History, incidence, and epidemiology of diverticulosis

[Diagnosis and Treatment of Colonic Diverticular Disease]

Colonic diverticulosis is one of the most common conditions of the digestive system and patients generally remain asymptomatic. However, about 20% of patients develop symptomatic diverticular disease such as acute diverticulitis or diverticular hemorrhage, and these have become a huge burden on healthcare systems worldwide. Recent understanding of the pathophysiology of diverticulosis and diverticular disease suggests the role of multiple factors including genetic and environment. Based on this understanding, a preventive strategy to reduce the risk factors of diverticulosis and diverticular disease is highly recommended. The diagnosis of the acute diverticulitis relies on imaging modalities such as an abdominal-pelvic CT scan together with symptoms and signs. Treatment of diverticular disease should be individualized and include modification of lifestyle, use of antibiotics, and surgery. Recent guidelines recommend pursuing less aggressive treatment for patients with acute diverticulitis. This review will provide an overview of both the existing and evolving understanding regarding colonic diverticulosis and diverticular disease and can help clinicians in the management of their patients with diverticular disease.

Predictors of colonic diverticulosis in non-elderly patients

Aim: To investigate the clinical and laboratory features patients under aged 65 years with diverticulosis and to compare them to subjects with no diverticula. Material and Method: This retrospective case-control study included subjects aged under 65 years who underwent a colonoscopy in the period from January 2016 to June 2018 for diverse indications. Patients with diverticulosis as detected by a colonoscopy were compared to patients without diverticulosis. The comparison parameters included demographic data, comorbidities, and laboratory parameters, including a complete blood count, blood biochemistry, erythrocyte sedimentation rate (ESR), and C-reactive protein. Results: The study included 129 patients with diverticulosis and age and sex-matched 130 patients with no diverticula. Diverticula were predominantly left-sided in 64.3%, right-sided in 9.3%, and bilateral in 26.4%. Hypertension was more prevalent among patients with diverticulosis compared to control subjects (31% vs 17%, p

Colonic Diverticulosis and Non-Alcoholic Fatty Liver Disease: Is There a Connection?

Background and Objectives: The development and severity of colonic diverticulosis and non-alcoholic fatty liver disease (NAFLD) has been associated with several components of metabolic syndrome (MetS). Therefore, this study aimed to evaluate a possible connection between NAFLD, colonic diverticulosis, and MetS. Materials and Methods: This retrospective study included patients diagnosed with diverticulosis between January 2017 and December 2019. Data regarding the patient demographics, Diverticular Inflammation and Complication Assessment (DICA) score and category, disease localization, hepatic steatosis, blood pressure, comprehensive metabolic panel, need for colonic surgery, and co-morbidities were collected from medical records. Results: A total of 407 patients with a median age of 68 years (range, 34-89 years) were included (male: 53.81%). The majority was diagnosed with left-sided diverticulosis (n = 367, 90.17%) and an uncomplicated disease course (DICA category 1, n = 347, 85.3%). Concomitant hepatic steatosis was detected in 47.42% (n = 193) of patients. The systolic blood pressure, triglycerides, total cholesterol, C-reactive protein (CRP), and fasting glucose were higher in the NAFLD group (p < 0.001, p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively). A higher prevalence of hypertension (HTA), type 2 diabetes mellitus (T2DM), and hypothyroidism was noted in the same group of patients (p < 0.001, p < 0.001, and p = 0.008, respectively). High-density lipoprotein cholesterol was lower in patients with more severe forms of diverticulosis (DICA category 2 and 3), while CRP levels were significantly higher (p = 0.006 and p = 0.015, respectively). HTA and NAFLD were more common in patients with more severe forms of colonic diverticulosis (p = 0.016 and p = 0.025, respectively). Using a multivariate logistic regression, the DICA score, CRP, total cholesterol, HTA, and hypothyroidism were identified as discriminating factors for the presence of hepatic steatosis. Conclusion: Components of metabolic dysregulation were prominent in patients diagnosed with colonic diverticulosis and concomitant hepatic steatosis. HTA, T2DM, and hypothyroidism were more frequently observed in this group. Hepatic steatosis was more commonly detected in more severe forms of colonic diverticulosis.

Chronic constipation is negatively associated with colonic diverticula

OBJECTIVES

Constipation has been considered the key risk factor for diverticulosis occurrence, but the underlying mechanism is unclear. We investigated the factors associated with diverticulosis, focusing on the association of constipation severity with the localization and number of diverticula.

MATERIALS AND METHODS

We analyzed consecutive patients who underwent colonoscopy between March and December 2019. Chronic constipation was diagnosed as constipation meeting Rome IV criteria or as that requiring laxative therapy for more than 6 months. The degree of constipation was scored using the Constipation Scoring System (CSS).

RESULTS

We assessed 1014 patients. Multivariate analysis revealed that age, alcohol consumption, and hypertension were positively associated with diverticulosis, whereas chronic constipation was negatively associated with diverticulosis (odds ratio [OR] = 0.74; 95% confidence interval [CI], 0.55-0.99). When assessed according to the location of diverticula, right-sided diverticula were significantly associated with a lower incidence of constipation (OR = 0.94; 95% CI, 0.89-0.98), whereas neither left-sided nor bilateral diverticula was associated with constipation. This negative association of diverticula with constipation was stronger in patients with a high CSS score. In stratified analysis, the number of diverticula decreased with increasing degree of constipation (p for trend <.01), and a high CSS score was associated with a decreased prevalence of ≥3 diverticula (OR = 0.64; 95% CI, 0.44-0.99).

CONCLUSIONS

Chronic constipation was negatively associated with colonic diverticulosis. The association increased with the degree of constipation and was strong only in cases with right-sided diverticula and those with ≥3 diverticula.

The Epidemiology and Etiology of Right-Sided Colonic Diverticulosis: A Review

Diverticulosis of the colon is a common condition in Western countries and most patients will remain asymptomatic, but some will present with symptoms of acute diverticulitis or bleeding. Our understanding of diverticulosis is evolving but is mostly derived from diverticulosis affecting the left-sided colon. In contrast, right-sided colonic diverticulosis (RCD) is more commonly seen in Asian countries but is much less common overall. Based on the marked differences in epidemiology, it is commonly thought that these are 2 distinct disease processes. A review of the literature describing the epidemiology and etiology of RCD was performed, with a comparison to the current understanding of left-sided diverticulosis. RCD is becoming increasingly common. The epidemiology of RCD shows it to be a mostly acquired condition, and not congenital as previously thought. Many factors in the etiology of RCD are similar to that seen in left-sided diverticulosis, with a few variations. It is therefore likely that most cases of RCD represent the same disease process that is seen in the left colon.

Recent trends in the prevalence and distribution of colonic diverticula in Japan evaluated using computed tomography colonography

BACKGROUND

Computed tomography colonography (CTC) may be superior to colonoscopy and barium enema for detecting diverticula. However, few studies have used CTC to diagnose diverticula.

AIM

To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC.

METHODS

This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial, which included 1181 participants from 14 hospitals in Japan. We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex. The relationship between the diverticula and the length of the large intestine was also analyzed.

RESULTS

Diverticulosis was present in 48.1% of the participants. The prevalence of diverticulosis was higher in the older participants (P < 0.001 for trend). The diverticula seen in younger participants were predominantly located in the right-sided colon. Older participants had a higher frequency of bilateral type (located in the right- and left-sided colon) diverticulosis (P < 0.001 for trend). The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula (P < 0.001).

CONCLUSION

The prevalence of colonic diverticulosis in Japan is higher than that previously reported. The prevalence was higher, and the distribution tended to be bilateral in older participants.

Relationship between colonic diverticulosis and colon neoplasms in Japanese patients

BACKGROUND AND AIM

Colonic diverticulosis (CD) has been reported to be associated with presence of colon neoplasms (CNs) in Western patients, since most of the associated risk factors are common between them. However, such correlation has not been fully investigated in Asian patients. In this study, the association of CNs with CD was evaluated in a multicenter investigation.

METHODS

We enrolled 5633 patients who underwent both colonoscopy and esophagogastroduodenoscopy due to annual follow-up, screening for positive occult blood testing and abdominal symptoms between January 2016 and December 2017 at three institutions. The relationship between the presence of CNs and CD was investigated, and predictors for presence of CNs were determined by multivariate logistic analysis.

RESULTS

The enrolled patients consisted of 1799 (31.9%) with CD (average age 70.0 years, male 64.0%) and 3834 without CD (66.0 years, male 52.9%), with the prevalence of CNs in those groups 46.6% and 44.2%, respectively (P = 0.090). Predictors for early colon cancer were shown to be age (OR 1.02, 95% CI 1.01-1.04, P = 0.010), laxatives use (OR 1.76, 95% CI 1.17-2.64, P = 0.007), gastric neoplasms (OR 2.16, 95% CI 1.23-3.81, P = 0.008), and CD (OR 1.64, 95% CI 1.16-2.31, P = 0.005). Early colon cancer in the distal colon was most frequently detected in patients with right-sided CD (RR 2.50, P = 0.001).

CONCLUSION

In Japanese patients, early colon cancer was more frequently found in those with as compared to those without CD. The presence of CD may be an important indicator for an index colonoscopy examination to detect colon cancer. (Clinical-trial-registry: UMIN000038985).

Treatment with Ceftriaxone in Complicated Diverticulitis Increases the Incidence of Intra-Abdominal Enterococcus faecium Detection

Background: Complicated diverticulitis of the sigmoid colon typically is treated by resection after initial antibiotic treatment. Third-generation cephalosporins are the drugs of choice but are not effective against enterococci and can induce colonic colonization by Enterococcus faecium within hours. Infections caused by enterococci, especially E. faecium, are difficult to treat but should be considered in the strategic treatment planning of hospital-acquired peritonitis (e.g., anastomotic leakage), especially in immunocompromised patients. Methods: To determine whether the duration of pre-operative ceftriaxone treatment in complicated diverticulitis increases the incidence of intra-abdominal E. faecium detection, we analyzed all patients operated on for diverticulitis of the sigmoid colon in our department between 2008 and 2016. Results: Analyzing 516 resections performed for complicated diverticulitis, we found that E. faecium generally was detected intra-abdominally more often in the group that underwent longer pre-operative ceftriaxone treatment (≥ 4 days). During primary resection, E. faecium was detected in 2.7%, 11.1%, and 37.0% cases in the group undergoing immediate operation, 1-3 days of antibiotic treatment, and ≥4 days of antibiotic treatment, respectively. Enterococcus faecium was detected in 0, 25.0%, and 70.6% of surgical revisions and 28.6%, 14.3%, and 56.0%, respectively, of incisional surgical site infections with identified pathogens. A multivariable analysis discovered anastomotic leakage and antibiotic treatment lasting ≥4 days to be independent risk factors for intra-abdominal isolation of E. faecium. Conclusion: A ceftriaxone treatment ≥4 days led to a higher incidence of intra-abdominal E. faecium. Our data further suggested that empiric coverage of E. faecium in the treatment of hospital-acquired peritonitis could be beneficial after a long duration of ceftriaxone treatment.

Clinical outcome for management of colonic diverticulitis: characteristics and surgical factor based on two institution data at South Korea

PURPOSE

The aim of this study was to analyze clinical outcomes after surgical and/or conservative management of patients with colonic diverticulitis.

MATERIAL AND METHODS

Between January 2001 and November 2018, data for 1175 patients (right (Rt.) side: n = 1037, left (Lt.) side: n = 138) who underwent conservative management (n = 987) and surgical management (n = 188) for colonic diverticulitis were retrieved from a retrospective database. The Rt. sided was defined up to the proximal two-thirds of the transverse colon and Lt. sided was defined from the distal one-third of the transverse colon.

RESULTS

The overall incidence of colonic diverticulitis is gradually increasing. The mean age of all patients was 43.2 ± 17 and was significantly higher in patients with Lt.-sided (57.0 ± 15.7) than with Rt.-sided (41.4 ± 13.4) diverticulitis (p = 0.001). The most common lesion site was cecum (71.7%, n = 843). First-time attacks were the most common (91.0%, n = 1069). The surgical rate was 12.2% on the right. sided and 44.9% on the left sided (p < 0.005). The mean age, age distribution, BMI, open surgery rate, stoma formation rate, and Hinchey types III and IV rate were significantly higher in Lt. sided than in Rt. sided (p < 0.005). Older age, higher BMI (≥ 25), and Hinchey types III and IV were significantly associated with surgical risk factors of diverticulitis (p < 0.005).

CONCLUSION

Base on present study, Lt.-sided colonic diverticulitis tends to be more severe than Rt. sided, and surgery is more often required. In addition, colonic diverticulitis that requires surgery seems to be older and more obese on Lt. sided.

Findings on Colonoscopy after Diverticulitis: A Multicenter Review

Diverticular disease is a common problem where patients with diverticulosis have a 1–4 per cent risk of acute diverticulitis. Current guidelines recommend a colonoscopy after.the resolution of acute diverticulitis. The aim of this study was to evaluate the yield of significant findings on colonoscopy after an episode of diverticulitis. This is a retrospective analysis of patients who underwent colonoscopy after an episode of diverticulitis between November 2005 and August 2017 at three major teaching hospitals. Advanced adenomas were defined as adenomas ≥1 cm, serrated adenomas, and tubulovillous or villous adenomas. A total of 584 patients (298 males; 51%) underwent colonoscopy for a history of diverticulitis after resolution of acute symptoms. Colonoscopy was complete in 488 patients (84%). Among these 488 patients, 446 had diverticular disease, 31 had advanced adenomas, and four had adenocarcinomas. Colonoscopies were incomplete in 96 patients (16%). Forty-six of those patients underwent surgery. The overall incidence of advanced adenomas and adenocarcinomas was 32 (5.4%) and nine (1.5%), respectively. In our study, the prevalence of advanced adenomas and adenocarcinomas was relatively high compared with the average risk individuals. Our findings support that patients after an episode of diverticulitis should continue to get a colonoscopy.

Influence of obesity on the risk of recurrent acute diverticulitis

BACKGROUND

Acute diverticulitis (AD) is a common surgical problem with increasing incidence. Obesity has become epidemic in western countries. Obesity has been shown to increase the risk of developing AD; however, little is known about its influence on the risk of recurrence. The decision to perform elective surgical resection to reduce the risk of recurrent AD is made on an individual basis considering perceived risk of recurrence weighed against patient comorbidity. The aim of this study is to assess whether obesity affects the likelihood of developing recurrent AD.

METHODS

A retrospective audit was conducted of all admissions with AD to a tertiary centre between 1998 and 2010. Medical records were reviewed and patients with an index presentation with AD included in the analysis. Imaging was used to calculate body mass index (BMI) for assessment of obesity. Follow-up was for a minimum of 3 years from admission.

RESULTS

A total of 1299 patients were admitted with an index presentation of AD in the study period. 18.3% overall had recurrent AD, all of whom had confirmation on imaging. Computed tomography was used to calculate BMI in 849 patients, of whom 470 (55.4%) were considered obese (BMI >30). The likelihood of recurrent AD was not significantly different in obese patients compared to their non-obese counterparts (P = 0.2473).

CONCLUSION

While obesity increases the risk of developing AD overall, it does not appear to increase the likelihood of developing recurrent AD. This has implications for risk stratification when considering surgical resection to prevent recurrent AD.

Epidemiology of colonic diverticula and recent advances in the management of colonic diverticular bleeding

There is the East-West paradox in prevalence and phenotype of colonic diverticula, but colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding worldwide. Death from CDB can occur in elderly patients with multiple comorbidities, thus the management of CDB is clinically pivotal amid the aging populations in the East and West. Colonoscopy is the key modality for managing the condition appropriately; however, conventional endoscopic hemostasis by thermal coagulation and clipping cannot achieve the expected results of preventing early rebleeding and conversion to intensive intervention by surgery or transcatheter arterial embolization. Ligation therapy by endoscopic band ligation or endoscopic detachable snare ligation has emerged recently to enable more effective hemostasis for CDB, with an early rebleeding rate of approximately 10% and very rare conversion to intensive intervention. Ligation therapy might in turn reduce long-term rebleeding rates by eliminating the target diverticulum itself. Adverse events have been reported with ligation therapy including diverticulitis of the ascending colon in less than 1% of cases and perforation of the sigmoid colon in a few cases, thus more data are necessary to verify the safety of ligation therapy. Endoscopic hemostasis is indicated only for diverticulum with stigmata of recent hemorrhage (SRH), but the detection rates of SRH are relatively low. Therefore, efforts to increase detection are also key for improving CDB management. Urgent colonoscopy and triage by early contrast-enhanced computed tomography may be candidates to increase detection but further data are necessary in order to make a conclusion.

Possible increased risk of colonic diverticular disease from alcohol intoxication or abuse

Alcohol consumption has been suggested as a potential risk factor for diverticular diseases. This study investigated the association between alcohol intoxication or abuse and colonic diverticular disease (CDD).Using the National Health Insurance Research Database of Taiwan from January 1, 2000, to December 31, 2008, 51, 866 subjects newly diagnosed with alcohol intoxication were enrolled in this study as the alcohol intoxication cohort. The control (nonalcohol intoxication) cohort was frequency-matched 1:4 by age, sex and index year. Data were analyzed using a Cox proportional hazards model.The overall incidence of CDD (per 10,000 person-years) for the alcohol intoxication and control cohorts was 16.4 and 3.46, respectively. Compared with patients in the control cohort (95% confidence interval [CI] = 2.76-3.74), those with alcohol intoxication exhibited a 3.21-fold risk of CDD; the risk was particularly higher in male patients (adjusted hazard ratio [aHR] = 3.19, 95% CI = 2.72-3.74) and in those aged <45 years (aHR = 4.95, 95% CI = 3.91-6.27). The alcohol intoxication still had higher risk of CDD than nonalcohol intoxication, regardless of subjects without comorbidity (aHR = 3.38, 95% CI = 2.77-4.11) or with (aHR = 2.85, 95% CI = 2.25-3.61).There was a significant relationship between alcohol intoxication or abuse and CDD.

Risk Factors for Asymptomatic Colon Diverticulosis

Backgrounds/Aims

The etiology of colon diverticulosis is related to a range of genetic, biological, and environmental factors, but the risk factors for asymptomatic diverticulosis of the colon are unclear. This study examined the risk factors for asymptomatic colon diverticulosis.

Methods

This retrospective study included examinees who underwent a colonoscopy for screening at the health check-up center of SAM Hospital between January 2016 and December 2016. The examinees with colon diverticulosis found by colonoscopy were compared with those without diverticulosis. The comparison factors were age, gender, alcohol consumption, smoking status, medical history, lipid profile, body mass index, visceral fat area, waist-hip ratio, and severity of a fatty liver.

Results

This study included 937 examinees and the overall prevalence of diverticulosis was 8.1% (76/937). Fatty liver was found in 69.7% (53/76) in cases of colon diverticulosis and 50.3% (433/861) in the control group (p=0.001). The average waist-hip ratio was 0.92±0.051 in colon diverticulosis and 0.90±0.052 in the control group (p=0.052). Multivariate analysis revealed the waist-hip ratio (OR=1.035, 95% CI 1.000-1.070, p=0.043), moderate fatty liver (OR=2.238, 95% CI 1.026-4.882, p=0.043), and severe fatty liver (OR=5.519, 95% CI 1.236-21.803, p=0.025) to be associated with an increased risk of asymptomatic colon diverticulosis.

Conclusions

The waist-hip ratio, moderate fatty liver, and severe fatty liver are risk factors for asymptomatic colon diverticulosis. Central obesity, which can be estimated by the waist-hip ratio, and fatty liver might affect the pathogenesis of asymptomatic colon diverticulosis.

Early Colonoscopy for Diverticular Bleeding Does Not Reduce Risk of Postdischarge Recurrent Bleeding: A Propensity Score Matching Analysis

BACKGROUND & AIMS

Colonoscopy within 24 hours (early colonoscopy) is recommended for patients with colonic diverticular bleeding, but it is unclear if this strategy improves postdischarge outcomes. We aimed to determine whether early colonoscopy is associated with decreased risk of rebleeding and hospital re-admission within 30 days.

METHODS

We performed a retrospective cohort study using Marketscan (Truven Health Analytics, Inc, Ann Arbor, MI), a nationwide insurance claims database. From January 2004 through September 2015, patients with a primary diagnosis of diverticular bleeding who underwent inpatient colonoscopy were included. We used propensity score matching to account for differences between recipients of early vs delayed colonoscopy. Multivariable logistic regression was performed to determine the association between early colonoscopy and rebleeding or hospital re-admission within 30 days of discharge.

RESULTS

In total, 20,010 patients underwent colonoscopy for diverticular bleeding; 11,690 underwent early colonoscopy. After propensity matching, 8320 pairs of patients were analyzed. In the matched analysis, higher proportions of patients who received early colonoscopy underwent additional colonoscopies (73%), compared with patients who did not receive early colonoscopy (4%) (P < .0001), but lower proportions received endoscopic interventions (3% vs 8%; P < .0001). On multivariable analysis, early colonoscopy (odds ratio [OR], 1.34; 95% CI, 1.08-1.66; P = .007), transfusion requirement (OR, 2.31; 95% CI, 1.88-2.83; P < .0001), and baseline chronic kidney disease (OR, 2.13; 95% CI, 1.49-3.04; P < .0001) were associated with increased risk of rebleeding within 30 days. Early colonoscopy (OR, 1.18; 95% CI, 1.02-1.36; P = .03), endoscopic intervention (OR, 1.37; 95% CI, 1.03-1.81; P = .03), transfusion requirement (OR, 2.17; 95% CI, 1.88-2.51; P < .0001), coronary artery disease (OR, 1.27; 95% CI, 1.06-1.51; P = .009), and chronic kidney disease (OR, 1.98; 95% CI, 1.54-2.54; P < .0001) were associated with increased re-admission to the hospital within 30 days.

CONCLUSIONS

In a propensity-matched analysis, we associated early colonoscopy with increased risk of rebleeding events and hospital re-admissions. However, these observations might be due to confounding factors.

A seven-year retrospective review of colonoscopy records from a single centre in Zambia

Introduction

Colorectal disease is common throughout the world, but the spectrum of diagnoses across Africa remains largely unexplored. There is anecdotal evidence of changing colorectal disease but this has not been systematically investigated. The aim of this study was to enhance our insight into the spectrum of colonoscopic diagnoses in Zambia.

Methods

We retrieved written colonoscopy reports from January 2008 to December 2015. Collected data were coded by experienced endoscopists and analysed by age, sex, referral source, indication and diagnosis.

Results

Included in this analysis were 573 colonoscopy reports. The most common diagnosis was haemorrhoids (n=151, 26%), followed by tumours (n=96,17%). Over this time period, the proportion of normal colonoscopies decreased by 32% (P<0.001), presumably due to introduction of screening of all requests, while the rate of polyp detection increased from 5% to 10% (P=0.006). The detection of polyps was highest in patients less than 16 years (OR 8.4; 95% CI 2.4–26.2, P<0.001). Of those with colorectal tumours, 33/96 (35%) were less than 45 years although the occurrence was higher with advancing age (P=0.02). Diverticular disease was more common in older age groups (median (IQR) age 70 (60–75) years, versus 47 (34–62) years for those without the disease; P=0.0001).

Conclusion

This audit has shown that more than a third of colorectal tumours seen during colonoscopy are in patients below the age of 45 years, with the occurrence of polyps being highest in those below 16 years. Diverticular disease is most common in older age groups.

Increasing Diverticulosis in an Aging Population: A Colonoscopy-Based Study of 5-Year Trends in 26 463 Patients in Northern China

Background

Because such data are scarce in northern China, the purpose of this study was to determine trends in diverticulosis over the past 5 years.

Material/Methods

A total of 26 463 patients (27 558 examinations, including 1095 repeated colonoscopies) performed between January 2011 and December 2015 were reviewed respectively. The distributions of diverticulosis were recorded, which were classified as right-sided, left-sided, and bilateral type. The trends in diverticulosis were analyzed in terms of aging and yearly increase. Additionally, associations of the occurrence of diverticulosis with age (≤39, 40–59, and ≥60 years) and sex were determined using a logistic regression model.

Results

We identified 1045 patients with colonic diverticulosis, with an overall prevalence of 3.8% (1045/27 558). A preponderance of right-sided diverticulosis was demonstrated, accounting for 72.9% (693/951) of included subjects. The proportion of colonic diverticulosis increased significantly (P<0.001 for trend), from 2.78% (112/4028) in 2011 to 4.98% (309/6208) in 2015. The proportion of patients of all age groups with diverticulosis increased significantly (P<0.001 for trend) in correlation with yearly increase. There was a greater proportion of diverticulosis, regardless of the distribution, in patients aged ≥60 than in younger age groups (P<0.001 for trend). Multivariate analysis showed older age and male sex (P<0.001) were independent risk factor for diverticulosis.

Conclusions

Colonic diverticulosis has been increasing in northern China, where rapid aging is ongoing.

Selective association of nonaspirin NSAIDs with risk of diverticulitis

PURPOSE

The purpose of this study is to investigate the association of intake of nonsteroidal anti-inflammatory drugs (NSAIDs) and in particular nonaspirin NSAIDs and compare it with other risk factors for the progression of diverticulosis to diverticulitis in patients who underwent colonoscopy.

METHODS

A total of 194 patients who underwent complete colonoscopy in our center between 2012 and 2016 were recruited: 144 with diverticulosis without prior diverticulitis (median age 71 years, 59.7% men) and 50 with diverticulitis (median age 64 years, 54.0% men). Data concerning current and previous medication as well as concomitant diseases were collected using a structured questionnaire and by revision of patients medical charts.

RESULTS

Patients with diverticulitis were significantly (p < 0.001) younger as compared to individuals with plain diverticulosis (median age 64 versus 71 years, respectively). The intake of NSAIDs significantly (p = 0.002) increased the risk of prior diverticulitis (OR 3.2, 95% CI 1.5-6.9). In the multivariate model, both age (p < 0.001) and NSAIDs (p = 0.03) proved to be independent determinants of diverticulitis. When analyzing aspirin intake, it was not associated with diverticulitis.

CONCLUSIONS

Our study demonstrates, in line with previous reports, that intake of NSAIDs is associated with diverticulitis. We show in particular that nonaspirin NSAIDs might be selectively associated with diverticulitis. These results point to divergent role of aspirin and nonaspirin NSAIDs in the development of diverticulitis.

Relationship between diverticulosis and nonalcoholic fatty liver disease in elderly patients

Objective

To compare clinical and laboratory features of elderly patients with and without diverticulosis and assess factors related to hepatosteatosis.

Method

This retrospective case–control study analysed the clinical and laboratory data, colonoscopy and abdominal ultrasonography records of patients >65 years who underwent colonoscopies. Subjects were categorized according to the presence and absence of colonic diverticulosis. Univariate/multivariate logistic regression analyses were performed to evaluate the independent predictive factors of hepatosteatosis.

Results

A total of 355 patients were enrolled in the study: 169 had colonic diverticulosis; and 186 without colonic diverticulosis formed the control group. Age, sex and chronic disorders associated with the metabolic syndrome did not differ between the diverticulosis and control groups. The rate of hepatosteatosis was lower in patients with diverticulosis compared with the control group (27% versus 42%, respectively). Diabetes mellitus, hyperlipidaemia and hepatosteatosis were more common among patients aged <75 years. In the multivariate logistic regression analysis, diverticulosis remained an independent predictor of hepatosteatosis (odds ratio 0.529; 95% confidence interval 0.323, 0.866). Other independent predictive factors in the multivariate analysis were triglyceride and albumin.

Conclusion

Diverticulosis in the elderly was found to be a negative predictor of hepatosteatosis. Higher values of albumin and triglyceride in conjunction with the absence of diverticulosis may be suggestive of nonalcoholic fatty liver disease in the elderly.

Emergency Department Burden of Diverticulitis in the USA, 2006-2013

GOALS

The aim of this study was to analyze recent trends in emergency department (ED) visits for diverticulitis between 2006 and 2013.

BACKGROUND

Acute diverticulitis is a serious medical condition that frequently leads to ED visits, hospitalizations, and surgeries resulting in a significant health care burden.

METHODS

Data were obtained from the National Emergency Department Sample (NEDS) records in which diverticulitis (ICD-9-CM codes 562.11 and 562.13) was the primary diagnosis in the ED between 2006 and 2013. The NEDS collects data from more than 25 million visits in over 950 hospital emergency departments and is weighted to provide national estimates. Our findings reflected patient and hospital characteristics such as demographics, geographical region, and total charges for ED and inpatient stays.

RESULTS

Between 2006 and 2013, the rate of diverticulitis-related ED visits increased by 26.8% from 89.8 to 113.9 visits per 100,000 population. The aggregate national cost of diverticulitis-related ED visits increased by 105%, from approximately $822 million in 2006 to over $1.6 billion in 2013. Cost data were adjusted for inflation and reported in 2015 dollars. The percentage of individuals admitted to the same hospital from the ED decreased from 58.0 to 47.1% from 2006 to 2013, respectively, while the rate of bowel surgeries per 100,000 ED visits for diverticulitis decreased by 33.7% from 2006 to 2013.

CONCLUSIONS

The number of ED visits due to diverticulitis and associated costs continued to rise between 2006 and 2013, while the rate of bowel surgeries and inpatient admissions through the ED for diverticulitis decreased.

Metformin use in diabetics with diverticular disease is associated with reduced incidence of diverticulitis

BACKGROUND AND AIMS

There is no current, evidence-based therapy to prevent acute diverticulitis in patients with diverticular disease. Metformin has been shown to have anti-inflammatory effects in a number of disease states, in both animal models and in human observational studies. The potential therapeutic efficacy of metformin in diverticular disease has not been investigated. This study aims to describe the relationship between metformin use and diverticular disease in patients with diabetes mellitus.

METHODS

This was a retrospective case-control study. It compared metformin and other hypoglycaemic medication use in diabetic patients with uncomplicated diverticulosis to those with acute diverticulitis. Patients were identified using hospital International Classification of Diseases 10 (ICD-10) data, and radiology, pathology and scanned medical record databases were used to confirm diagnoses and collect all information. Chi square tests were used to determine significance of difference in categorical variables, and Mann-Whitney tests were used for continuous data.

RESULTS

There were 174 patients with uncomplicated diverticulosis and 175 patients with acute diverticulitis. A diagnosis of acute diverticulitis was associated with a significantly lower incidence of metformin use, than a diagnosis of uncomplicated diverticular disease (44% compared to 60%, respectively, p = .002). Other oral hypoglycaemic drugs and insulin were not associated with a lower incidence of diverticulitis (p = .12 and p = .24, respectively).

CONCLUSION

Metformin use is associated with reduced incidence of diverticulitis in diabetic patients with diverticular disease. The utility of metformin as a therapeutic agent to reduce the risk of diverticulitis in patients with diverticular disease warrants further randomised, prospective, interventional investigation.

Diagnosis of symptomatic uncomplicated diverticular disease and the role of Rifaximin in management

Patients with diverticulosis who develop persistent abdominal pain, bloating and changes in bowel habits not associated with overt inflammation may have symptomatic uncomplicated diverticular disease (SUDD). The severity and frequency of SUDD symptoms may have an impact on daily activities and severely affect quality of life. Effective management of SUDD should follow a three part strategy: divert, tackle and maintain. Divert to make the correct diagnosis: several symptoms of SUDD are common to other conditions that require different therapeutic approaches. However, several key differences should be used to diagnose SUDD. Pain in SUDD is normally in the iliac fossa, persistent, often lasting more than 24 hrs, and is not relieved by bowel movement, as is often the case with irritable bowel syndrome. Another difference is in the timing: the prevalence of SUDD increases with age, and patients under the age of 40 years are less likely to have diverticula. It is useful to establish whether a patient has diverticulosis, especially if the patient is relatively young; lack of diverticula excludes SUDD. Cross-sectional imaging is indicated; however, recent archival image data or ultrasonography may be useful alternatives. Laboratory tests should be ordered to exclude overt inflammation. Once the diagnosis of SUDD is made, the patient should receive effective therapy to tackle the condition. This should include dietary fibre supplementation and cyclic treatment with rifaximin 400 mg twice daily for 7 days per month. Once symptom control is achieved, it should be maintained by continuing therapy for at least 12 months.

Outcomes and Risk Factors Affecting Mortality in Patients Who Underwent Colorectal Emergency Surgery

Purpose

Emergency colorectal surgery has a high risk of mortality and morbidity because of incomplete bowel preparation, bacterial proliferation, and contamination. In this study, we investigated the outcomes and the risk factors affecting mortality in patients who had undergone emergency surgery for the treatment of various colorectal diseases.

Methods

This study is a retrospective analysis of prospectively collected data to survey the clinical results for patients who had undergone emergency colorectal surgery from January 2014 to December 2014. We analyzed various clinicopathologic factors, which were divided into 3 categories: preoperative, intraoperative, and postoperative.

Results

A total of 50 patients had undergone emergency colorectal surgery during the time period covered by this study. Among them, 10 patients (20%) died during the postoperative period. A simple linear regression analysis showed that the risk factors for mortality were old age, preoperative hypotension, and a high American Society of Anesthesiologist (ASA) score. Moreover, a multiple linear regression analysis showed a high ASA score and preoperative hypotension to be independent risk factors.

Conclusion

In this study, emergency colorectal surgery showed a relatively high mortality rate. Furthermore, the independent risk factors for mortality were preoperative hypotension and high ASA score; thus, patients with these characteristics need to be evaluated more carefully and receive better care if the mortality rate is to be reduced.

Prevalence of colonic diverticulosis in mainland China from 2004 to 2014

The aim of this study was to determine the prevalence of colonic diverticulosis in mainland China. Sixty two thousand and thirty-four colonoscopies performed between Jan 2004 and Dec 2014 were reviewed retrospectively. The overall diverticulosis prevalence was 1.97% and out of this, 85.3% was right-sided. Prevalence does not change, significantly, on trends between the period 2004-2014. The peak of prevalence of diverticulosis was compared between the female group aged >70 years to the male one of 41-50 years. The other peak, otherwise, was compared between the group of 51-60 years with the right-sided diverticulosis to the one of >70 years with left-sided disease. Multivariate analysis suggested that the male gender could be a risk factor for diverticulosis in the group aged ≤70 years, but not for the older patients. In addition, among men was registered an increased risk factor for right-sided diverticulosis and, at the same time, a protective one for left-sided localization. In conclusion, the prevalence of colonic diverticulosis is very low in mainland China and it does not change significantly on trends over the time. Both the prevalence of this condition and its distribution changes according to the age and the genders. These findings may lead the researchers to investigate the mechanisms causing this kind of disease and its distribution in regard of the age and the gender.

Colorectal Disorders in Acute Human Immunodeficiency Virus Infection: A Case Series

Background.  The gastrointestinal (GI) tract is important in the pathogenesis of human immunodeficiency virus (HIV) infection. We report a case series of lower GI endoscopic and histopathologic findings of HIV-infected individuals after presentation with acute infection. Methods.  We performed a retrospective case review of individuals infected with HIV who enrolled between August 2010 and April 2013 in a primary infection treatment trial. All participants started the trial during acute infection and underwent colonoscopy with biopsies at baseline and after the start of antiretroviral treatment. Results.  Twenty acutely infected individuals were included in the study (mean age, 33 years; range, 20-54 years). All participants were male who reported having receptive anal sex as an HIV risk factor. Nine individuals (45%) had at least 1 finding by colorectal pathology; 1 person had 2 diagnoses (diverticulosis and focal active proctitis). The histopathological findings revealed anal dysplasia in 3 cases: 2 had high-grade anal intraepithelial neoplasia (AIN) and 1 had low-grade AIN. Two persons had a colorectal polyp, 1 hyperplastic and 1 adenomatous. Three persons were diagnosed with diverticulosis, and 2 persons were diagnosed with proctitis, including 1 with focal active proctitis and 1 with cytomegalovirus proctitis. Conclusions.  To our knowledge, this is the first case series report of lower GI disorders in acute HIV-infected individuals. Although the causal relationship remains uncertain, we describe the endoscopic findings that were observed during acute HIV infection among men who have sex with men. Understanding the prevalence of these pathologies may likely shed light on how acute HIV infection damages the lower GI tract.

Effect of oral mesalamine on inflammatory response in acute uncomplicated diverticulitis

AIM: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis.

METHODS: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay.

RESULTS: Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03).

CONCLUSION: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.

Trend and risk factors of diverticulosis in Japan: age, gender, and lifestyle/metabolic-related factors may cooperatively affect on the colorectal diverticula formation

BACKGROUND

Despite the marked increase of diverticulosis, its risk factors have not been adequately elucidated. We therefore aim to identify significantly associated factors with diverticulosis. We also aim to investigate the present state of diverticulosis in Japan.

METHODS

We reviewed the medical records from 1990 to 2010 that included the data of consecutive 62,503 asymptomatic colonoscopy examinees from the general population in Japan. Most recent 3,327 examinees were analyzed with 16 background factors.

RESULTS

Among the 62,503 subjects (47,325 men and 15,178 women; 52.1 ± 9.2 years old), diverticulosis was detected in 11,771 subjects (18.8%; 10,023 men and 1,748 women). The incidences of diverticulosis in 1990-2000 and 2001-2010 were respectively 13.0% (3,771 of 29,071) and 23.9% (8,000 of 33,432): the latter was much higher than the former in all age groups and for both genders. Considering the anatomical locations of colorectal diverticula, left-sided ones have markedly increased with age but not significantly changed with times. Univariate analyses of the 3,327 subjects showed significant association of diverticulosis with four basic factors (age, sex, body mass index, blood pressure), three life style-related factor (smoking, drinking, severe weight increase in adulthood), and two blood test values (triglyceride, HbA1c). The multiple logistic analysis calculating standardized coefficients (β) and odds ratio (OR) demonstrated that age (β = 0.217-0.674, OR = 1.24-1.96), male gender (β = 0.185, OR = 1.20), smoking (β = 0.142-0.200, OR = 1.15-1.22), severe weight increase in adulthood (β = 0.153, OR = 1.17), HbA1c (β = 0.136, OR = 1.15), drinking (β = 0.109, OR = 1.11), and serum triglyceride (β = 0.098, OR = 1.10) showed significantly positive association with diverticulosis whereas body mass index and blood pressure did not.

CONCLUSIONS

The large-scale data of asymptomatic colonoscopy examinees from the general population from 1990 to 2010 indicated that the prevalence of diverticulosis is still increasing in Japan. Age, male gender, smoking, severe weight increase in adulthood, serum HbA1c, drinking, and serum triglyceride showed significant positive association with diverticulosis.

Prevalence and risk factors of asymptomatic colorectal diverticulosis in Taiwan

Background

To investigate the prevalence and risk factors of asymptomatic colorectal diverticulosis in Taiwanese general population.

Methods

From January 2009 to December 2011, consecutive asymptomatic subjects undergoing a health check-up were evaluated by colonoscopy. The colorectal diverticulosis was assessed, and a medical history and demographic data were obtained from each subject. Logistic regression analysis was conducted to search the risk factors of colorectal diverticulosis.

Results

Of the 1899 asymptomatic subjects, the prevalence of colorectal diverticulosis was 13.5%. On univariate logistic regression analysis, age over 60 years old, male, adenomatous polyp, current smoking and heavy alcohol consumption were significantly associated with diverticulosis. Multivariate logistic regression analysis revealed that age over 60 years old (relative risk [RR], 2.57; 95% confidence interval [CI], 1.64-6.47), adenomatous polyps (RR, 2.18; 95% CI, 1.18-4.61) and heavy alcohol consumption (RR, 1.82; 95% CI, 1.04-3.08) were independent predictors for colorectal diverticulosis.

Conclusions

The prevalence of asymptomatic colorectal diverticulosis was 13.5% in Taiwan. Age over 60 years old, adenomatous polyp and heavy alcohol consumption may affect the risk of development of the disease.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines

AIM

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient.

RESULTS

Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence.

CONCLUSION

Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Diverticulosis and the risk of interval colorectal cancer

BACKGROUND

Diverticulosis, a prevalent condition at screening colonoscopy, has been associated with colorectal cancers that develop after a clearing colonoscopy, or interval cancers.

AIMS

To quantify the overall risk of diverticulosis in the development of interval cancers and examine this association in relevant subgroups.

METHODS

Using a linked database containing SEER tumor registry data and Medicare claims, we identified patients aged ≥69 years with colorectal cancer who underwent colonoscopy within 6 months of diagnosis. Patients with an additional colonoscopy from 36 to 6 months prior to cancer diagnosis were characterized as having interval cancers. We compared characteristics of patients with interval cancers and detected cancers according to a diagnosis of diverticulosis not associated with a colonoscopy procedure from 1991 through the date of the most recent colonoscopy in both univariate and multivariate models.

RESULTS

A previous diagnosis of diverticulosis was documented in 14,452 (26.9 %) patients with detected cancers compared to 2,905 (69.3 %) patients with interval cancers (p < 0.001); these results were consistent in multivariable analysis. Moreover, the association was found as well in the proximal colon (OR 2.88, 95 % CI 2.66, 3.12), distal colon (OR 3.56, 95 % CI 3.09, 4.11), and rectum (OR 4.07, 95 % CI 3.34, 4.95). The vast majority of diverticulosis diagnoses were without complications such as hemorrhage or diverticulitis.

CONCLUSIONS

Diverticulosis was strongly associated with interval colorectal cancers in all segments of the colon. Given its known predominance in the left colon, the findings argue against impaired visualization of lesions at colonoscopy as the only pathogenic factor.

[A prospective study of factors influencing on the clinical characteristics of colonic diverticulosis]

BACKGROUND/AIMS

The prevalence of colonic diverticulosis in Korea is increasing in conjunction with the adoption of western dietary pattern, extension of lifespan, and advances in diagnostic modalities. The clinical characteristics of colonic diverticulosis seem to be gradually becoming similar to those of Western societies. Therefore, factors associated with the clinical characteristics of colonic diverticulosis in Korea were investigated.

METHODS

The data of 200 patients diagnosed with colonic diverticulosis using colonoscopy between May 2010 and April 2012 at Inje University Seoul Paik Hospital (Seoul, Korea) were prospectively collected. Clinical parameters acquired through a questionnaire include age, body mass index, waist circumference, exercise, diet, smoking, drinking habits, etc. Correlation between these factors and the clinical features of diverticulosis were analyzed.

RESULTS

Mean age of the patients was 54.9±11.9 (range 17-79) years and male to female ratio was 2.2:1. Most diverticula were located on the right side of the colon (83%) and the mean number of diverticulum was 4.07±3.9. Factor associated with the location of diverticulum on the left side was age (p=0.001). There was a positive correlation between the waist circumference and the number of diverticulum (partial correlation coefficient r'=0.143, p=0.047). Diverticulitis occurred more frequently in younger patients than in older patients (p=0.002).

CONCLUSIONS

Colonic diverticulosis in older patients is found more frequently on the left colon, and the number of diverticulosis is associated with central obesity.

Increase in colonic diverticulosis and diverticular hemorrhage in an aging society: lessons from a 9-year colonoscopic study of 28,192 patients in Japan

PURPOSES

Colonoscopic evidence of epidemiological trends in diverticulosis and diverticular bleeding is scarce. We evaluated trends in diverticular disease and associated factors over 9 years.

METHODS

Twenty-eight thousand one hundred ninety-two patients who underwent colonoscopy at an emergency hospital were reviewed from an electronic endoscopy database. Diverticula were classified as right-sided, left-sided, and bilateral types, and time trends in the proportion in diverticulosis, type, and diverticular bleeding were determined. Associations of age (≤39, 40-59, and ≥60 years), sex, and year increase with disease and odds ratios were estimated using logistic regression.

RESULTS

Diverticulosis was identified in 6,150 patients (20.3 %; mean age, 67.6 years) and was predominantly right-sided (48.0 %). Diverticular bleeding was found in 427 (1.5 %; mean age, 69.7 years) and was predominantly bilateral (47.0 %). Proportion of colonic diverticulosis increased significantly (P < 0.01 for trend) from 66.0 % (1,424/2,157) in 2003 to 70.1 % (2,914/4,159) in 2011 and was associated (P < 0.01) with an increased number of patients aged ≥60 years. Proportion of diverticular bleeding increased significantly (P < 0.01 for trend) from 1.02 % (22/2,157) in 2003 to 1.67 % (69/4,159) in 2011 and was associated (P = 0.04) with an increased number of patients aged 40-59 years. Diverticulosis, right and bilateral type, and diverticular bleeding were independently associated with the 9-year trend after adjustment by age and sex.

CONCLUSIONS

Colonic diverticulosis and diverticular bleeding are prevalent and increasing in Japan. Given the significant association of age with this trend, both diseases can be expected to increase for decades to come.

Pattern and distribution of colonic diverticulosis: Analysis of 2877 barium enemas in Thailand

AIM: To determine the pattern and distribution of colonic diverticulosis in Thai adults.

METHODS: A review of the computerized radiology database for double contrast barium enema (DCBE) in Thai adults was performed at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Incomplete studies and DCBE examinations performed in non-Thai individuals were excluded. The pattern and distribution of colonic diverticulosis detected during DCBE studies from June 2009 to October 2011 were determined. The occurrence of solitary cecal diverticulum, rectal diverticulum and giant diverticulum were reported. Factors influencing the presence of colonic diverticulosis were evaluated.

RESULTS: A total of 2877 suitable DCBE examinations were retrospectively reviewed. The mean age of patients was 59.8 ± 14.7 years. Of these patients, 1778 (61.8%) were female and 700 (24.3%) were asymptomatic. Colonic diverticulosis was identified in 820 patients (28.5%). Right-sided diverticulosis (641 cases; 22.3%) was more frequently reported than left-sided diverticulosis (383 cases; 13.3%). Pancolonic diverticulosis was found in 98 cases (3.4%). The occurrence of solitary cecal diverticulum, rectal diverticulum and giant diverticulum were 1.5% (42 cases), 0.4% (12 cases), and 0.03% (1 case), respectively. There was no significant difference in the overall occurrence of colonic diverticulosis between male and female patients (28.3% vs 28.6%, P = 0.85). DCBE examinations performed in patients with some gastrointestinal symptoms revealed the frequent occurrence of colonic diverticulosis compared with those performed in asymptomatic individuals (29.5% vs 25.3%, P = 0.03). Change in bowel habit was strongly associated with the presence of diverticulosis (a relative risk of 1.39; P = 0.005). The presence of diverticulosis was not correlated with age in symptomatic patients or asymptomatic individuals (P > 0.05).

CONCLUSION: Colonic diverticulosis was identified in 28.5% of DCBE examinations in Thai adults. There was no association between the presence of diverticulosis and gender or age.

Alcohol and smoking affect risk of uncomplicated colonic diverticulosis in Japan

Colonic diverticula are located predominantly on the right side in Asia and on the left side in Europe and the United States. Factors associated with uncomplicated colonic diverticulosis and its distribution pattern have been unknown. Our aims are to investigate the prevalence and risk factors for uncomplicated colonic diverticulosis. We conducted a prospective cross-sectional study in adults who underwent colonoscopy. Alcohol, alcohol related flushing, smoking, medications, and comorbidities were assessed by interview on the colonoscopy day. Alcohol consumption was categorized as nondrinker, light (1–180 g/week), moderate (181–360 g/week), and heavy (≥361 g/week). Smoking index was defined as the number of cigarettes per day multiplied by the number of smoking years and categorized as nonsmoker, <400, 400–799, and ≥800. A total of 2,164 consecutive patients were enrolled. Overall, 542 patients (25.1%) had uncomplicated colonic diverticulosis located on the right side (50%), bilaterally (29%), and on the left side (21%). Univariate analysis revealed age, male, smoking index, alcohol consumption, aspirin use, anticoagulants use, corticosteroid use, hypertension, and atherosclerotic disease as factors significantly associated with diverticulosis. Alcohol related flushing was not associated with the disease. Multivariate analysis showed increasing age (P<0.01), increasing alcohol consumption (P<0.01) and smoking (P<0.01), and atherosclerotic disease (P<0.01) as significantly associated factors. Alcohol and smoking were associated with right-sided and bilateral diverticula. In conclusion, one in four Japanese adults have colonic diverticulosis (50% right-sided). Age, alcohol consumption, and smoking were found to be significant risk factors for uncomplicated colonic diverticulosis, particularly right-sided and bilateral.

Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy

BACKGROUND & AIMS

Colonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10% to 25% lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. We measured the long-term risk of acute diverticulitis among patients with confirmed diverticulosis discovered incidentally on colonoscopy.

METHODS

We performed a retrospective study using administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, collecting data on patients who underwent colonoscopies from January 1996 through January 2011. We identified patients diagnosed with diverticulosis, determined incidence rates per 1000 patient-years, and analyzed a subgroup of patients with rigorously defined events confirmed by imaging or surgery. We used a Cox proportional hazards model to identify factors associated with the development of diverticulitis.

RESULTS

We identified 2222 patients with baseline diverticulosis. Over an 11-year follow-up period, 95 patients developed diverticulitis (4.3%; 6 per 1000 patient-years); of these, 23 met the rigorous definition of diverticulitis (1%; 1.5 per 1000 patient-years). The median time-to-event was 7.1 years. Each additional decade of age at time of diagnosis reduced the risk for diverticulitis by 24% (hazard ratio, 0.76; 95% confidence interval, 0.6-0.9).

CONCLUSIONS

Based on a study of the Veterans Affairs Greater Los Angeles Healthcare System, only about 4% of patients with diverticulosis develop acute diverticulitis, contradicting the common belief that diverticulosis has a high rate of progression. We also found that younger patients have a higher risk of diverticulitis, with risk increasing per year of life. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.

Alcohol consumption is a risk factor for colonic diverticulosis

BACKGROUND AND AIM

The exact factors predisposing to colonic diverticulosis other than age are unknown.

METHODS

Cross-sectional study of asymptomatic subjects undergoing screening colonoscopy. A detailed dietary and social questionnaire was completed on all participants. A worldwide review of the literature was performed to further investigate any association between identified risk factors and diverticulosis.

RESULTS

Seven hundred forty-six consecutive individuals were enrolled (mean age, 61.1±8.3 y; female: male=0.98). Overall, the prevalence of diverticulosis was 32.8% (95% CI, 29.5-36.2). Diverticula were left-sided, right-sided, or both in 71.5%, 5.8%, and 22.7% of affected subjects, respectively. On univariate analysis, age, sex, adenomatous polyps, advanced neoplasia (adenoma≥1 cm, villous histology, or cancer), aspirin, and alcohol use were significantly associated with diverticulosis. Diet, body mass index, physical activity, and bowel habits were not associated with the disease. On multivariate analysis, increasing age (P<0.001), advanced neoplasia (P=0.021), and alcohol consumption (P<0.001) were significantly associated with diverticulosis. The adjusted odds ratio for diverticulosis in alcohol users was 1.91 (1.36 to 2.69), with increasing prevalence with higher alcohol consumption (P-value for trend=0.001). When the prevalence of diverticulosis reported from 18 countries was analyzed against alcohol use, there was a strong correlation with national per-capita alcohol consumption rates (Pearson correlation coefficient r=0.68; P=0.002).

CONCLUSIONS

Alcohol use is a significant risk factor for colonic diverticulosis and may offer a partial explanation for the existing East-West paradox in disease prevalence and phenotype. Further studies are needed to investigate this association and its putative pathophysiological mechanisms.

Randomised clinical trial: mesalazine (Salofalk granules) for uncomplicated diverticular disease of the colon--a placebo-controlled study

BACKGROUND

Robust evidence regarding medical intervention for symptomatic uncomplicated colonic diverticular disease (DD) is sparse.

AIM

To investigate mesalazine (Salofalk granules) in this setting.

METHODS

In a double-blind, placebo-controlled, multicentre, 6-week trial, patients were randomised to mesalazine 1000 mg three times daily or placebo. Primary efficacy endpoint was change in lower abdominal pain to week 4 (baseline defined using pain score from 7 days pre-treatment).

RESULTS

Median change in lower abdominal pain with mesalazine vs. placebo was -37 (n = 56) vs. -33 (n = 61) [P = 0.374; 95% CI (-11; 4)] in the intent-to-treat (ITT) population, and -41 (n = 40) vs. -33 (n = 51) [P = 0.053; 95% CI (-18; 0)] in the per-protocol (PP) population, i.e. the primary endpoint was not significantly different. Post hoc adjustment for confounding factors ('baseline pain intensity', 'baseline symptom score (Brodribb)', and 'localisation of diverticula in the descending colon') resulted in P = 0.111 [ITT, 95% CI (-15.4; 1.6)] and P = 0.005 [PP, 95% CI (-19.7; -3.5)]. Between-group differences increased using pain score on day 1 as baseline, and reached significance for the PP population [mesalazine -42, placebo -26, P = 0.010; 95% CI (-25; -3)]. Median change in combined symptom score from baseline to week 4 was 257 mm with mesalazine vs. 198 mm with placebo [P = 0.064; 95% CI (-3; 105)]. More placebo-treated patients received analgesic/spasmolytic concomitant medication (34.4% vs. mesalazine 21.4%), indicating improved pain relief with mesalazine (P = 0.119). Safety was comparable.

CONCLUSIONS

A daily dose of 3.0 g mesalazine may relieve pain during a symptomatic flare of uncomplicated DD. In this, the first placebo-controlled double-blind trial in acute uncomplicated DD, mesalazine showed promising therapeutic efficacy.

Prevalence and patterns of diverticulosis in patients undergoing colonoscopy in a southern Indian hospital

The prevalence of diverticular disease of colon of colon is reportedly low in Asian compared to Western countries. We analyzed the prevalence of colonic diverticulosis in a selected cohort of patients undergoing colonoscopy. Retrospective study of records of patients undergoing colonoscopy in a tertiary hospital in southern India.

Aging of the human metaorganism: the microbial counterpart

Human beings have been recently reviewed as 'metaorganisms' as a result of a close symbiotic relationship with the intestinal microbiota. This assumption imposes a more holistic view of the ageing process where dynamics of the interaction between environment, intestinal microbiota and host must be taken into consideration. Age-related physiological changes in the gastrointestinal tract, as well as modification in lifestyle, nutritional behaviour, and functionality of the host immune system, inevitably affect the gut microbial ecosystem. Here we review the current knowledge of the changes occurring in the gut microbiota of old people, especially in the light of the most recent applications of the modern molecular characterisation techniques. The hypothetical involvement of the age-related gut microbiota unbalances in the inflamm-aging, and immunosenescence processes will also be discussed. Increasing evidence of the importance of the gut microbiota homeostasis for the host health has led to the consideration of medical/nutritional applications of this knowledge through the development of probiotic and prebiotic preparations specific for the aged population. The results of the few intervention trials reporting the use of pro/prebiotics in clinical conditions typical of the elderly will be critically reviewed.

A high-fiber diet does not protect against asymptomatic diverticulosis

BACKGROUND & AIMS

The complications of diverticulosis cause considerable morbidity in the United States; health care expenditures for this disorder are estimated to be $2.5 billion per year. Many physicians and patients believe that a high-fiber diet and frequent bowel movements prevent the development of diverticulosis. Evidence for these associations is poor. We sought to determine whether low-fiber or high-fat diets, diets that include large quantities of red meat, constipation, or physical inactivity increase risk for asymptomatic diverticulosis.

METHODS

We performed a cross-sectional study of 2104 participants, 30-80 years old, who underwent outpatient colonoscopy from 1998 to 2010. Diet and physical activity were assessed in interviews using validated instruments.

RESULTS

The prevalence of diverticulosis increased with age, as expected. High intake of fiber did not reduce the prevalence of diverticulosis. Instead, the quartile with the highest fiber intake had a greater prevalence of diverticulosis than the lowest (prevalence ratio = 1.30; 95% confidence interval, 1.13-1.50). Risk increased when calculated based on intake of total fiber, fiber from grains, soluble fiber, and insoluble fiber. Constipation was not a risk factor. Compared to individuals with <7 bowel movements per week, individuals with >15 bowel movements per week had a 70% greater risk for diverticulosis (prevalence ratio = 1.70; 95% confidence interval, 1.24-2.34). Neither physical inactivity nor intake of fat or red meat was associated with diverticulosis.

CONCLUSIONS

A high-fiber diet and increased frequency of bowel movements are associated with greater, rather than lower, prevalence of diverticulosis. Hypotheses regarding risk factors for asymptomatic diverticulosis should be reconsidered.

Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians

OBJECTIVE

To examine the associations of a vegetarian diet and dietary fibre intake with risk of diverticular disease.

DESIGN

Prospective cohort study.

SETTING

The EPIC-Oxford study, a cohort of mainly health conscious participants recruited from around the United Kingdom.

PARTICIPANTS

47,033 men and women living in England or Scotland of whom 15,459 (33%) reported consuming a vegetarian diet.

MAIN OUTCOME MEASURES

Diet group was assessed at baseline; intake of dietary fibre was estimated from a 130 item validated food frequency questionnaire. Cases of diverticular disease were identified through linkage with hospital records and death certificates. Hazard ratios and 95% confidence intervals for the risk of diverticular disease by diet group and fifths of intake of dietary fibre were estimated with multivariate Cox proportional hazards regression models.

RESULTS

After a mean follow-up time of 11.6 years, there were 812 cases of diverticular disease (806 admissions to hospital and six deaths). After adjustment for confounding variables, vegetarians had a 31% lower risk (relative risk 0.69, 95% confidence interval 0.55 to 0.86) of diverticular disease compared with meat eaters. The cumulative probability of admission to hospital or death from diverticular disease between the ages of 50 and 70 for meat eaters was 4.4% compared with 3.0% for vegetarians. There was also an inverse association with dietary fibre intake; participants in the highest fifth (≥25.5 g/day for women and ≥26.1 g/day for men) had a 41% lower risk (0.59, 0.46 to 0.78; P<0.001 trend) compared with those in the lowest fifth (<14 g/day for both women and men). After mutual adjustment, both a vegetarian diet and a higher intake of fibre were significantly associated with a lower risk of diverticular disease.

CONCLUSIONS

Consuming a vegetarian diet and a high intake of dietary fibre were both associated with a lower risk of admission to hospital or death from diverticular disease.

Epidemiological trends and geographic variation in hospital admissions for diverticulitis in the United States

AIM: To characterize the increasing incidence and geographic variation of acute diverticulitis.

METHODS: Using the nationwide inpatient sample (NIS) we identified a cohort who had been admitted with diverticulitis between 1998 and 2005. We calculated age-, sex-, and region-specific rates of hospitalizations for diverticulitis over time.

RESULTS: The age-adjusted hospitalization rate for diverticulitis increased from 61.8 per 100 000 to 75.5 per 100 000 between 1998 and 2005, and increased similarly in both sexes. Diverticulitis-associated admissions were male-predominant in those younger than age 45 years but were female-predominant thereafter. Admission rates increased the most among those < 45 years, while remaining unchanged for those ≥ 65 years. By 2005, the majority of hospitalized patients were < 65 years. Age-adjusted rates of diverticulitis-associated hospitalizations were lower in the West (50.4/100 000) compared to the Northeast (77.7/100 000), South (73.9/100 000), and Midwest (71.0/100 000).

CONCLUSION: Diverticulitis-associated hospitalizations have steeply risen, especially in young adults. These epidemiological trends vary by geographic region and warrant further investigation into potential dietary and environmental etiologies.

Aging of the human metaorganism: the microbial counterpart

Human beings have been recently reviewed as 'metaorganisms' as a result of a close symbiotic relationship with the intestinal microbiota. This assumption imposes a more holistic view of the ageing process where dynamics of the interaction between environment, intestinal microbiota and host must be taken into consideration. Age-related physiological changes in the gastrointestinal tract, as well as modification in lifestyle, nutritional behaviour, and functionality of the host immune system, inevitably affect the gut microbial ecosystem. Here we review the current knowledge of the changes occurring in the gut microbiota of old people, especially in the light of the most recent applications of the modern molecular characterisation techniques. The hypothetical involvement of the age-related gut microbiota unbalances in the inflamm-aging, and immunosenescence processes will also be discussed. Increasing evidence of the importance of the gut microbiota homeostasis for the host health has led to the consideration of medical/nutritional applications of this knowledge through the development of probiotic and prebiotic preparations specific for the aged population. The results of the few intervention trials reporting the use of pro/prebiotics in clinical conditions typical of the elderly will be critically reviewed.

Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis

INTRODUCTION

It was previously reported that in patients with acute perforated diverticulitis with Hinchey categories I to III sigmoidectomy with primary anastomosis (PA) is superior to Hartmann's procedure (HP) as later closure of colostomy involves substantial morbidity. We evaluated our experience with PA for patients with perforated diverticulitis over a 10-year period and aimed to investigate whether Hinchey category or co-morbidity are more relevant for postoperative outcome.

METHODS

Records of all patients treated at our institution for sigmoid diverticulitis between 1996 and 2006 were retrieved from an in-hospital database (N = 787, median age 66 years, range 30 to 94, female:male ratio 1.3:1); 73 patients who underwent immediate emergency surgery for perforated diverticulitis were included in this study. American Society of Anesthesiology (ASA) classification to gauge co-morbidity and Hinchey category for intraoperative extent of inflammation were evaluated as regards their relevance for postoperative mortality and major complications.

RESULTS

47 patients (64%) underwent sigmoid colectomy and PA, which was combined with loop ileostomy in 11 patients (15%). Sigmoid colectomy and HP was performed in 26 patients (36%). Major postoperative complications occurred in 26 patients (36%). In the PA group, 10 of 47 patients (21%) had anastomotic leakage. Three leakages occurred despite a loop ileostomy. Anastomotic leakage was independent of Hinchey category (Hinchey I: three patients, Hinchey II: four patients, Hinchey III: three patients, n.s.), but associated with co-morbidity (one patient ASA II, six patients ASA III, three patients ASA IV, P < 0.05). Total mortality was 12%. Seven patients died after HP and two patients after PA. No mortality was observed in PA patients with loop ileostomy.

CONCLUSIONS

Emergency surgery for perforated sigmoid diverticulitis is associated with high morbidity and mortality rates. Anastomotic leakage was associated with patient co-morbidity rather than with intraoperative Hinchey category, suggesting that the decision to perform PA should better be based on patient's general condition rather than on intraoperative extent of inflammation.