Bahrain, College of Science, Sakhir Campus P. O. Box, 32038 Kingdom of Bahrain
| | - Mariangela Rondanelli
- IRCCS Mondino Foundation, Pavia, 27100 Italy.,Department of Public Health, Experimental and Forensic Medicine, Unit of Human and Clinical Nutrition, University of Pavia, Pavia, 27100 Italy
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Quality of Life After Elective Laparoscopic Sigmoidectomy for Symptomatic Uncomplicated Diverticular Disease. Surg Laparosc Endosc Percutan Tech 2020; 31:193-195. [PMID: 32941354 DOI: 10.1097/sle.0000000000000860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Symptomatic uncomplicated diverticular disease (SUDD) is characterized by abdominal pain and altered bowel function and may affect quality of life. When symptoms are severe and conservative therapy is ineffective, surgical intervention becomes an option. OBJECTIVE This study aims to investigate quality of life after elective sigmoidectomy for patients affected by SUDD. MATERIALS AND METHODS Retrospective multicenter review of consecutive patients affected by SUDD that underwent elective laparoscopic sigmoidectomy from January 2015 to March 2018. SUDD was defined as the presence of diverticula with persistent localized pain and diarrhea or constipation without macroscopic inflammation. Quality of life was investigated using the Gastrointestinal Quality of Life Index questionnaire at baseline, and at 6 and 12 months after surgery. Readmissions, unplanned clinical examination, mesalazine resumption, and emergency department visit for abdominal symptoms were recorded. RESULTS Fifty-two patients were included in the analysis. Gastrointestinal Quality of Life Index score at 6 months from surgery did not statistically differ from baseline (96±10.2 vs. 89±11.2; P>0.05), while patients reported a better quality of life at 12 months after surgery (109±8.6; P<0.05). Within the first year of follow-up, 3 patients (5.8%) were readmitted for acute enteritis, 8 patients (15.4%) had emergency room access for abdominal pain, and 8 patients had unplanned outpatients' medical examinations for referred lower abdominal pain and bowel changes. Mesalazine was resumed in 17.3% of patients. CONCLUSION Elective laparoscopic sigmoidectomy for SUDD is safe and effective in improving quality of life, although in some cases symptoms may persist.
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Synthesis and biological activity of polyfluorinated p-aminosalicylic acids and their amides. MENDELEEV COMMUNICATIONS 2020. [DOI: 10.1016/j.mencom.2020.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63:728-747. [PMID: 32384404 DOI: 10.1097/dcr.0000000000001679] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Cremon C, Carabotti M, Cuomo R, Pace F, Andreozzi P, Barbaro MR, Annibale B, Barbara G. Italian nationwide survey of pharmacologic treatments in diverticular disease: Results from the REMAD registry. United European Gastroenterol J 2019; 7:815-824. [PMID: 31316786 PMCID: PMC6620876 DOI: 10.1177/2050640619845990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although diverticular disease is a common condition, its effective treatment is challenging in clinical practice. OBJECTIVE The objective of this article is to assess pharmacological management in different clinical settings of diverticular disease and factors associated with treatment using the Italian registry Registro Malattia Diverticolare (REMAD). METHODS At study enrolment, patients were categorised into subgroups: diverticulosis, symptomatic uncomplicated diverticular disease and previous diverticulitis. We registered demographic, clinical and lifestyle factors, quality of life and the use of treatments for diverticular disease in the last year. Logistic regression analysis assessed the association between clinical factors and treatment consumption. RESULTS A total of 500 of the 1206 individuals included had had at least one treatment for diverticular disease in the last year: 23.6% (166/702) of patients with diverticulosis, 55.9% (165/295) of patients with symptomatic diverticular disease, and 80.9% (169/209) of patients with previous diverticulitis (p < 0.001). In multivariate analysis, the following factors were significantly associated with treatment use: female gender, family history of colonic diverticula, organic digestive comorbidity and impaired physical quality of life components. CONCLUSION Individuals with diverticular disease take medications based on the different clinical settings of disease. We identified different features associated with treatment use in the distinct clinical entities of diverticular disease.ClinicalTrial.gov Identifier: NCT03325829.
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Affiliation(s)
- Cesare Cremon
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Rosario Cuomo
- Sant’Anna and San Sebastiano Hospital, Gastroenterology and Digestive Endoscopy Unit, Caserta, Italy
| | - Fabio Pace
- Unit of Gastroenterology, “Bolognini” Hospital, Bergamo, Italy
| | - Paolo Andreozzi
- Sant’Anna and San Sebastiano Hospital, Gastroenterology and Digestive Endoscopy Unit, Caserta, Italy
| | - Maria Raffaella Barbaro
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Rome, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
- Giovanni Barbara, St Orsola-Malpighi Hospital, Department of Medical and Surgical Sciences, Building #5, Via Massarenti, 9, I-40138 Bologna, Italy.
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche J, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres J, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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24
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Raña-Garibay R, Salgado-Nesme N, Carmona-Sánchez R, Remes-Troche JM, Aguilera-Carrera J, Alonso-Sánchez L, Arnaud-Carreño C, Charúa-Guindic L, Coss-Adame E, de la Torre-Bravo A, Espinosa-Medina D, Esquivel-Ayanegui F, Roesch-Dietlen F, López-Colombo A, Muñoz-Torres JI, Noble-Lugo A, Rojas-Mendoza F, Suazo-Barahona J, Stoopen-Rometti M, Torres-Flores E, Vallejo-Soto M, Vergara-Fernández O. The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2019; 84:220-240. [PMID: 31014749 DOI: 10.1016/j.rgmx.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.
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Affiliation(s)
| | - N Salgado-Nesme
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - R Carmona-Sánchez
- Unidad de Médica Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México.
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - J Aguilera-Carrera
- Hospital de Especialidades Médicas de la Salud, San Luis Potosí, S.L.P., México
| | | | - C Arnaud-Carreño
- Departamento de Cirugía, Hospital General «Dr. Aurelio Valdivieso», Secretaría de Salud del Estado de Oaxaca, Oaxaca, Oaxaca, México
| | | | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | | | | | - F Esquivel-Ayanegui
- Hospital General «Dr. Miguel Silva», Secretaría de Salud de Michoacán, Morelia, Michoacán, México
| | - F Roesch-Dietlen
- Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A López-Colombo
- Direccción de Educación e Investigación, UMAE Hospital de Especialidades CMN Manuel Ávila Camacho, Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - J I Muñoz-Torres
- Facultad de Medicina, Universidad Autónoma de Baja California, Mexicali, BC, México
| | | | | | - J Suazo-Barahona
- Centro de Enfermedades Digestivas, Hospital del Valle, San Pedro Sula, Honduras
| | - M Stoopen-Rometti
- Departamento de Radiología e Imagen, CT Scanner Lomas Altas, Ciudad de México, México
| | - E Torres-Flores
- Hospital General de Zona # 1, Instituto Mexicano del Seguro Social, Pachuca, Hidalgo, México
| | | | - O Vergara-Fernández
- División de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
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Role of Inflammation in the Pathogenesis of Diverticular Disease. Mediators Inflamm 2019; 2019:8328490. [PMID: 31001067 PMCID: PMC6437747 DOI: 10.1155/2019/8328490] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/13/2019] [Accepted: 02/04/2019] [Indexed: 12/19/2022] Open
Abstract
Diverticulosis of the colon is the most common condition in Western societies and it is the most common anatomic alteration of the human colon. Recurrent abdominal pain is experienced by about 20% of patients with diverticulosis, but the pathophysiologic mechanisms of its occurrence are not completely understood. In the last years, several fine papers have showed clearly the role of low-grade inflammation both in the occurrence of symptoms in people having diverticulosis, both in symptom persistence following acute diverticulitis, even if the evidence available is not so strong. We do not know yet what the trigger of this low-grade inflammation occurrence is. However, some preliminary evidence found colonic dysbiosis linked to low-grade inflammation and therefore to symptom occurrence in those patients. The aim of this paper is to summarize current evidences about the role of inflammation in symptom occurrence in symptomatic uncomplicated diverticular disease and in symptom persistence after an episode of acute diverticulitis.
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Abstract
BACKGROUND Uncomplicated colonic diverticulitis is common. There is no consensus regarding the most appropriate management. Some authors have reported the efficacy and safety of observational management, and others have argued for a more aggressive approach with oral or intravenous antibiotic treatment. OBJECTIVE The purpose of this study was to perform an updated meta-analysis of the different management strategies for uncomplicated diverticulitis with 2 separate meta-analyses. DATA SOURCES MEDLINE, Embase, and Cochrane databases were used. STUDY SELECTION All randomized clinical trials, prospective, and retrospective comparative studies were included. INTERVENTIONS Observational and antibiotics treatment or oral and intravenous antibiotics treatment were included. MAIN OUTCOME MEASURES Successful management (emergency management, recurrence, elective management) was measured. RESULTS After review of 293 identified records, 11 studies fit inclusion criteria: 7 studies compared observational management and antibiotics treatment (2321 patients), and 4 studies compared oral and intravenous antibiotics treatment (355 patients). There was no significant difference between observational management and antibiotics treatment in terms of emergency surgery (0.7% vs 1.4%; p = 0.1) and recurrence (11% vs 12%; p = 0.3). In this part, considering only randomized trials, elective surgery during the follow-up occurred more frequently in the observational group than the antibiotic group (2.5% vs 0.9%; p = 0.04). The second meta-analysis showed that failure and recurrence rates were similar between oral and intravenous antibiotics treatment (6% vs 7% (p = 0.6) and 8% vs 9% (p = 0.8)). LIMITATIONS Inclusion of nonrandomized studies, identification of high risks of bias (selection, performance, and detection bias), and presence of heterogeneity between the studies limited this work. CONCLUSIONS Observational management was not statistically different from antibiotic treatment for the primary outcome of needing to undergo surgery. However, in patients being treated by antibiotics, our studies demonstrated that oral administration was similar to intravenous administration and provided lower costs. Although it may be difficult for physicians to do, there is mounting evidence that not treating uncomplicated colonic diverticulitis with antibiotics is a viable treatment alternative.
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"Mesalazine in the Treatment of Symptomatic Uncomplicated Diverticular Disease: Reply". J Clin Gastroenterol 2019; 53:e130-e132. [PMID: 27875358 DOI: 10.1097/mcg.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Irritable bowel syndrome and colonic diverticular disease: overlapping symptoms and overlapping therapeutic approaches. Curr Opin Gastroenterol 2019; 35:27-33. [PMID: 30407258 DOI: 10.1097/mog.0000000000000499] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Irritable bowel syndrome (IBS) is a common symptomatic disorder in the Western world and colonic diverticula are also prevalent; however, relationships between IBS-type symptoms and diverticula have been a source of much debate. Our goal was to reassess these relationships in the light of new data. RECENT FINDINGS On removing from consideration clinical scenarios which are directly related to diverticula (i.e., diverticulitis, diverticular hemorrhage, and complications of diverticulitis, such as stricture and fistula), relationships between IBS and diverticula can be seen to revolve around a number of questions. First, are IBS and symptomatic uncomplicated diverticular disease (SUDD) the same condition? Or, in other words is SUDD no more than IBS in an individual who just happens to have diverticula? Although coincident IBS and diverticula inevitably do occur there is some evidence to indicate that SUDD may be somewhat distinctive with SUDD being characterized by more frequent and severe pain. Second, and analogous to interactions between IBS and inflammatory bowel disease or celiac disease, can an episode of acute diverticulitis lead to the de novo development of IBS? There is now epidemiological and pathophysiological evidence to support this occurrence. SUMMARY Although relationships between uncomplicated diverticular disease and IBS have been reexamined their status remains unclear. As yet, however, none of the newer concepts related to this relationship have led to new therapeutic approaches in IBS or diverticular disease.
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Ubaldi E, Grattagliano I, Lapi F, Pecchioli S, Cricelli C. Overview on the management of diverticular disease by Italian General Practitioners. Dig Liver Dis 2019; 51:63-67. [PMID: 30143468 DOI: 10.1016/j.dld.2018.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although very common in Western countries, poor epidemiological data on diverticular disease (DD) is available from the family practice. AIMS To evaluate the behavior of Italian General Practitioners (GPs) on approaching DD. METHODS Health Search Database was analyzed retrospectively. RESULTS On a population of 975,523 individuals, 33,597 patients had a registered diagnosis of DD ("lifetime" prevalence = 3.4%, M = 3.2%, F = 3.7%; higher values are found in females over-65 years old; low rates of complications: diverticulitis = 0.3%, bleeding = 0.002%). As risk factors, NSAIDs and ASA were taken by 14.8% and 26.5% respectively, opioids by 7.5%, corticosteroids by 5.2%; as protective factors, 30.4% were under statins and 17.7% under calcium-antagonists. Approximately 13% of patients were referred to specialists. Colonoscopy and abdominal CT were prescribed to 48.5% and to 13% of already diagnosed patients. Among DD sufferers, 27% experienced hospitalization, but only 3.4% of cases were for a DD-linked problem. Treatment included rifaximin (61%), mesalazine (14.7%), probiotics (12.4%), ciprofloxacin (7.6%). CONCLUSION DD has a large impact in general practice with a higher prevalence in the elderly. GPs are required to pay particular attention to risk factors both for disease development and for its complications in order to reduce the costs deriving from diagnostic procedures, referral and hospitalization.
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Affiliation(s)
- Enzo Ubaldi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | - Francesco Lapi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Serena Pecchioli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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Mesalazine in the Treatment of Symptomatic Uncomplicated Diverticular Disease. J Clin Gastroenterol 2019; 53:77-78. [PMID: 27898520 DOI: 10.1097/mcg.0000000000000748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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31
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Symptomatic Uncomplicated Diverticular Disease: Chronic Abdominal Pain in Diverticulosis Is Not Enough to Make the Diagnosis. Clin Gastroenterol Hepatol 2018; 16:2001-2002. [PMID: 30454933 DOI: 10.1016/j.cgh.2018.06.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 02/07/2023]
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Abstract
The incidence of diverticulosis and diverticular disease of the colon is increasing worldwide. Although the majority of patients remains asymptomatic long-life, the prevalence of diverticular disease of the colon, including acute diverticulitis, is substantial and is becoming a significant burden on National Health Systems in terms of direct and indirect costs. Fiber, non-absorbable antibiotics and probiotics seem to be effective in treating symptomatic and uncomplicated patients, and 5-aminosalicylic acid might help prevent acute diverticulitis. Unfortunately, robust evidence on the effectiveness of a medical strategy to prevent acute diverticulitis recurrence is still lacking. Focus is now being drawn on identifying a new endoscopic classification of the disease to evaluate the correct therapeutic approach by testing various treatments.
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Affiliation(s)
- Walter Elisei
- Division of Gastroenterology, ASL Roma 6, Albano Laziale, Rome, Italy
| | - Giovanni Brandimarte
- Division of Internal Medicine and Gastroenterology, Cristo Re Hospital, Rome, Italy
| | - Antonio Tursi
- Service of Gastroenterology, ASL BAT, Andria, Italy -
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Lanas A, Abad-Baroja D, Lanas-Gimeno A. Progress and challenges in the management of diverticular disease: which treatment? Therap Adv Gastroenterol 2018; 11:1756284818789055. [PMID: 30046356 PMCID: PMC6056793 DOI: 10.1177/1756284818789055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/11/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.
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Affiliation(s)
- Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico
Universitario Lozano Blesa, C/ San Juan Bosco 15, Zaragoza, 50009, Spain.
University of Zaragoza. IIS Aragón. CIBERehs
| | - Daniel Abad-Baroja
- Servicio de Aparato Digestivo University Clinic
Hospital Lozano Blesa, Spain
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Khan RMA, Ali B, Hajibandeh S, Hajibandeh S. Effect of mesalazine on recurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease: a meta-analysis with trial sequential analysis of randomized controlled trials. Colorectal Dis 2018. [PMID: 29520987 DOI: 10.1111/codi.14064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM he aim was to investigate the effect of mesalazine on the recurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease (SUDD). METHODS We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials (RCTs) investigating the effect of mesalazine on the recurrence of diverticulitis in patients with SUDD. We used the Cochrane tool to assess the quality of included studies. Random effects models were applied to calculate pooled outcome data. Trial sequential analysis was performed to assess the possibility of type I or II errors and to compute the information size required for conclusive meta-analysis. RESULTS We identified six RCTs which enrolled a total of 1918 patients. There was no difference in the recurrence of diverticulitis between the mesalazine and placebo groups (OR 1.20, 95% CI 0.96-1.50, P = 0.11). A low level of heterogeneity among the studies existed (I2 = 9%, P = 0.36). When the mesalazine dose was ≤ 2 g/day, there was no difference in recurrence rate between the two groups (OR 1.10, 95% CI 0.79-1.54, P = 0.58). When the mesalazine dose was > 2 g/day, the risk of recurrence was higher in the mesalazine group (OR 1.28, 95% CI 1.02-1.62, P = 0.04). The information size was calculated as 2461 patients. Trial sequential analysis showed that the meta-analysis was conclusive and the risk of type II error was minimal. CONCLUSIONS Mesalazine does not prevent the recurrence of diverticulitis in patients with SUDD. Further studies are required to investigate the role of mesalazine as an adjunct to other medical agents in the prevention of diverticulitis in patients with SUDD.
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Affiliation(s)
- R M A Khan
- Department of General Surgery, North Manchester General Hospital, Manchester, UK
| | - B Ali
- Department of General Surgery, North Manchester General Hospital, Manchester, UK
| | - S Hajibandeh
- Department of General Surgery, Stepping Hill Hospital, Stockport, UK
| | - S Hajibandeh
- Department of General Surgery, Royal Bolton Hospital, Bolton, UK
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Ceresoli M, Lo Bianco G, Gianotti L, Nespoli L. Inflammation management in acute diverticulitis: current perspectives. J Inflamm Res 2018; 11:239-246. [PMID: 29881303 PMCID: PMC5985778 DOI: 10.2147/jir.s142990] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The pathogenesis of diverticular disease and acute diverticulitis is still unclear and many different hypotheses have been formulated. Seemingly, there are several related factors such as chronic inflammation, gut microbiome, obesity and the immunogenic properties of fat tissue and diet. Inflammation plays a pivotal role in diverticular disease and acute diverticulitis. The aim of the present review is to investigate the role of inflammation in diverticular disease as well as in mild and complicated acute diverticulitis with a focus on current research and treatment perspectives.
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Affiliation(s)
- Marco Ceresoli
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giulia Lo Bianco
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luca Gianotti
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luca Nespoli
- Department of General Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Scarpignato C, Barbara G, Lanas A, Strate LL. Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017. Therap Adv Gastroenterol 2018; 11:1756284818771305. [PMID: 29844795 PMCID: PMC5964860 DOI: 10.1177/1756284818771305] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/21/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticulosis is a common anatomical condition, which appears to be age-dependent. Individuals who develop chronic gastrointestinal symptoms or complications are referred to as having diverticular disease. Although the diagnosis of this condition can be relatively straightforward, randomized controlled trials are scarce and management often follows tradition rather than principles of evidence-based medicine. This report deals with the topics discussed during a symposium held during the United European Gastroenterology Week (Barcelona, October 2017). During the meeting, the role of dysbiosis in the pathogenesis of diverticular disease and its treatment were thoroughly discussed, by examining the efficacy and mechanisms of action of the currently used drugs. Recent studies have shown the presence of dysbiosis in patients with diverticular disease and suggest an imbalance in favor of bacteria with pro-inflammatory and pathogenetic potential. These microbiota changes correlate with mucosal immune activation, mirrored by a marked increase of macrophages in colonic mucosa, both in the diverticular region and at distant sites. The low-grade inflammation, driven by bacteria-induced immune activation, could be involved in the pathophysiology of symptoms. As a consequence, pharmacological approaches targeting enteric bacteria (with poorly absorbed antibiotics, like rifaximin, or probiotics) or intestinal inflammation (with 5-ASA derivatives or rifaximin) have shown capability of controlling symptoms and also preventing complications, albeit more research is needed to establish the optimal regimen (daily dose and duration) of therapy. Well-designed randomized-controlled trials (RCTs), including homogeneous populations of patients, are therefore needed. The future of management of many GI diseases, including symptomatic uncomplicated diverticular disease, will rely on the so-called 'microbiota-directed therapies'.
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Affiliation(s)
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Angel Lanas
- Clinic Hospital Lozano Blesa, University of Zaragoza, Zaragoza, Spain
| | - Lisa L. Strate
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
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Iannone A, Ruospo M, Wong G, Barone M, Principi M, Di Leo A, Strippoli GFM. Mesalazine for People with Diverticular Disease: A Systematic Review of Randomized Controlled Trials. Can J Gastroenterol Hepatol 2018; 2018:5437135. [PMID: 30320044 PMCID: PMC6167594 DOI: 10.1155/2018/5437135] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 08/12/2018] [Accepted: 08/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms. AIM We systematically reviewed current evidence on benefits and harms of mesalazine versus all other treatments in people with diverticular disease. METHODS We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov for studies published to July 2018. We estimated risk ratios (RR) for dichotomous outcomes (disease remission/recurrence, acute diverticulitis in symptomatic uncomplicated diverticular disease, need for surgery/hospitalization, all-cause/disease-related mortality, adverse events), mean differences (MD) or standardized MD (SMD) for continuous outcomes (quality of life, symptoms score, time to recurrence/remission), and their 95% confidence intervals (CI) using random-effects models. We quantified heterogeneity by Chi2 and I2 tests. We performed subgroup analyses by disease subtype, comparator, follow-up duration, mesalazine dose, and mode of administration. RESULTS We identified 13 randomized trials (n=3028 participants). There was a higher likelihood of disease remission with mesalazine than controls in acute uncomplicated diverticulitis (1 trial, 81 participants, RR=2.67, 95%CI=1.05-6.79), but not in symptomatic uncomplicated diverticular disease (1 trial, 123 participants, RR=1.04, 95%CI=0.81-1.34). There was a lower likelihood of disease recurrence with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 216 participants, RR=0.52, 95%CI=0.28-0.97), but not in acute uncomplicated diverticulitis (7 trials, 2196 participants, RR=0.90, 95%CI=0.61-1.33). There was no difference in the likelihood of developing acute diverticulitis in symptomatic uncomplicated diverticular disease between the two groups (3 trials, 484 participants, RR=0.26, 95%CI=0.06-1.20). There was a higher global symptoms score reduction with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 326 participants, SMD=-1.01, 95%CI=-1.51,-0.52) and acute uncomplicated diverticulitis (2 trials, 153 participants, SMD=-0.56, 95%CI=-0.88,-0.24). CONCLUSIONS Mesalazine may reduce recurrences in symptomatic uncomplicated diverticular disease. There is uncertainty on the effect of mesalazine in achieving diverticular disease remission. Mesalazine may not prevent acute diverticulitis in symptomatic uncomplicated diverticular disease.
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Affiliation(s)
- Andrea Iannone
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Marinella Ruospo
- 2Diaverum Medical Scientific Office, Lund, Sweden
- 3Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Germaine Wong
- 4Sydney School of Public Health, University of Sydney, Australia
- 5Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
| | - Michele Barone
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Mariabeatrice Principi
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Alfredo Di Leo
- 1Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Giovanni F. M. Strippoli
- 2Diaverum Medical Scientific Office, Lund, Sweden
- 4Sydney School of Public Health, University of Sydney, Australia
- 6Diaverum Academy, Lund, Sweden
- 7Section of Nephrology, Department of Emergency and Organ Transplantation, University of Bari, Italy
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Abstract
Diverticulitis has become increasingly more common in the 20th century and is now one of the most frequent indications for gastrointestinal tract-related hospitalizations. The spectrum of clinical presentation can vary widely from mild, uncomplicated disease that can be managed as an outpatient, to complicated diverticulitis with peritonitis and sepsis. Historically, all patients with diverticulitis were managed with, at a minimum, a course of antibiotics, with many patients undergoing urgent or emergent surgery with a sigmoid colectomy, end colostomy, and oversewn rectosigmoid "Hartmann's" stump. However, the treatment paradigm has shifted away from more aggressive surgical management over the years, with recent literature supporting the notion that nonoperative management may lead to equivalent or even superior outcomes in many circumstances. Therefore, the purpose of this review is to summarize and interpret the existing literature on the management of uncomplicated and complicated left-sided diverticulitis in 2017.
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Affiliation(s)
- Sarah E Deery
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, WAC 4-460, Boston, MA, 02114, USA
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, WAC 4-460, Boston, MA, 02114, USA.
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Abstract
Purpose of Review Since the treatment of acute diverticulitis has become more conservative over the last years, knowledge of conservative treatment strategies is increasingly important. Recent Findings Several treatment strategies that previously have been imposed as routine treatment are now obsolete. Uncomplicated diverticulitis patients can be treated without antibiotics, without bed rest, and without dietary restrictions; and a selected group of patients can be treated as outpatients. Also, patients with isolated pericolic extraluminal air can be treated conservatively as well. Whereas some patient subgroups have been suggested to suffer from a more virulent disease course or higher recurrence rates, current evidence does not support all traditional understandings. Patients on immunosuppression or non-steroidal anti-inflammatory drugs seem to have a higher risk of complicated diverticulitis, but young patients do not. Data on the risk of recurrent diverticulitis in young patients is conflicting but the risk seems comparable to elderly patients. Besides the traditional treatments, several new treatment strategies have emerged but have failed thus far. Mesalazine does not have any beneficial effect on preventing recurrent diverticulitis based on current literature. Rifaximin and probiotics have been studied insufficiently in acute diverticulitis patients to conclude on their efficacy. Summary This review provides an overview of recent developments in conservative treatment strategies of acute diverticulitis and discusses the latest evidence on patient subgroups that have been suggested to suffer from an aberrant disease course.
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Kruis W, Greinwald R. Editorial: mesalazine to prevent recurrent acute diverticulitis-the final nail in the coffin. Authors' reply. Aliment Pharmacol Ther 2017; 46:462-463. [PMID: 28707787 PMCID: PMC5763405 DOI: 10.1111/apt.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- W. Kruis
- Evangelisches Krankenhaus KalkUniversity of CologneCologneGermany
| | - R. Greinwald
- Research & DevelopmentDr. Falk Pharma GmbHFreiburgGermany
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Tursi A, Elisei W, Picchio M, Nasi G, Mastromatteo AM, Di Mario F, Di Rosa E, Brandimarte MA, Brandimarte G. Impact of diverticular inflammation and complication assessment classification on the burden of medical therapies in preventing diverticular disease complications in Italy. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:320. [PMID: 28861417 DOI: 10.21037/atm.2017.06.39] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several treatments are currently advised to manage diverticular disease (DD) patients, but their impact on the burden of the disease is unknown. Our aim was to assess the economic analysis of using the recent Diverticular Inflammation and Complication Assessment (DICA) endoscopic classification on the burden of medical therapies prescribed in preventing DD complications occurrence in Italy. METHODS We assessed retrospectively the cost/year of treatments in estimated DICA 1, DICA 2 and DICA 3 population. Analysis of diverticulosis prevalence was estimated according to data population provided by Italian Institute of Statistics (ISTAT). Cost of treatments calculated according to data on drugs' consumption collected during the DICA study. RESULTS We estimated that >8 million of Italian people >60 years may have diverticulosis, and that about 75% of diverticular population are on DICA 1, about 30% on DICA 2, and about 13% on DICA 3. We estimated that >387 million of euros could be spent in DICA 1 population, >203 million of euros in DICA 2 population, and >88 million of euros in DICA 3 population. Since medical treatments did not show any significant advantage when treating DICA 1 and DICA 3 people in terms of prevention of acute diverticulitis occurrence/recurrence and surgery occurrence, we can estimated that >475 million of euros could be spent in Italy without any significant benefit in preventing DD complications occurrence. CONCLUSIONS DICA endoscopic classification may have a significant impact on the burden of DD in Italy, because it helps to select DD people who effectively need treatments in terms of prevention of acute diverticulitis occurrence/recurrence and surgery occurrence.
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Affiliation(s)
| | - Walter Elisei
- Division of Gastroenterology, ASL RM6, Albano Laziale, Rome, Italy
| | - Marcello Picchio
- Division of Surgery, "P. Colombo" Hospital, ASL RM6, Velletri, Rome, Italy
| | - Gabriella Nasi
- Clinical Management Staff, "Cristo Re" Hospital, Rome, Italy
| | | | - Francesco Di Mario
- Department of Clinical & Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
| | - Enrico Di Rosa
- Department of Hygiene and Public Health, ASL RM1, Rome, Italy
| | | | - Giovanni Brandimarte
- Division of Internal Medicine and Gastroenterology, "Cristo Re" Hospital, Rome, Italy
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