Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease--a double-blind, randomised, placebo-controlled study

Symptomatic uncomplicated diverticular disease: a critical appraisal

INTRODUCTION

Symptomatic uncomplicated diverticular disease (SUDD) is a clinical condition included in the spectrum of symptomatic diverticular disease. The symptom profile associated with SUDD is highly heterogeneous, as there are currently discordant definitions, that encompass many clinical scenarios.

AREAS COVERED

We conducted a narrative review to assess the symptom profile and diagnostic criteria of SUDD based on the available evidence. A thorough literature search was performed on PubMed following the SANRA scale. Abdominal pain, regardless of its duration and location, emerges as the cardinal symptom of SUDD, suggesting that it should be central to its diagnosis. Although abdominal bloating and changes in bowel habits are commonly reported, they do not appear to be specifically attributable to SUDD. Other issues considered are the possible overlap with irritable bowel syndrome and the identification of a subcategory of SUDD patients with chronic symptoms following an episode of acute diverticulitis.

EXPERT OPINION

The future agenda should include the development of shared diagnostic criteria for SUDD, including well-defined inclusion and exclusion clinical features and symptom patterns.

Probiotics: are they beneficial?

There are wide-ranging probiotic choices in Australasia. We reviewed the efficacy of probiotics for the management of gastrointestinal (GI) conditions in adults and assessed relevance to clinical practice. The benefits of probiotics were inconsistent, with a strong consensus reached for only a few of the indications. As different species/strains and combinations differ in efficacy, results cannot be extrapolated from one to another. This review endorses specific probiotics for limited indications. Efficacy of most marketed probiotic formulations remains unstudied and unproven, warranting further research.

Unmet needs in treatment of symptomatic uncomplicated diverticular disease and prevention of recurrent acute diverticulitis: a scoping review

Background

Diverticular disease (DD) represents a common gastrointestinal condition that poses a heavy burden on healthcare systems worldwide. A high degree of uncertainty surrounds the therapeutic approaches for the control of symptoms in patients with symptomatic uncomplicated diverticular disease (SUDD) and primary and secondary prevention of diverticulitis and its consequences.

Objectives

To review the current knowledge and discuss the unmet needs regarding the management of SUDD and the prevention of acute diverticulitis.

Eligibility criteria

Randomized trials, observational studies, and systematic reviews on lifestyle/dietary interventions and medical treatment (rifaximin, mesalazine, and probiotics) of SUDD or prevention of acute diverticulitis.

Sources of evidence

The literature search was performed from inception to April 2023, without language restriction, following the modified Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) reporting guidelines. References of the papers selected were checked to identify additional papers of potential interest. The final list of references was evaluated by a panel of experts, who were asked to check for any lack of relevant studies.

Charting methods

Information on patient population, study design, intervention, control group, duration of the observation, and outcomes assessed was collected by two authors independently.

Results

The review shows a high degree of uncertainty about therapeutic interventions, both dietary/lifestyle and pharmacological, in patients with SUDD, because of the scarcity and weakness of existing evidence. Available studies are generally of low quality, heterogeneous, and outdated, precluding the possibility to draw robust conclusions. Similarly, acute diverticulitis prevention has been seldom investigated, and there is a substantial lack of evidence supporting the role of dietary/lifestyle or pharmacological approaches to reduce the risk of diverticulitis.

Conclusion

The lack of robust evidence regarding therapeutic options for gastrointestinal symptoms in SUDD patients and for primary and secondary prevention of acute diverticulitis remains an important unmet need in the management of DD.

Fragility of Statistically Significant Outcomes in Colonic Diverticular Disease Randomized Trials: A Systematic Review

BACKGROUND

The p value has been criticized as an oversimplified determination of whether a treatment effect exists. One alternative is the fragility index. It is a representation of the minimum number of nonevents that would need to be converted to events to increase the p value above 0.05.

OBJECTIVE

To determine the fragility index of randomized controlled trials assessing the efficacy of interventions for patients with diverticular disease since 2010 to assess the robustness of current evidence.

DESIGN

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to August 2022.

SETTINGS

Articles were eligible for inclusion if they were randomized trials conducted between 2010 and 2022 with parallel, superiority designs evaluating interventions in patients with diverticular disease. Only randomized trials with dichotomous primary outcomes with an associated p value of <0.05 were considered for inclusion.

PARTICIPANTS

Any surgical or medical intervention for patients with diverticular disease.

MAIN OUTCOME MEASURES

The fragility index was determined by adding events and subtracting nonevents from the groups with the smaller number of events. Events were added until the p value exceeded 0.05. The smallest number of events required was considered the fragility index.

RESULTS

After screening 1271 citations, 15 randomized trials met the inclusion criteria. Nine of the studies evaluated surgical interventions and 6 evaluated medical interventions. The mean number of patients randomly assigned and lost to follow-up per randomized controlled trial was 92 (SD 35.3) and 9 (SD 11.4), respectively. The median fragility index was 1 (range, 0-5). The fragility indices for the included studies did not correlate significantly with any study characteristics.

LIMITATIONS

Small sample, heterogeneity, and lack of inclusion of studies with continuous outcomes.

CONCLUSIONS

The randomized trials evaluating surgical and medical interventions for diverticular disease are not robust. Changing a single-outcome event in most studies was sufficient to make a statistically significant study finding not significant. See Video Abstract .

FRAGILIDAD DE LOS RESULTADOS ESTADSTICAMENTE SIGNIFICATIVOS EN ENSAYOS ALEATORIOS DE ENFERMEDAD DIVERTICULAR DEL COLON UNA REVISIN SISTEMTICA

ANTECEDENTES:El valor p ha sido criticado por una determinación demasiado simplificada de si existe un efecto del tratamiento. Una alternativa es el Índice de Fragilidad. Es una representación del número mínimo de no eventos que deberían convertirse en eventos para aumentar el valor p por encima de 0,05.OBJETIVO:Determinar el IF de ensayos controlados aleatorios que evalúan la eficacia de las intervenciones para pacientes con enfermedad diverticular desde 2010 para evaluar la solidez de la evidencia actual.FUENTES DE DATOS:Se realizaron búsquedas en MEDLINE, Embase y CENTRAL desde el inicio hasta agosto de 2022.SELECCIÓN DE ESTUDIOS:Los artículos eran elegibles para su inclusión si eran ensayos aleatorizados realizados entre 2010 y 2022 con diseños paralelos de superioridad que evaluaran intervenciones en pacientes con enfermedad diverticular. Sólo se consideraron para su inclusión los ensayos aleatorizados con resultados primarios dicotómicos con un valor de p asociado menor que 0,05.INTERVENCIÓNES:Cualquier intervención quirúrgica o médica para pacientes con enfermedad diverticular.PRINCIPALES MEDIDAS DE VALORACIÓN:El índice de fragilidad se determinó sumando eventos y restando no eventos de los grupos con el menor número de eventos. Se agregaron eventos hasta que el valor p superó 0,05. El menor número de eventos requeridos se consideró índice de fragilidad.RESULTADOS:Después de examinar 1271 citas, 15 ensayos aleatorios cumplieron los criterios de inclusión. Nueve de los estudios evaluaron intervenciones quirúrgicas y seis evaluaron intervenciones médicas. El número medio de pacientes aleatorizados y perdidos durante el seguimiento por ECA fue 92 (DE 35,3) y 9 (DE 11,4), respectivamente. La mediana del índice de fragilidad fue 1 (rango: 0-5). Los índices de fragilidad de los estudios incluidos no se correlacionaron significativamente con ninguna característica del estudio.LIMITACIONES:Muestra pequeña, heterogeneidad y falta de inclusión de estudios con resultados continuos.CONCLUSIONES:Los ensayos aleatorios que evalúan las intervenciones quirúrgicas y médicas para la enfermedad diverticular no son sólidos. Cambiar un solo evento de resultado en la mayoría de los estudios fue suficiente para que un hallazgo estadísticamente significativo del estudio no fuera significativo. (Traducción- Dr. Ingrid Melo ).

Diagnostic delay in symptomatic uncomplicated diverticular disease: an Italian tertiary referral centre study

The magnitude of the diagnostic delay of symptomatic uncomplicated diverticular disease (SUDD) is unknown; we aimed to evaluate SUDD diagnostic delay and its risk factors. SUDD patients diagnosed at a tertiary referral centre were retrospectively enrolled (2010-2022). Demographic and clinical data were retrieved. Overall, patient-, and physician-dependant diagnostic delays were assessed. Univariate and multivariate analyses were fitted to identify risk factors for diagnostic delay. Overall, 70 SUDD patients (median age 65 years, IQR 52-74; F:M ratio = 1.6:1) were assessed. The median overall diagnostic delay was 7 months (IQR 2-24), patient-dependant delay was 3 months (IQR 0-15), and physician-dependant delay was 1 month (IQR 0-6). Further, 25% of patients were misdiagnosed with irritable bowel syndrome (IBS). At multivariate analysis, previous misdiagnosis was a significant risk factor for overall and physician-dependant diagnostic delay (OR 9.99, p = 0.01, and OR 6.46, p = 0.02, respectively). Also, a high educational level (> 13 years) was associated with a greater overall diagnostic delay (OR 8.74 p = 0.02), while previous abdominal surgery was significantly associated to reduced physician-dependant diagnostic delay (OR 0.19 p = 0.04). To conclude, SUDD may be diagnosed late, IBS being the most frequent misdiagnosis. Timely diagnosis is crucial to tackle the burden of SUDD on patients and healthcare.

Diverticular disease: update on pathophysiology, classification and management

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.

The role of microbiota and its modulation in colonic diverticular disease

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.

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

   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.

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

   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.

Future Modulation of Gut Microbiota: From Eubiotics to FMT, Engineered Bacteria, and Phage Therapy

The human gut is inhabited by a multitude of bacteria, yeasts, and viruses. A dynamic balance among these microorganisms is associated with the well-being of the human being, and a large body of evidence supports a role of dysbiosis in the pathogenesis of several diseases. Given the importance of the gut microbiota in the preservation of human health, probiotics, prebiotics, synbiotics, and postbiotics have been classically used as strategies to modulate the gut microbiota and achieve beneficial effects for the host. Nonetheless, several molecules not typically included in these categories have demonstrated a role in restoring the equilibrium among the components of the gut microbiota. Among these, rifaximin, as well as other antimicrobial drugs, such as triclosan, or natural compounds (including evodiamine and polyphenols) have common pleiotropic characteristics. On one hand, they suppress the growth of dangerous bacteria while promoting beneficial bacteria in the gut microbiota. On the other hand, they contribute to the regulation of the immune response in the case of dysbiosis by directly influencing the immune system and epithelial cells or by inducing the gut bacteria to produce immune-modulatory compounds, such as short-chain fatty acids. Fecal microbiota transplantation (FMT) has also been investigated as a procedure to restore the equilibrium of the gut microbiota and has shown benefits in many diseases, including inflammatory bowel disease, chronic liver disorders, and extraintestinal autoimmune conditions. One of the most significant limits of the current techniques used to modulate the gut microbiota is the lack of tools that can precisely modulate specific members of complex microbial communities. Novel approaches, including the use of engineered probiotic bacteria or bacteriophage-based therapy, have recently appeared as promising strategies to provide targeted and tailored therapeutic modulation of the gut microbiota, but their role in clinical practice has yet to be clarified. The aim of this review is to discuss the most recently introduced innovations in the field of therapeutic microbiome modulation.

Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

Insights into Mesalazine Use in Clinical Practice of Young Gastroenterologists

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.

Diverticular Disease and Rifaximin: An Evidence-Based Review

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.

German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management

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.

[Diverticular disease: treatment and management by general practitioners in Germany - high importance of probiotics in primary care]

INTRODUCTION

The symptomatic uncomplicated diverticular disease (SUDD) is often difficult to treat and guidelines only provide few evidence-based treatment options.

METHOD

For the German-wide survey, a questionnaire was sent to 13790 physicians. It contained questions concerning the status of medical care for patients with diverticula and queried their individual option in regards to current treatment options and challenges for the daily medical routine.

RESULTS

In total, 526 questionnaires were sent back for analysis. The biggest challenge for doctors handling patients with chronic diverticular disease (SUDD) is to make the correct diagnosis (17%) and the distinction to the irritable bowel syndrome (22%). Despite the high abundance of SUDD pathology, only 6% of the medical practitioners feel themselves sufficiently informed about it. The support for general practitioners by medical specialists (gastroenterologists) is limited: In the case of a SUDD or a diverticulitis diagnosis, the physicians sometimes receive an acute therapy plan (27%), but rarely get recommendations for diverticulitis pre- and post-care (11% and 18%), or assisting information for patient education (4%). For primary prophylaxis for persons with asymptomatic diverticula, practitioners give nutrition (41%) and life style (37%) recommendations, as well as probiotics (18%). After an acute diverticulitis, 42% recommend life style and nutrition modifications and 26% the intake of probiotics. For the treatment of SUDD symptoms, they advise mostly life style and nutrition modifications (45%) and probiotics (30%). About 60% of the doctors are satisfied with the efficacy of probiotics. Another 15% stated that they have not yet used them to treat SUDD. The main reasons for it seem to be the lack of reimbursability for probiotics (31%), the poor adherence of patients to therapy (20%) due to the slow onset of positive effects, and the difficulty of finding an evidence-based probiotic (16%).

CONCLUSION

In the daily medical routine the correct diagnosing of SUDD is a major challenge and supporting information by medical specialist is scarce. Physicians frequently choose life style and nutrition recommendations and the use of probiotics as treatment options. The majority of the general practitioners is thereby satisfied with the efficacy of probiotics for patients with chronic diverticular disease, even though the choice of an evidence-based probiotic is an obstacle.

Microbiota Composition in Diverticular Disease: Implications for Therapy

Gut microbiota (GM) composition and its imbalance are crucial in the pathogenesis of several diseases, mainly those affecting the gastrointestinal tract. Colon diverticulosis and its clinical manifestations (diverticular disease, DD) are among the most common digestive disorders in developed countries. In recent literature, the role of GM imbalance in the onset of the different manifestations within the clinical spectrum of DD has been highlighted. This narrative review aims to summarize and critically analyze the current knowledge on GM dysbiosis in diverticulosis and DD by comparing the available data with those found in inflammatory bowel disease (IBD). The rationale for using probiotics to rebalance dysbiosis in DD is also discussed.

Lactobacillus paracasei CNCM I 1572: A Promising Candidate for Management of Colonic Diverticular Disease

Diverticular disease (DD) is a common gastrointestinal condition. Patients with DD experience a huge variety of chronic nonspecific symptoms, including abdominal pain, bloating, and altered bowel habits. They are also at risk of complications such as acute diverticulitis, abscess formation, hemorrhage, and perforation. Intestinal dysbiosis and chronic inflammation have recently been recognized as potential key factors contributing to disease progression. Probiotics, due to their ability to modify colonic microbiota balance and to their immunomodulatory effects, could present a promising treatment option for patients with DD. Lactobacillus paracasei CNCM I 1572 (LCDG) is a probiotic strain with the capacity to rebalance gut microbiota and to decrease intestinal inflammation. This review summarizes the available clinical data on the use of LCDG in subjects with colonic DD.

Summary of Probiotic Potential of the Kefir for the Prevention and Alleviation of Functional GI Diseases

Background:

Functional Gastrointestinal (GI) disease is a term that refers to a range of disease conditions involving chronic diarrhea, irritable bowel syndrome, constipation, inflammatory bowel disease (IBD), and lactose intolerance. Statistical reports have documented >40% of the world's population is being afflicted by functional GI disorders. Consequences of frequent intake of antibiotics include mortality of gut microflora, antibiotic-associated diarrhea, the establishment of antibiotic resistance, and inference with healthy bodily functions. To overcome the harms of antibiotics, studies are being conducted to determine the potential of probiotics as alternatives to antibiotics.

Aim of Study:

The purpose of constructing this literature review is to outline the potential attributes of Kefir and to assess the solitary efficiency of this beverage in the amelioration of GI disease conditions.

Methodology:

Extraction of data entailed digging of literature hubs including PubMed, PubMed Central, Research Gate, Science Direct, and Google Scholar, employing a different combination of keywords to retrieve substantial details. Selection criteria of the articles involved the published reports of preceding 10 years (2012-2021) that exhibited relevancy with the topic

Conclusion:

Kefir grains having different origins provide a distinct array of antimicrobial spectrums and are found to be effective against different pathogens. IBDs, diarrheal sicknesses, and constipation can be alleviated by the consumption of this beverage. Moreover, the probioticantibiotic combination is also essential for the mitigation of several diseases. The synergistic impact of several microbial strains is vital for the treatment of celiac disease. Lactose maldigestion can be relieved by the consumption of kefir having β-galactosidase enzyme activity.

Updates in the understanding and management of diverticular disease

PURPOSE OF REVIEW

Diverticulosis leads to significant morbidity and mortality and is increasing in prevalence worldwide. In this paper, we review the clinical features, diagnosis, and management of diverticular disorders, followed by a discussion of recent updates and changes in the clinical approach to diverticular disease.

RECENT FINDINGS

Recent literature suggests that antibiotics are likely not necessary for low-risk patients with acute uncomplicated diverticulitis, and not all patients with recurrent diverticulitis require colectomy. Dietary restrictions do not prevent recurrent diverticulitis. Visceral hypersensitivity is increasingly being recognized as a cause of persistent abdominal pain after acute diverticulitis and should be considered along with chronic smoldering diverticulitis, segmental colitis associated with diverticula, and symptomatic uncomplicated diverticular disease.

SUMMARY

Clinicians should be aware that traditionally held assumptions regarding the prevention and management of diverticular disorders have recently been called into question and should adjust their clinical practice accordingly.

Probiotics Modulate Mouse Gut Microbiota and Influence Intestinal Immune and Serotonergic Gene Expression in a Site-Specific Fashion

Probiotic microorganisms may benefit the host by influencing diverse physiological processes, whose nature and underlying mechanisms are still largely unexplored. Animal models are a unique tool to understand the complexity of the interactions between probiotic microorganisms, the intestinal microbiota, and the host. In this regard, in this pilot study, we compared the effects of 5-day administration of three different probiotic bacterial strains (Bifidobacterium bifidum MIMBb23sg, Lactobacillus helveticus MIMLh5, and Lacticaseibacillus paracasei DG) on three distinct murine intestinal sites (ileum, cecum, and colon). All probiotics preferentially colonized the cecum and colon. In addition, probiotics reduced in the ileum and increased in the cecum and colon the relative abundance of numerous bacterial taxonomic units. MIMBb23sg and DG increased the inducible nitric oxide synthase (iNOS) in the ileum, which is involved in epithelial homeostasis. In addition, MIMBb23sg upregulated cytokine IL-10 in the ileum and downregulated the cyclooxygenase COX-2 in the colon, suggesting an anti-inflammatory/regulatory activity. MIMBb23sg significantly affected the expression of the main gene involved in serotonin synthesis (TPH1) and the gene coding for the serotonin reuptake protein (SERT) in the ileum and colon, suggesting a potential propulsive effect toward the distal part of the gut, whereas the impact of MIMLh5 and DG on serotonergic genes suggested an effect toward motility control. The three probiotics decreased the expression of the permeability marker zonulin in gut distal sites. This preliminary in vivo study demonstrated the safety of the tested probiotic strains and their common ability to modulate the intestinal microbiota. The probiotics affected host gene expression in a strain-specific manner. Notably, the observed effects in the gut were site dependent. This study provides a rationale for investigating the effects of probiotics on the serotonergic system, which is a topic still widely unexplored.

Probiotic Administration Increases Amino Acid Absorption from Plant Protein: a Placebo-Controlled, Randomized, Double-Blind, Multicenter, Crossover Study

The fate of dietary protein in the gut is determined by microbial and host digestion and utilization. Fermentation of proteins generates bioactive molecules that have wide-ranging health effects on the host. The type of protein can affect amino acid absorption, with animal proteins generally being more efficiently absorbed compared with plant proteins. In contrast to animal proteins, most plant proteins, such as pea protein, are incomplete proteins. Pea protein is low in methionine and contains lower amounts of branched-chain amino acids (BCAAs), which play a crucial role in muscle health. We hypothesized that probiotic supplementation results in favorable changes in the gut microbiota, aiding the absorption of amino acids from plant proteins by the host. Fifteen physically active men (24.2 ± 5.0 years; 85.3 ± 12.9 kg; 178.0 ± 7.6 cm; 16.7 ± 5.8% body fat) co-ingested 20 g of pea protein with either AminoAlta™, a multi-strain probiotic (5 billion CFU L. paracasei LP-DG® (CNCM I-1572) plus 5 billion CFU L. paracasei LPC-S01 (DSM 26760), SOFAR S.p.A., Italy) or a placebo for 2 weeks in a randomized, double-blind, crossover design, separated by a 4-week washout period. Blood samples were taken at baseline and at 30-, 60-, 120-, and 180-min post-ingestion and analyzed for amino acid content. Probiotic administration significantly increased methionine, histidine, valine, leucine, isoleucine, tyrosine, total BCAA, and total EAA maximum concentrations (Cmax) and AUC without significantly changing the time to reach maximum concentrations. Probiotic supplementation can be an important nutritional strategy to improve post-prandial changes in blood amino acids and to overcome compositional shortcomings of plant proteins. ClinicalTrials.gov Identifier: ISRCTN38903788.

The natural history of symptomatic uncomplicated diverticular disease: a long-term follow-up study

Background

Symptomatic uncomplicated diverticular disease (SUDD) affects about 20% of patients who have diverticulosis. However, the natural history of SUDD is not yet completely understood. Our aim was to assess the outcomes of a cohort of SUDD patients during a long-term follow up.

Methods

One hundred eighty-five patients suffering from SUDD were identified from a large electronic database. Symptoms assessed were abdominal pain, bloating, bowel movement/day, each of which was scored using a visual analogic scale (VAS); the symptom score was calculated by considering the value of the worst symptom present during assessment. Another VAS was used to assess patients' quality of life (QoL). Patients were treated at the physician's discretion (with rifaximin, mesalazine, probiotics, spasmolytics) only when symptoms occurred during the follow up. Follow-up visit was performed every year or whenever patients consider it necessary.

Results

During the follow up (156 months, interquartile range 9-171), 47 patients were lost to follow up. Among these, 9 died from causes not related to SUDD. Acute diverticulitis occurred in 14 patients (7.6% of the overall population): 6 patients (3.2% of the overall population) underwent surgery, and 2 patients (1.1% of the overall population) died because of peritonitis. Both the symptom score and the QoL score were substantially unmodified during the study period.

Conclusions

SUDD is an important disease able to affect patients significantly in the long term. Acute diverticulitis may sometimes occur in these patients, often leading to surgery with possible severe complications.

Development and validation of a diverticular clinical score for symptomatic uncomplicated diverticular disease after acute diverticulitis in a prospective patient cohort

BACKGROUND

Following an attack of acute diverticulitis (AD), many patients continue to suffer from a complex of symptoms, titled 'symptomatic uncomplicated diverticular disease (SUDD)'. To date, there is no validated clinical score for standardized assessment of patients with SUDD, thereby hampering the interpretation of observational studies and the conductance of clinical trials.We aimed to develop a validated SUDD clinical score.

METHODS

Data from previous prospective study of patients after AD was used to devise the score's first version. Validation was first performed using a focus group of patients after AD SUDD who underwent a structured cognitive personal interview. Thereafter, the diverticular clinical score (DICS) was applied for a second validation cohort. DICS scores of validation cohort were compared with physicians' global assessment for disease severity and inflammatory markers.

RESULTS

In DICS second validation using 48 patients prospectively recruited after AD SUDD, a correlation matrix demonstrated strong correlation between total questionnaire's score and the presence of elevated inflammatory markers (ρ = 0.84). Mean score in patients with elevated inflammatory markers compared with those without inflammation was 17.8 versus 6.2, respectively, p < 0.001. Cronbach's α for measuring internal consistency was 0.91. DICS discriminated accurately between patients with/without active disease, as gauged by the physicians global assessment (area under the curve receiver operating characteristic = 0.989).

CONCLUSIONS

Patients suffering from post-AD SUDD exhibit a wide range of symptoms. The newly developed DICS accurately and reproducibly quantitates SUDD-related symptom severity. The DICS may prove useful for monitoring SUDD in clinical practice and in research settings, as well as facilitating patient stratification and therapeutic decisions.

Colonic diverticular disease

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.

Microbiota modulation-based therapy for luminal GI disorders: current applications of probiotics and fecal microbiota transplantation

Introduction: Alteration in the intestinal microbiota also termed as intestinal dysbiosis has been demonstrated in numerous gastrointestinal disorders linked to aberrant immune processes, acquisition of pathogenic organisms and often administration of antibiotics. Restoration of microbiota through probiotics and fecal microbiota transplantation (FMT) has gained tremendous popularity among researchers in the prevention and treatment of gastrointestinal diseases.Areas covered: In this review, studies testing the safety and efficacy of probiotics and FMT for the treatment of various infectious and inflammatory luminal gastrointestinal diseases are reviewed. Randomized control studies are given priority while important uncontrolled studies are also highlighted.Expert opinion: Probiotics have demonstrated efficacy in the prevention of antibiotic-associated diarrhea and in the eradication of Helicobacter pylori infection. Their utility in the primary and secondary prevention of Clostridioides difficile infection is debatable. The future of medicine should bring forth a personalized approach to probiotic use. FMT has revolutionized the treatment of recurrent CDI as well as severe and fulminant CDI. At the same time, it has galvanized gut microbiota research in the last decade. While FMT in ulcerative colitis appears promising, further studies on the durability and long-term safety are needed before it can be recommended in clinical practice.

Diverticular Disease in the Elderly

PURPOSE OF REVIEW

While few diseases are limited solely to the elderly, diverticular disease is clearly more prevalent with increasing age and therefore the aim of this review is to focus on the clinical implications of diverticular disease in the elderly.

RECENT FINDINGS

Diverticulitis in the elderly is best managed with an individualized treatment approach including considerations for selective antibiotic usage even in uncomplicated disease. Furthermore, due to the increased prevalence of ischemic colitis in the elderly and the similarities in presentation with diverticular hemorrhage, there needs to be a high index of suspicion and appropriate evaluation for ischemic colitis in patients with hematochezia, particularly if they have abdominal pain. The elderly are a vulnerable population where the index of suspicion for complications of diverticular disease should be high.

Italian nationwide survey of pharmacologic treatments in diverticular disease: Results from the REMAD registry

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.

Prospecting prebiotics, innovative evaluation methods, and their health applications: a review

Prebiotics are necessary natural and synthetic food ingredients that help in the growth and development of gut microflora. There is a complex relationship between gut dysbiosis and microbes, so alteration in both probiotics and prebiotics can reduce illness of gut, which further plays a decisive role in human health. The prebiotic efficiency can be validated using various in vitro and in vivo experiments, and this gives an important insight to this field. This review focuses on these aspects including the standardized assessment of prebiotics and its metabolic products for customary applications. This review has also summarized the mechanism of their beneficial actions such as immunomodulation, nutrient absorption, pathogen inhibition, etc., and its significance in human nutrition. In addition to this, some fascinating applications of prebiotics in health-related disorders have also discussed, with current challenges in this facet.

Prolonged Recurrent Abdominal Pain is Associated With Ongoing Underlying Mucosal Inflammation in Patients who had an Episode of Acute Complicated Diverticulitis

BACKGROUND

Recent data suggest continuous chronic inflammation in patients after an acute diverticulitis (AD) episode.

GOALS

The aim of this article was to compare clinical parameters, inflammatory cytokine expression, and immune-cell infiltrates between patients after severe versus nonsevere AD, as defined by radiology examination during the acute episode.

STUDY

Sixteen patients, after suffering an episode of AD, were included, and, of them, 8 had severe disease. Demographic data, disease characteristics, and inflammatory markers were collected. Tissue samples from diverticular and unaffected tissue were obtained during colonoscopy. Mucosal inflammation was assessed histologically and by measuring inflammatory cytokine mRNA expression.

RESULTS

Clinically, continued nonspecific abdominal symptoms were significantly more prevalent among patients after severe AD compared with patients after nonsevere AD (P=0.0002). Patients after severe AD also had significantly higher C reactive protein levels (9.85±7.5 vs. 3±2.1 mg/dL; P=0.027) and tendency for higher calprotectin levels (115.7±85 vs. 35±8.7 mg/g; P=0.08). Reverse transcription polymerase chain reaction-determined cytokines levels were 5.4±4.4, 5.14±10, and 0.8±0.82 for tumor necrosis factor alpha, interleukin-6, and interleukin-1β, respectively, in affected mucosa compared with 1.06±1.57, 1.56±2.1, and 0.35±0.5, respectively, in nonaffected mucosa (P=0.01, 0.05, 0.14, respectively). Cytokine expression in patients after nonsevere AD did not differ significantly between affected and nonaffected mucosa. Histologic scores for crypt distortion, lymphoid aggregates, and lymphocyte infiltration were all significantly higher in patients after severe AD compared with patients after nonsevere AD (P<0.05 for all comparisons).

CONCLUSIONS

Patients after severe AD have more prolonged chronic symptoms, higher inflammatory markers, higher tissue inflammatory cytokine levels, and more inflammatory infiltrates in diverticular colonic tissue than patients after nonsevere AD. These results may contribute to patients' risk stratification and guide therapeutic decisions.

Meta-analyses of Current Strategies to Treat Uncomplicated Diverticulitis

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.

Irritable bowel syndrome and colonic diverticular disease: overlapping symptoms and overlapping therapeutic approaches

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.

Overview on the management of diverticular disease by Italian General Practitioners

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.

Long-term efficacy of rifaximin to manage the symptomatic uncomplicated diverticular disease of the colon

Although rifaximin is currently advised in managing symptomatic uncomplicated diverticular disease (SUDD) of the colon, no long-term data are available. This retrospective study assessed the outcome of a large cohort of patients with SUDD, treated with rifaximin, during an 8-year follow-up. The study group (group A) included 346 patients with SUDD (median age 64 years, IQR 58-69, 62.4% females), treated with rifaximin 800 mg/d for 7 days every month. The control group (group B) included 470 patients with SUDD (median age 65 years, IQR 59-74 years, 60.8% females), taking any other treatment on demand. Two symptoms (left lower abdominal pain and bloating) were assessed by a visual analog scale (VAS), graded from 0=no symptom to 10=the most severe symptom. Daily bowel movements were also reported. Median (IQR) VAS score for pain was 6 (5-7) in group A and 6 (6-7) in group B at baseline (p=0.109); at 8-year follow-up it was 3 (3-4) and 6 (5-7), respectively (p<0.000). Both bloating and daily bowel movements were significantly reduced in group A. Acute diverticulitis occurred in 9 (2.6%) patients in group A and in 21 (4.5%) patients in group B (p=0.155). Surgery occurred in 4 (1.2%) patients in group A and 9 (1.9%) in group B (p=0.432). Disease-related mortality occurred in no patient in group A and 2 (0.4%) patients in group B (p=0.239). No side effects were recorded during the entire study period. Rifaximin is effective to relieve symptoms and reduce the risk of disease-related complications in patients with SUDD.

Treatment of diverticular disease, targeting symptoms or underlying mechanisms

Diverticular disease (DD) is a highly prevalent disease in western industrialized countries that encompasses a complex set of disorders. Because of its complexity and heterogeneity, both from a pathogenic and a clinical point of view, the management of this disease represent a challenge in clinical practice. This review aims to analyze and summarize the most recent evidence on the medical strategies for DD, considering separately the different stages of the disease, from prevention of diverticula formation to treatment of acute diverticulitis and prevention of recurrences. Based on some evidence, dietary fiber is useful to prevent diverticula formation and in diverticulosis, with no pharmacological treatment in these settings. Treatment of symptomatic uncomplicated diverticular disease as well as primary prevention of acute diverticulitis is based on probiotics, fibres, mesalazine and rifaximin, individually or as combination therapy, although a standard approach has not yet been defined. On the contrary, in acute diverticulitis (AD) recent acquisitions have clarified and standardized the role of systemic antibiotics, reserving its use only to complicated forms and in selected cases of uncomplicated disease. Secondary prevention of AD is essentially based on mesalazine and rifaximin but, despite promising results, no strong evidence have been produced. To date, grey areas remain in the medical management of DD.

Survival of L. casei DG® (Lactobacillus paracasei CNCMI1572) in the gastrointestinal tract of a healthy paediatric population

Purpose

Ability to survive the digestive process is a major factor in determining the effectiveness of a probiotic. In this study, the ability of the probiotic L. casei DG^® (Lactobacillus paracasei CNCMI1572) to survive gastrointestinal transit in healthy children was investigated for the first time.

Methods

Twenty children aged 3–12 years received L. casei DG^® as drinkable solution of 1 × 10⁹ colony forming units (CFU), once daily for 7 consecutive days. Recovery in faecal samples was evaluated at baseline and at different time-points during and after administration. Defecation frequency, faeces consistency, digestive function and product safety were also assessed.

Results

Nineteen (95%) of the 20 enrolled children presented viable L. casei DG^® cells in their faeces at least once during the study, with a maximum count (mean 4.3 log₁₀ CFU/g ± 2.3) reached between day 4 and 6 from the beginning of consumption. Notably, for 11 (57.9%) of the 19 children with viable cells, L. casei DG^® survived in faecal samples up to 3 days after treatment end. Defecation frequency, faeces consistency and digestive function did not change considerably during or after study treatment. Safety of the study product was very good.

Conclusions

This study showed for the first time that L. casei DG^® survives the gastrointestinal transit when ingested by children with a paediatric probiotic drinkable solution containing 1 × 10⁹ CFU, and persists in the gut up to 3 days after the end of product intake, demonstrating resistance to gastric juices, hydrolytic enzymes and bile acids.

Electronic supplementary material

The online version of this article (10.1007/s00394-018-1860-5) contains supplementary material, which is available to authorized users.

Diverticular Disease: An Update on Pathogenesis and Management

Diverticular disease is one of the most common conditions in the Western world and one of the most common findings identified at colonoscopy. Recently, there has been a significant paradigm shift in our understanding of diverticular disease and its management. The pathogenesis of diverticular disease is thought to be multifactorial and include both environmental and genetic factors in addition to the historically accepted etiology of dietary fiber deficiency. Symptomatic uncomplicated diverticular disease (SUDD) is currently considered a type of chronic diverticulosis that is perhaps akin to irritable bowel syndrome. Mesalamine, rifaximin and probiotics may achieve symptomatic relief in some patients with SUDD, although their role(s) in preventing complications remain unclear. Antibiotic use for acute diverticulitis and elective prophylactic resection surgery are considered more individualized treatment modalities that take into account the clinical status, comorbidities and lifestyle of the patient. Our understanding of the pathogenesis of diverticular disease continues to evolve and is likely to be diverse and multifactorial. Paradigm shifts in several areas of the pathogenesis and management of diverticular disease are explored in this review.

Pre- and probiotic overview

The dynamic relationship between gut microbiota and its human host is also known as a trophic association that might range from commensalism, where only the microbe enjoys a positive effect from the relationship, to intestinal symbiosis where both host and microbe benefit from their interaction. In the last years, we have started to understand how alterations of the gut microbiota composition leading to the disruption of host-microbial interactions are associated and/or predispose individuals to disease conditions ranging from inflammatory bowel diseases to allergy and functional gastrointestinal disorders, such as irritable bowel syndrome. While we await important insights in this field, the microbiota is already a therapeutic target. Based on the actual definitions, prebiotics are defined as substrates that are selectively utilized by host microorganisms conferring a health benefit, while probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. Although their health promoting activities encompasses numerous effects, including immunostimulation, competitive exclusion of pathogens, and gut barrier enhancement, the exact mechanism of action by which these compounds exert their beneficial actions in humans is only partially known. In this review, we highlight the current insights into the clinical applications of prebiotics and probiotics in gastroenterology.

Quantitative Recovery of Viable Lactobacillus paracasei CNCM I-1572 (L. casei DG®) After Gastrointestinal Passage in Healthy Adults

Probiotics are live microorganisms, and viability after transit through the gastrointestinal tract (GIT) is considered an inherent property of the health benefits of probiotics. The aim of the present study was to quantify the viable and total loads of Lactobacillus paracasei DG cells after passage through the GIT following the consumption of the probiotic product Enterolactis (L. casei DG®; L. paracasei CNCM I-1572; L. paracasei DG) from drinkable vials by healthy adults. We developed a novel method for discriminating and enumerating culturable L. paracasei DG cells based on the unique sticky, filamentous phenotype of this strain on MRS agar containing vancomycin and kanamycin. The identity of DG was also confirmed with strain-specific primers by colony PCR. This method was used for a recovery study of the DG strain to quantify viable cells in the fecal samples of 20 volunteers during a 1-week probiotic consumption period and a 1-week follow-up. We isolated L. paracasei DG from at least one fecal sample from all the volunteers. The highest concentration of viable DG cells [ranging from 3.6 to 6.7 log₁₀ colony-forming unit (CFU) per gram of feces] in the feces was observed between 4 and 8 days from the beginning of Enterolactis intake and for up to 5 days after cessation of intake. As expected, the total DG count determined by real-time quantitative PCR (qPCR) was mostly higher than the viable DG cells recovered. Viable count experiments, carried out by combining ad hoc culture-based discriminative conditions and strain-specific molecular biological protocols, unambiguously demonstrated that L. paracasei DG can survive gastrointestinal transit in healthy adults when ingested as Enterolactis in drinkable vials containing no less than one billion CFU at the end of shelf life.

Probiotics in Gastroenterology: How Pro Is the Evidence in Adults?

Probiotic usage has become popular with both medical practitioners and the community in general; patients commonly seek advice regarding what, if any, such preparation would be useful for their own diseases. Since such advice should be evidence-based, identified randomized clinical trials (RCTs) for a number of gastrointestinal conditions were reviewed; the data were organized by individual probiotic genera/species. Only trials in adults were considered. Most of the identified RCTs were small and low-quality, so any conclusions to be drawn will be limited at least by methodologic problems. Using the GRADE system to consider the reliability of the evidence generated from these RCTs, it did appear that the use of fecal microbial transplantation to treat recurrent Clostridium difficile infection is well justified. Given the methodologic issues, there was moderately good evidence for preventing antibiotic-associated diarrhea with Lactobacillus, Bifidobacterium, Streptococcus, or Saccharomyces boulardii and for using Lactobacillus, Bifidobacterium, or Saccharomyces as adjunct therapy in the treatment of Helicobacter pylori. There were other conditions for which some supportive evidence was available. These conditions include VSL#3 for maintaining remissions in patients with pouchitis or treating active ulcerative colitis (UC), fecal microbial transplantation for treating active UC, Bifidobacterium for treating patients with UC in remission, Lactobacillus in patients with painful diverticulosis, a variety of probiotics (Lactobacillus, Bifidobacterium, Streptococcus, or VSL#3) in patients with minimal hepatic encephalopathy, and providing synbiotics to patients postoperatively after liver transplantation. Unfortunately, other limitations in the evidence made it very likely that future research will have an effect on the estimated benefit; these interventions cannot yet be recommended for routine use.

Emergency Presentations of Diverticulitis

Acute diverticulitis is a common condition that has been increasing in incidence in the United States. It is associated with increasing age, but the pathophysiology of acute diverticulitis is still being elucidated. It is now believed to have a significant contribution from inflammatory processes rather than being a strictly infectious process. There are still many questions to be answered regarding the optimal management of acute diverticulitis because recent studies have challenged traditional practices, such as the routine use of antibiotics, surgical technique, and dietary restrictions for prevention of recurrence.

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

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.