Colorectal visceral perception in diverticular disease

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.

Genetic, epigenetic and environmental factors in diverticular disease: systematic review

BACKGROUND

Diverticulosis is a normal anatomical variant of the colon present in more than 70% of the westernized population over the age of 80. Approximately 3% will develop diverticulitis in their lifetime. Many patients present emergently, suffer high morbidity rates and require substantial healthcare resources. Diverticulosis is the most common finding at colonoscopy and has the potential for causing a significant morbidity rate and burden on healthcare. There is a need to better understand the aetiology and pathogenesis of diverticular disease. Research suggests a genetic susceptibility of 40-50% in the formation of diverticular disease. The aim of this review is to present the hypothesized functional effects of the identified gene loci and environmental factors.

METHODS

A systematic literature review was performed using PubMed, MEDLINE and Embase. Medical subject headings terms used were: 'diverticular disease, diverticulosis, diverticulitis, genomics, genetics and epigenetics'. A review of grey literature identified environmental factors.

RESULTS

Of 995 articles identified, 59 articles met the inclusion criteria. Age, obesity and smoking are strongly associated environmental risk factors. Intrinsic factors of the colonic wall are associated with the presence of diverticula. Genetic pathways of interest and environmental risk factors were identified. The COLQ, FAM155A, PHGR1, ARHGAP15, S100A10, and TNFSF15 genes are the strongest candidates for further research.

CONCLUSION

There is increasing evidence to support the role of genomics in the spectrum of diverticular disease. Genomic, epigenetic and omic research with demographic context will help improve the understanding and management of this complex disease.

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.

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.

Pathophysiology of Diverticular Disease: From Diverticula Formation to Symptom Generation

Diverticular disease is a common clinical problem, particularly in industrialized countries. In most cases, colonic diverticula remain asymptomatic throughout life and sometimes are found incidentally during colonic imaging in colorectal cancer screening programs in otherwise healthy subjects. Nonetheless, roughly 25% of patients bearing colonic diverticula develop clinical manifestations. Abdominal symptoms associated with diverticula in the absence of inflammation or complications are termed symptomatic uncomplicated diverticular disease (SUDD). The pathophysiology of diverticular disease as well as the mechanisms involved in the shift from an asymptomatic condition to a symptomatic one is still poorly understood. It is accepted that both genetic factors and environment, as well as intestinal microenvironment alterations, have a role in diverticula development and in the different phenotypic expressions of diverticular disease. In the present review, we will summarize the up-to-date knowledge on the pathophysiology of diverticula and their different clinical setting, including diverticulosis and SUDD.

Update on the management of sigmoid diverticulitis

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

Update on the management of sigmoid diverticulitis

Diverticular disease and diverticulitis are the most common non-cancerous pathology of the colon. It has traditionally been considered a disease of the elderly and associated with cultural and dietary habits. There has been a growing evolution in our understanding and the treatment guidelines for this disease. To provide an updated review of the epidemiology, pathogenesis, classification and highlight changes in the medical and surgical management of diverticulitis. Diverticulitis is increasingly being seen in young patients (< 50 years). Genetic contributions to diverticulitis may be larger than previously thought. Potential similarities and overlap with inflammatory bowel disease and irritable bowel syndrome exist. Computed tomography imaging represents the standard to classify the severity of diverticulitis. Modifications to the traditional Hinchey classification might serve to better delineate mild and intermediate forms as well as better classify chronic presentations of diverticulitis. Non-operative management is primarily based on antibiotics and supportive measures, but antibiotics may be omitted in mild cases. Interval colonoscopy remains advisable after an acute attack, particularly after a complicated form. Acute surgery is needed for the most severe as well as refractory cases, whereas elective resections are individualized and should be considered for chronic, smoldering, or recurrent forms and respective complications (stricture, fistula, etc.) and for patients with factors highly predictive of recurrent attacks. Diverticulitis is no longer a disease of the elderly. Our evolving understanding of diverticulitis as a clinical entity has led into a more nuanced approach in both the medical and surgical management of this common disease. Non-surgical management remains the appropriate treatment for greater than 70% of patients. In individuals with non-relenting, persistent, or recurrent symptoms and those with complicated disease and sequelae, a segmental colectomy remains the most effective surgical treatment in the acute, chronic, or elective-prophylactic setting.

Evidence-based treatment strategies for acute diverticulitis

PURPOSE

Diverticular disease is a common acquired condition of the lower gastrointestinal tract that may be associated with significant morbidity. The term encompasses a spectrum of pathological processes with varying clinical manifestations. The purpose of this review was to update the reader on modern evidence-based treatment strategies for acute diverticulitis.

METHODS

A literature search of the PUBMED database was performed using the keywords 'diverticulosis', 'diverticular disease' and 'diverticulitis'. Only articles published in the English language were included.

RESULTS

Evidence-based treatment strategies for acute diverticulitis have evolved over time. Data have questioned the need for antibiotic therapy for Hinchey I disease and the role of percutaneous abscess drainage for Hinchey II. Clinical trials have demonstrated laparoscopic lavage is an appropriate option for select patients with Hinchey III disease and primary resection with anastomosis and defunctioning stoma may be considered in some cases of Hinchey IV disease.

CONCLUSION

Risk-adapted treatment strategies and operative decision-making for acute diverticulitis are increasingly based on a combination of patient and disease factors.

Diverticular Disease: A Review on Pathophysiology and Recent Evidence

Diverticular disease is common condition globally, especially in Western countries. Diverticulitis, Symptomatic uncomplicated Diverticular disease and Segmental Colitis associated with diverticula constitute diverticular disease. Although most patients with diverticula are asymptomatic, around 25% of patients will experience symptoms whilst 5% of patients have an episode of acute diverticulitis. The prevalence increases with age with more than one theory being put forward to explain its pathogenesis. Faecolith entrapment in diverticula results in colonic mucosal damage and oedema, bacterial proliferation and toxin accumulation leading to perforation. This mechanism may explain diverticulitis in elderly patients with multiple, larger diverticula. Ischaemic damage could be the cause of acute diverticulitis in younger patients with sparse diverticula where more frequent and forceful muscular contractions in response to colonic stimuli occlude the vasculature leading to ischaemia and microperforation. Chronic colonic active inflammation in the presence of diverticular disease is termed Segmental colitis associated with diverticulosis. Its pathophysiology is still indeterminate but together with its clinical picture, may mimic Inflammatory Bowel Disease. Treatment includes a high fibre diet together with antibiotics and/or salicylates with surgery in severe cases. Indications for elective surgery in diverticular disease have changed over the past decades as this may not suggest a reduction in morbidity and mortality. Prophylaxis with probiotics, laxatives, anti-spasmotics, anticholinergic drugs and salicylates are at the centre of recent studies. Studies are also challenging previously believed facts regarding dietary fibre, nuts and seeds whilst emphasizing the effect of healthy lifestyle and smoking on the increasing incidence of DD.

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.

Long-term Outcome of Surgery Versus Conservative Management for Recurrent and Ongoing Complaints After an Episode of Diverticulitis: 5-year Follow-up Results of a Multicenter Randomized Controlled Trial (DIRECT-Trial)

OBJECTIVE

The aim of this study was to establish whether surgical or conservative treatment leads to a higher quality of life (QoL) in patients with recurring diverticulitis and/or ongoing complaints.

SUMMARY OF BACKGROUND DATA

The 6 months' results of the DIRECT trial, a randomized trial comparing elective sigmoidectomy with conservative management in patients with recurring diverticulitis (>2 episodes within 2 years) and/or ongoing complaints (>3 months) after an episode of diverticulitis, demonstrated a significantly higher QoL after elective sigmoidectomy. The aim of the present study was to evaluate QoL at 5-year follow-up.

METHODS

From January 2010 to June 2014, 109 patients were randomized to either elective sigmoidectomy (N = 53) or conservative management (N = 56). In the present study, the primary outcome was QoL measured by the Gastrointestinal Quality of Life Index (GIQLI) at 5-year follow-up. Secondary outcome measures were SF-36 score, Visual Analogue Score (VAS) pain score, EuroQol-5D-3L (EQ-5D-3L) score, morbidity, mortality, perioperative complications, and long-term operative outcome.

RESULTS

At 5-year follow-up, mean GIQLI score was significantly higher in the operative group [118.2 (SD 21.0)] than the conservative group [108.5 (SD 20.0)] with a mean difference of 9.7 (95% confidence interval 1.7-17.7). All secondary QoL outcome measures showed significantly better results in the operative group, with a higher SF-36 physical (P = 0.030) and mental score (P = 0.010), higher EQ5D score (P = 0.016), and a lower VAS pain score (P = 0.011). Twenty-six (46%) patients in the conservative group ultimately required surgery due to severe ongoing complaints. Of the operatively treated patients, 8 (11%) patients had anastomotic leakage and reinterventions were required in 11 (15%) patients.

CONCLUSION

Consistent with the short-term results of the DIRECT trial, elective sigmoidectomy resulted in a significantly increased QoL at 5-year follow-up compared with conservative management in patients with recurring diverticulitis and/or ongoing complaints. Surgeons should counsel these patients for elective sigmoidectomy weighing superior QoL, less pain, and lower risk of new recurrences against the complication risk of surgery.

Disease phenotype rather than treatment strategy impacts the long-term quality of life in patients with diverticular disease

PURPOSE

To identify the impact of the severity of diverticular disease on long-term quality of life.

METHODS

Consecutive patients, hospitalized between October 2009 and November 2015 due to uncomplicated (UD) and complicated diverticulitis (CD) of the left colon, were analyzed. Patients undergoing emergent surgery for perforated disease were excluded. Primary endpoint was health-related quality of life (HrQol), measured by the Short Form 36 questionnaire (SF-36). Physical (PCS) and mental (MCS) compository scores were calculated from SF-36 subscales. To overcome bias, one-to-one propensity score matching and multivariable logistic regression analysis were performed.

RESULTS

Two hundred eighty of the overall 392 patients (Male 138, Female 142; mean age 60.5 years, range 27-91) answered the SF-36 questionnaire. The median follow-up period was 37.8 months (range 15-85). After propensity score matching, each group consisted of 51 patients. Results of the SF-36 questionnaires showed a statistically significant difference, favoring patients with CD in 5 of 8 domains. Also, PCS (56.3 vs. 52.9, p = 0.13) and MCS (53.3 vs. 46.7, p = 0.005) were higher in patients treated for CD. By a multivariate analysis, complicated disease was independently associated with a better scoring on 6 out of 8 SF-36 subscales and on MCS. Treatment strategy (surgery or conservative) did not have any impact on SF-36 subscales, MCS, or PCS on multivariate analysis.

CONCLUSION

In contrast to complicated disease, the uncomplicated diverticular disease is associated with an impaired long-term quality of life especially in domains composing mental health scores independently of chosen treatment strategy.

STUDY REGISTRATION

The study is registered with the Research Registry at June 19, 2019. Research registry UIN: researchregistry4959 .

Nerve fiber overgrowth in patients with symptomatic diverticular disease

BACKGROUND

Colonic diverticulosis is a common condition in industrialized countries. Up to 25% of patients with diverticula develop symptoms, a condition termed symptomatic uncomplicated diverticular disease (SUDD). The aim of the present study was to characterize neuroimmune interactions and nerve fiber plasticity in the colonic mucosa of patients with diverticula.

METHODS

Controls, patients with diverticulosis and with SUDD were enrolled in the study. Mucosal biopsies were obtained close to diverticula (diverticular region) and in a normal mucosa (distant site), corresponding to sigmoid and descending colon in the controls. Quantitative immunohistochemistry was used to assess mast cells, T cells, macrophages, nerve fibers, and neuronal outgrowth (growth-associated protein 43, GAP43+fibers).

KEY RESULTS

No difference emerged in mast cells and T cells among the three groups. Macrophages were increased in patients with SUDD and diverticulosis as compared to controls. Nerve fibers were enhanced in patients with SUDD and diverticulosis in comparison with controls in the diverticular region. GAP43+ fibers were increased only in patients with SUDD as compared to controls and to patients with diverticulosis in the diverticular region. In patients with SUDD, GAP43 density was increased in the diverticular region compared to distant site. Macrophages close to GAP43+ fibers were increased in the diverticular region of patients with SUDD. Significant correlations were found between GAP43+ fibers and immune cells.

CONCLUSIONS AND INFERENCES

Patients with diverticula are characterized by increased macrophage counts, while nerve fiber sprouting is increased only in the diverticular region of patients with SUDD suggesting a role in symptom generation.

Role of Inflammation in the Pathogenesis of Diverticular Disease

Diverticulosis of the colon is the most common condition in Western societies and it is the most common anatomic alteration of the human colon. Recurrent abdominal pain is experienced by about 20% of patients with diverticulosis, but the pathophysiologic mechanisms of its occurrence are not completely understood. In the last years, several fine papers have showed clearly the role of low-grade inflammation both in the occurrence of symptoms in people having diverticulosis, both in symptom persistence following acute diverticulitis, even if the evidence available is not so strong. We do not know yet what the trigger of this low-grade inflammation occurrence is. However, some preliminary evidence found colonic dysbiosis linked to low-grade inflammation and therefore to symptom occurrence in those patients. The aim of this paper is to summarize current evidences about the role of inflammation in symptom occurrence in symptomatic uncomplicated diverticular disease and in symptom persistence after an episode of acute diverticulitis.

Recurrent Acute Diverticulitis: When to Operate?

Objective

Recurrent acute diverticulitis carries a major burden to any form of health care. Patients present repeatedly to medical centers with a multitude of symptoms and may require different modalities of treatment with significant morbidities and impact on quality of life.

Methods

We therefore wanted to identify factors that would imply the need and time of surgery versus conservative management. The literature was thoroughly searched for major studies tackling this topic. Furthermore, studies reporting on decision making based on quality of life were included. Risks of developing recurrent diverticulitis and the potential need of surgery were identified. Relevant surgical details that would decrease recurrence were also denoted.

Results

Surgery has been the mainstay of treatment for quite some time. However, the paradigms of treatment have changed over the last few years, especially when long-term population studies confirmed that not all patients require surgical treatment with its associated risk of morbidity.

Conclusion

Treatment now has to be patient-tailored with special attention to the subgroup of high-risk patients. These patients must be adequately selected, identifying the impact of the disease on the quality of life and weighing in the risks of the surgical intervention.

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.

Cortical differences in diverticular disease and correlation with symptom reports

BACKGROUND

Recent studies have shown that the brain of patients with gastrointestinal disease differ both structurally and functionally from that of controls. Highly somatizing diverticular disease (HSDD) patients were also shown to differ from low somatizing (LSDD) patients functionally. This study aimed to investigate how they differed structurally.

METHODS

Four diseases subgroups were studied in a cross-sectional design: 20 patients with asymptomatic diverticular disease (ADD), 18 LSDD, 16 HSDD, and 18 with irritable bowel syndrome. We divided DD patients into LSDD and HSDD using a cutoff of 6 on the Patient Health Questionnaire 12 Somatic Symptom (PHQ12-SS) scale. All patients underwent a 1-mm isotropic structural brain MRI scan and were assessed for somatization, hospital anxiety, depression, and pain catastrophizing. Whole brain volumetry, cortical thickness analysis and voxel-based morphometry were carried out using Freesurfer and SPM.

KEY RESULTS

We observed decreases in gray matter density in the left and right dorsolateral prefrontal cortex (dlPFC), and in the mid-cingulate and motor cortex, and increases in the left (19, 20) and right (19, 38) Brodmann Areas. The average cortical thickness differed overall across groups (P = .002) and regionally: HSDD > ADD in the posterior cingulate cortex (P = .03), HSDD > LSDD in the dlPFC (P = .03) and in the ventrolateral PFC (P < .001). The thickness of the anterior cingulate cortex and of the mid-prefrontal cortex were also found to correlate with Pain Catastrophizing (Spearman's ρ = 0.24, P = .043 uncorrected and Spearman's ρ = 0.25, P = .03 uncorrected).

CONCLUSION & INFERENCES

This is the first study of structural gray matter abnormalities in diverticular disease patients. The data show brain differences in the pain network.

The Pathophysiology of Colonic Diverticulosis: Inflammation versus Constipation?

Background

Diverticulosis of the colon is the most common anatomic alteration of the human colon, but the pathophysiologic mechanisms of its occurrence are not completely understood.

Summary

Constipation has been considered the key factor for diverticulosis occurrence. However, several fine papers questioned this pathogenetic hypothesis, showing on the contrary an inverse relationship between low number of bowel movements and diverticulosis occurrence. In the last years, several papers have showed the role of low-grade inflammation in the occurrence of symptoms in people having diverticulosis, as well as its role on symptom persistence following acute diverticulitis, even if the evidence available is not so strong. Although the trigger of this low-grade inflammation is currently under debate, some preliminary evidence found colonic dysbiosis linked to symptom occurrence in those patients.

Key Messages

Constipation no longer seems the leading cause for diverticulosis occurrence, while low-grade inflammation could play a role in symptom occurrence.

A novel endoscopic grading system for prediction of disease-related outcomes in patients with diverticulosis

BACKGROUND

We describe a simple endoscopic grading system of diverticular disease for the assessment of disease severity and prediction of outcomes.

METHODS

A retrospective analysis of prospectively maintained colonoscopy database was conducted. A single endoscopist prospectively graded disease severity according to the number and size of diverticula, the degree of muscular hypertrophy and rigidity of the sigmoid colon.

RESULTS

762 patients were included in the analysis. Mean patient age was 70 years (range 37-97). Endoscopic severity of diverticulosis was predictive of the need for surgery, with 2% in the mild-moderate, 12% in the severe and 33% in the acute group (p < 0001). Time to surgery showed correlation to severity grade, with mean periods of 107.5 months in the moderate group vs. 3 and 2.5 months in the severe and acute group (p < 0001). The mean follow up was 11 years.

CONCLUSION

Surgeons should consider using endoscopic grading as an adjunct to clinical management decisions.

Diverticular Disease: The Old, the New, and the Ever-Changing View

Our understanding of diverticular disease has evolved significantly during the last 25 years, and as such, a reexamination is in order. We performed a literature search for the years 1960-2017 of PubMed, Medline, and Google Scholar for updates regarding the epidemiology, risk factors, and therapies for traditional diverticulitis as well as the recently described subtypes of diverticular disease, segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Although the prevalence of diverticulosis is still extremely common in the general population, the literature suggests that the incidence of diverticulitis is much less than previously believed and occurrences do not necessarily increase with age. In addition, the commonly held beliefs that low-fiber diets alone contribute to the development of diverticulosis and diverticulitis have not been verified; however, the combination of a low-fiber diet and a high red meat/high-fat diet is a risk factor for diverticulitis. Surgery continues to be the treatment for severe complications of diverticulitis, but new literature suggests that it has a poor utility in preventing a recurrence of diverticulitis in the long term; therefore, elective surgery after two episodes of diverticulitis is no longer the standard.

Abundance of Enterobacteriaceae in the colon mucosa in diverticular disease

AIM

To compare gut bacterial diversity and amount of Enterobacteriaceae in colonic mucosa between patients with and without diverticular disease (DD).

METHODS

Patients in a stable clinical condition with planned elective colonoscopy were included. Blood samples and colon mucosa biopsies were collected at the colonoscopy. Study questionnaires including questions about gastrointestinal symptoms were completed by the patients and physicians. DNA from mucosa samples was isolated and the amount of Enterobacteriaceae was estimated using PCR assay. Terminal restriction fragment length polymorphism was applied to assess microbial diversity. Diversity was estimated by calculations of richness (number of terminal restriction fragments) and Shannon-Wiener and Simpson’s indices.

RESULTS

A total of 51 patients were included, 16 patients with DD [68 (62-76) years] and 35 controls [62 (40-74) years] without any diverticula. Patients with DD had significantly higher levels of Enterobacteriaceae than those without DD (P = 0.043), and there was an inverse relationship between the amount of Enterobacteriaceae and the Simpson’s index (rs = -0.361, P = 0.033) and the Shannon-Wiener index (rs = -0.299, P = 0.081). The Simpson’s index (P = 0.383), Shannon-Wiener index (P = 0.401) or number of restrictions fragments (P = 0.776) did not differ between DD and controls. The majority of patients experienced gastrointestinal symptoms, and 22 patients (43.1%) fulfilled the criteria for irritable bowel syndrome, with no difference between the groups (P = 0.212). Demography, socioeconomic status, lifestyle habits, inflammatory biomarkers, or symptoms were not related to the amount of Enterobacteriaceae or bacterial diversity.

CONCLUSION

Patients with DD had higher amount of Enterobacteriaceae in the colon mucosa compared to patients without diverticula.

Rifaximin and diverticular disease: Position paper of the Italian Society of Gastroenterology (SIGE)

Management of diverticular disease has significantly improved in the last decade. Antibiotic treatment is used for symptom relief and prevention of complications. In Italy, the non-absorbable antibiotic rifaximin is one of the most frequently used drugs, and it is perceived as the reference drug to treat symptomatic diverticular disease. Its non-systemic absorption and high faecal concentrations have oriented rifaximin use to the gastrointestinal tract, where rifaximin exerts eubiotic effects representing an additional value to its antibiotic activity. This position paper was commissioned by the Italian Society of Gastroenterology governing board for a panel of experts (RC, GB, BA) to highlight the indications for treatment of diverticular disease. There is a lack of rationale for drug use for the primary prevention of diverticulitis in patients with diverticulosis; thus, rifaximin use should be avoided. The cyclic use of rifaximin, in association with high-fibre intake, is safe and useful for the treatment of symptomatic uncomplicated diverticular disease, even if the cost-efficacy of long-term treatment remains to be determined. The use of rifaximin in the prevention of diverticulitis recurrence is promising, but the low therapeutic advantage needs to be verified. No evidence is available on the efficacy of rifaximin treatment on acute uncomplicated diverticulitis.

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.

Diverticular Disease and IBS: Overlapping or Misunderstanding?

Although over half of patients over 65 years old will have diverticulosis, only a minority experience symptoms. These are often similar to those of irritable bowel syndrome with pain and disordered bowel habit, but differ in having an onset in the sixth to seventh decade. The underlying mechanisms include visceral hypersensitivity which maybe postinflammatory, but may also be due to altered central pain processing. Somatization is a useful clue to a predominantly central pathology, while its absence points to local causes including altered enteric nerves and mucosal immune activation. Treatments should be tailored to the individual patient who shows either predominantly peripheral or central abnormalities.

Diverticular Disease of the Colon: Neuromuscular Function Abnormalities

Colonic diverticular disease is a frequent finding in daily clinical practice. However, its pathophysiological mechanisms are largely unknown. This condition is likely the result of several concomitant factors occurring together to cause anatomic and functional abnormalities, leading as a result to the outpouching of the colonic mucosa. A pivotal role seems to be played by an abnormal colonic neuromuscular function, as shown repeatedly in these patients, and by an altered visceral perception. There is recent evidence that these abnormalities might be related to the derangement of the enteric innervation, to an abnormal distribution of mucosal neuropeptides, and to low-grade mucosal inflammation. The latter might be responsible for the development of visceral hypersensitivity, often causing abdominal pain in a subset of these patients.

Role of cyclooxygenase isoforms in the altered excitatory motor pathways of human colon with diverticular disease

BACKGROUND AND PURPOSE

The COX isoforms (COX-1, COX-2) regulate human gut motility, although their role under pathological conditions remains unclear. This study examines the effects of COX inhibitors on excitatory motility in colonic tissue from patients with diverticular disease (DD).

EXPERIMENTAL APPROACH

Longitudinal muscle preparations, from patients with DD or uncomplicated cancer (controls), were set up in organ baths and connected to isotonic transducers. Indomethacin (COX-1/COX-2 inhibitor), SC-560 (COX-1 inhibitor) or DFU (COX-2 inhibitor) were assayed on electrically evoked, neurogenic, cholinergic and tachykininergic contractions, or carbachol- and substance P (SP)-induced myogenic contractions. Distribution and expression of COX isoforms in the neuromuscular compartment were assessed by RT-PCR, Western blot and immunohistochemical analysis.

KEY RESULTS

In control preparations, neurogenic cholinergic contractions were enhanced by COX inhibitors, whereas tachykininergic responses were blunted. Carbachol-evoked contractions were increased by indomethacin or SC-560, but not DFU, whereas all inhibitors reduced SP-induced motor responses. In preparations from DD patients, COX inhibitors did not affect electrically evoked cholinergic contractions. Both indomethacin and DFU, but not SC-560, decreased tachykininergic responses. COX inhibitors did not modify carbachol-evoked motor responses, whereas they counteracted SP-induced contractions. COX-1 expression was decreased in myenteric neurons, whereas COX-2 was enhanced in glial cells and smooth muscle.

CONCLUSIONS AND IMPLICATIONS

In control colon, COX-1 and COX-2 down-regulate cholinergic motility, whereas both isoforms enhance tachykininergic motor activity. In the presence of DD, there is a loss of modulation by both COX isoforms on the cholinergic system, whereas COX-2 displays an enhanced facilitatory control on tachykininergic contractile activity.

Pathophysiology and Therapeutic Strategies for Symptomatic Uncomplicated Diverticular Disease of the Colon

Colonic diverticulosis imposes a significant burden on industrialized societies. The current accepted causes of diverticula formation include low fiber content in the western diet with decreased intestinal content and size of the lumen, leading to the transmission of muscular contraction pressure to the wall of the colon, inducing the formation of diverticula usually at the weakest point of the wall where penetration of the blood vessels occurs. Approximately 20 % of the patients with colonic diverticulosis develop abdominal symptoms (i.e., abdominal pain and discomfort, bloating, constipation, and diarrhea), a condition which is defined as symptomatic uncomplicated diverticular disease (SUDD). The pathogenesis of SUDD symptoms remains uncertain and even less is known about how to adequately manage bowel symptoms. Recently, low-grade inflammation, altered intestinal microbiota, visceral hypersensitivity, and abnormal colonic motility have been identified as factors leading to symptom development, thus changing and improving the therapeutic approach. In this review, a comprehensive search of the literature regarding on SUDD pathogenetic hypotheses and pharmacological strategies was carried out. The pathogenesis of SUDD, although not completely clarified, seems to be related to an interaction between colonic microbiota alterations, and immune, enteric nerve, and muscular system dysfunction (Cuomo et al. in United Eur Gastroenterol J 2:413-442, 2014). Greater understanding of the inflammatory pathways and gut microbiota composition in subjects affected by SUDD has increased therapeutic options, including the use of gut-directed antibiotics, mesalazine, and probiotics (Bianchi et al. in Aliment Pharmacol Ther 33:902-910, 2011; Comparato et al. in Dig Dis Sci 52:2934-2941, 2007; Tursi et al. in Aliment Pharmacol Ther 38:741-751, 2013); however, more research is necessary to validate the safety, effectiveness, and cost-effectiveness of these interventions.

Diverticulosis today: unfashionable and still under-researched

Diverticulosis of the colon is a widespread disease, and its prevalence is increasing especially in the developing world. The underlying pathological mechanisms that cause the formation of colonic diverticula remain unclear but are likely to be the result of complex interactions among age, diet, genetic factors, colonic motility, and changes in colonic structure. The large majority of patients remain asymptomatic throughout their life, one fifth of them become symptomatic (developing the so-called 'diverticular disease') while only a minority of these will develop acute diverticulitis. The factors predicting the development of symptoms remain to be identified. Again, it is generally recognized that diverticular disease occurrence is probably related to complex interactions among colonic motility, diet, lifestyle, and genetic features. Changes in intestinal microflora due to low-fiber diet and consequent low-grade inflammation are thought to be one of the mechanisms responsible for symptoms occurrence of both diverticular disease and acute diverticulitis. Current therapeutic approaches with rifaximin and mesalazine to treat the symptoms seem to be promising. Antibiotic treatment is currently advised only in acute complicated diverticulitis, and no treatment has currently proven effective in preventing the recurrence of acute diverticulitis. Further studies are required in order to clarify the reasons why diverticulosis occurs and the factors triggering occurrence of symptoms. Moreover, the reasons why rifaximin and mesalazine work in symptomatic diverticular disease but not in acute diverticulitis are yet to be elucidated.

Management of diverticular disease

Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.

Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon

BACKGROUND

The incidence of diverticulosis and diverticular disease of the colon, including diverticulitis, is increasing worldwide, and becoming a significant burden on national health systems. Treatment of patients with diverticulosis and DD is generally based on high-fibre diet and antibiotics, respectively. However, new pathophysiological knowledge suggests that further treatment may be useful.

AIM

To review the current treatment of diverticulosis and diverticular disease.

METHODS

A search of PubMed and Medline databases was performed to identify articles relevant to the management of diverticulosis and diverticular disease. Major international conferences were also reviewed.

RESULTS

Two randomised controlled trials (RCT) found the role of antibiotics in managing acute diverticulitis to be questionable, particularly in patients with no complicating comorbidities. One RCT found mesalazine to be effective in preventing acute diverticulitis in patients with symptomatic uncomplicated diverticular disease. The role of rifaximin or mesalazine in preventing diverticulitis recurrence, based on the results of 1 and 4 RCTs, respectively, remains unclear. RCTs found rifaximin and mesalazine to be effective in treating symptomatic uncomplicated diverticular disease. The use of probiotics in diverticular disease and in preventing acute diverticulitis occurrence/recurrence appears promising but unconclusive. Finally, the role of fibre in treating diverticulosis remains unclear.

CONCLUSIONS

Available evidence suggests that antibiotics have a role only in the treatment of complicated diverticulitis. It appears to be some evidence for a role for rifaximin and mesalazine in treating symptomatic uncomplicated diverticular disease. Finally, there is not currently adequate evidence to recommend any medical treatment for the prevention of diverticulitis recurrence.

Morphologic Basis for Developing Diverticular Disease, Diverticulitis, and Diverticular Bleeding

Diverticula of the colon are pseudodiverticula defined by multiple outpouchings of the mucosal and submucosal layers penetrating through weak spots of the muscle coat along intramural blood vessels. A complete prolapse consists of a diverticular opening, a narrowed neck, and a thinned diverticular dome underneath the serosal covering. The susceptibility of diverticula to inflammation is explained by local ischemia, translocation of pathogens due to retained stool, stercoral trauma by fecaliths, and microperforations. Local inflammation may lead to phlegmonous diverticulitis, paracolic/mesocolic abscess, bowel perforation, peritonitis, fistula formation, and stenotic strictures. Diverticular bleeding is due to an asymmetric rupture of distended vasa recta at the diverticular dome and not primarily linked to inflammation. Structural and functional changes of the bowel wall in diverticular disease comprise: i) Altered amount, composition, and metabolism of connective tissue; ii) Enteric myopathy with muscular thickening, deranged architecture, and altered myofilament composition; iii) Enteric neuropathy with hypoganglionosis, neurotransmitter imbalance, deficiency of neurotrophic factors and nerve fiber remodeling; and iv) Disturbed intestinal motility both in vivo (increased intraluminal pressure, motility index, high-amplitude propagated contractions) and in vitro (altered spontaneous and pharmacologically triggered contractility). Besides established etiologic factors, recent studies suggest that novel pathophysiologic concepts should be considered in the pathogenesis of diverticular disease.

Moderate to severe and prolonged left lower-abdominal pain is the best symptom characterizing symptomatic uncomplicated diverticular disease of the colon: a comparison with fecal calprotectin in clinical setting

BACKGROUND

Left lower-abdominal pain is considered the best symptom to differentiate between symptomatic uncomplicated diverticular disease (SUDD) and irritable bowel syndrome (IBS). However, this statement has not been validated yet.

GOALS

The aim of this study was to assess whether prolonged left lower-quadrant pain is the best symptom characterizing SUDD and be able to differentiate SUDD from IBS-like symptoms in diverticulosis, and to compare the location of abdominal pain with fecal calprotectin (FC) expression.

STUDY

Seventy-two patients suffering from abdominal pain and having diverticula at colonoscopy were enrolled. Patients were classified according to SUDD definition (abdominal pain for at least 24 consecutive hours in left lower abdomen) (42 patients) and IBS-like symptoms fulfilling Rome III criteria (30 patients). Abdominal pain was assessed using a 10-point visual scale, assigning numerical values from 0 (absence of pain) to 10 (severe pain). FC expression was assessed by a rapid test in all patients enrolled.

RESULTS

FC test was positive in 27 (64.3%) patients in the SUDD group and in no patient in the IBS-like group (P<0.0001). In patients with SUDD, there was a significant correlation between the severity of the abdominal pain and the FC score (P=0.0015). Extension of diverticulosis correlated with FC score (P=0.022) and the severity of diverticulosis (P=0.005).

CONCLUSIONS

Severe and prolonged left lower-abdominal pain seems to be the best symptom characterizing SUDD, and it can differentiate these patients from those harboring diverticula but suffering from IBS-like according to Rome III criteria.

[Anatomy and pathogenesis of diverticular disease]

BACKGROUND

Although diverticular disease is one of the most frequent gastrointestinal disorders the pathogenesis is not yet sufficiently clarified.

OBJECTIVES

The aim is to define the anatomy and pathogenesis of diverticular disease considering the risk factors and description of structural and functional alterations of the bowel wall.

METHODS

This article gives an appraisal of the literature, presentation and evaluation of classical etiological factors, analysis and discussion of novel pathogenetic concepts.

RESULTS

Colonic diverticulosis is defined as an acquired out-pouching of multiple and initially asymptomatic pseudodiverticula through muscular gaps in the colon wall. Diverticular disease is characterized by diverticular bleeding and/or inflammatory processes (diverticulitis) with corresponding complications (e.g. abscess formation, fistula, covered and open perforation, peritonitis and stenosis). Risk factors for diverticular disease include increasing age, genetic predisposition, congenital connective tissue diseases, low fiber diet, high meat consumption and pronounced overweight. Alterations of connective tissue cause a weakening of preformed exit sites of diverticula and rigidity of the bowel wall with reduced flexibility. It is assumed that intestinal innervation disorders and structural alterations of the musculature induce abnormal contractile patterns with increased intraluminal pressure, thereby promoting the development of diverticula. Moreover, an increased release of pain-mediating neurotransmitters is considered to be responsible for persistent pain in chronic diverticular disease.

CONCLUSIONS

According to the present data the pathogenesis of diverticular disease cannot be attributed to a single factor but should be considered as a multifactorial event.

Association between the location of diverticular disease and the irritable bowel syndrome: a multicenter study in Japan

OBJECTIVES

No previous reports have shown an association between location of diverticular disease (DD) and the irritable bowel syndrome (IBS).

METHODS

We included 1,009 consecutive patients undergoing total colonoscopy in seven centers in Japan from June 2013 to September 2013. IBS was diagnosed using Rome III criteria, and diverticulosis was diagnosed by colonoscopy with transparent soft-short-hood. Left-sided colon was defined as sigmoid colon, descending colon, and rectum. Right-sided colon was defined as cecum, ascending colon, and transverse colon. We divided the patients into IBS and non-IBS groups and compared characteristics.

RESULTS

Patient characteristics included mean age, 64.2±12.9 years and male:female ratio, 1.62:1. Right-sided DD was identified in 21.6% of subjects. Left-sided and bilateral DD was identified in 6.6 and 12.0% of subjects, respectively. IBS was observed in 7.5% of subjects. Multiple logistic regression analysis showed left-sided DD (odds ratio, 3.1; 95% confidence interval (CI): 1.4-7.1; P=0.0060) and bilateral DD (odds ratio, 2.6; 95% CI, 1.3-5.2; P=0.0070) were independent risk factors for IBS. Right-sided DD was not a risk factor for IBS.

CONCLUSIONS

Our data showed that the presence of left-sided and bilateral DD, but not right-sided disease, was associated with a higher risk of IBS, indicating that differences in pathological factors caused by the location of the DD are important in the development of IBS. Clarifying the specific changes associated with left-sided DD could provide a better understanding of the pathogenic mechanisms of IBS (Trial registration # R000012739).

Editorial: new thoughts on the association between diverticulosis and irritable bowel syndrome

As our population ages it is increasingly common to encounter patients with irritable bowel syndrome (IBS)-like symptoms and diverticulosis, but the nature of the association is obscure. This Editorial discusses the paper from Japan showing an association between IBS-like symptoms and left-sided but not right-sided diverticulosis. The left colon with its higher motor activity is more likely to be associated with complications of diverticulosis, including perforation and abscess formation. The underlying pathophysiology of the syndrome of post-diverticulitis IBS is discussed and clinical markers of centrally driven symptoms suggested as a means to avoid ineffective colonic resections in those with IBS-like diverticular disease.

Incidence and predictive factors of irritable bowel syndrome after acute diverticulitis in Korea

PURPOSE

Evidence indicates that irritable bowel syndrome can occur after gastroenteritis. However, little is known about its incidence after diverticulitis. This study was designed to identify the incidence and risk factors of irritable bowel syndrome after diverticulitis in Korea.

METHODS

A survey regarding irritable bowel syndrome was performed in patients allocated to the cases hospitalized for acute diverticulitis and controls hospitalized for non-gastrointestinal disorders between January 2007 and June 2012. Patients meeting criteria for irritable bowel syndrome before hospitalization or with a history of bowel resection were excluded for analysis. Response rate of telephone interviews was 28.1 % (139 of 494) and 73.3 % (220 of 300) in cases and controls, respectively. After exclusion, 102 patients in the cases and 205 patients in the controls were analyzed.

RESULTS

At 31 months median follow-up, irritable bowel syndrome had developed in 13 patients (12.8 %) in the cases and 11 patients (5.4 %) in the controls with significant statistical difference (p = 0.02). No clinical difference was seen between the two groups. No clinical factor was significant for the development of irritable bowel syndrome after diverticulitis, and no independent factor was associated with the development of irritable bowel syndrome. Among the 13 patients who developed post-diverticulitis irritable bowel syndrome, the diarrhea-predominant type (53.9 %) was most common.

CONCLUSION

A higher incidence of irritable bowel syndrome after diverticulitis was evident in this study. However, no clinical feature for prediction of its development after diverticulitis was found. Further large-scale analysis will be needed to generalize this result.

Italian consensus conference for colonic diverticulosis and diverticular disease

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

[Diverticular disease - diagnosis and classification]

A reliable diagnosis is fundamental for operative, interventional and conservative treatment of the different facets of diverticular disease. Not only differential diagnoses but also overlap or coincidence with other entities sharing similar symptoms must be considered. Furthermore, an adequate surgical strategy and correct stratification of complications is mandatory. Subsequently, in the light of currently validated diagnostic techniques, the consensus conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV) has released a new classification of diverticulitis displaying the different facets of diverticular disease. This classification also comprises symptomatic uncomplicated diverticular disease (SUDD), largely resembling irritable bowel syndrome, as well as diverticular bleeding. While detailed history, physical examination and laboratory testing are of great importance for exploring a patient with diverticular disease, they are not sufficient to diagnose (or stratify) diverticulitis without cross-sectional imaging using ultrasonography (US) or computed tomography (CT). The diagnostic value of qualified US is equipotent to qualified CT, complies with relevant legislation for radiation exposure protection and is frequently effective for diagnosis. Therefore, US is considered to be the first choice for imaging in diverticular disease. In contrast, CT has definite indications in unclear, discrepant situations or insufficient US performance. Strengths and weaknesses of both methods are discussed. Endoscopy is not required for the diagnosis of diverticulitis and should not be performed in an acute attack. Colonoscopy, however, is warranted after healing of diverticulitis, prior to elective surgery and in cases of an atypical course. Prior exclusion of perforation is considered mandatory. An unequivocal indication for colonoscopy is diverticular bleeding and the rapid performance (within 12-24 h) allows better identification of sites of bleeding and endoscopic interventions.

Review article: The pathogenesis and management of acute colonic diverticulitis

BACKGROUND

Acute diverticulitis, defined as acute inflammation associated with a colonic diverticulum, is a common emergency presentation managed by both surgeons and physicians. There have been advances in both the medical and the surgical treatments offered to patients in recent years.

AIM

To review the current understanding of the aetiology and treatment of acute diverticulitis.

METHODS

A search of PubMed and Medline databases was performed to identify articles relevant to the aetiology, pathogenesis and management of acute diverticulitis.

RESULTS

There are 75 hospital admissions per year for acute diverticulitis per 100,000 of the population in the United States. Recent reports suggest a 26% increase in admissions over a 7-year period. Factors predisposing to the development of acute diverticulitis include obesity, smoking, diet, lack of physical activity and medication use such as aspirin and nonsteroidal anti-inflammatory drugs. The condition is associated with a low mortality of about 1% following medical therapy, rising to 4% in-hospital mortality in those requiring surgery. There is limited evidence on the efficacy of individual antibiotic regimens, and antibiotic treatment may not be required in all patients. The rates of recurrence reported for patients with acute diverticulitis following medical management vary from 13% to 36%. The surgical management of those patients who fail medical treatment has moved towards a laparoscopic nonresectional approach; however, the evidence supporting this is limited.

CONCLUSIONS

Further high-quality randomised controlled trials are required of both medical and surgical treatments in patients with acute diverticulitis, if management is to be evidence-based.

Microencapsulated sodium butyrate administered to patients with diverticulosis decreases incidence of diverticulitis--a prospective randomized study

BACKGROUND

Microencapsulated sodium butyrate (MSB) has been previously associated with anti-inflammatory and regenerative properties regarding large bowel mucosa. We aimed to examine a role of MSB in patients with diverticulosis, hypothesizing its potential for reduction of diverticulitis episodes and diverticulitis prevention.

METHODS

Seventy-three patients with diverticulosis (diagnosed in colonoscopy or/and barium enema or/and CT colography) were recruited for the study and randomized. The investigated group was administered MSB 300 mg daily; the control group was administered placebo. After 12 months, a total of 52 patients completed the study and were subject to analysis (30 subjects and 22 controls). During the study, the number of episodes of diverticulitis (symptomatic diagnosis with acute pain, fever, and leukocytosis), hospitalizations, and surgery performed for diverticulitis were recorded. Additionally, a question regarding subjective improvement of symptoms reflected changes in quality of life during the analysis.

RESULTS

After 12 months, the study group noted a significantly decreased number of diverticulitis episodes in comparison to the control group. The subjective quality of life in the study group was higher than in the control group. There were no side effects of the MSB during the therapy.

CONCLUSIONS

MSB reduces the frequency of diverticulitis episodes, is safe, and improves the quality of life. It can play a role in the prevention of diverticulitis.

Increased risk for irritable bowel syndrome after acute diverticulitis

BACKGROUND & AIMS

Individuals with diverticulosis frequently also have irritable bowel syndrome (IBS), but there are no longitudinal data to associate acute diverticulitis with subsequent IBS, functional bowel disorders, or related emotional distress. In patients with postinfectious IBS, gastrointestinal disorders cause long-term symptoms, so we investigated whether diverticulitis might lead to IBS. We compared the incidence of IBS and functional bowel and related affective disorders among patients with diverticulitis.

METHODS

We performed a retrospective study of patients followed up for an average of 6.3 years at a Veteran's Administration medical center. Patients with diverticulitis were identified based on International Classification of Diseases, 9th revision codes, selected for the analysis based on chart review (cases, n = 1102), and matched with patients without diverticulosis (controls, n = 1102). We excluded patients with prior IBS, functional bowel, or mood disorders. We then identified patients who were diagnosed with IBS or functional bowel disorders after the diverticulitis attack, and controls who developed these disorders during the study period. We also collected information on mood disorders, analyzed survival times, and calculated adjusted hazard ratios.

RESULTS

Cases were 4.7-fold more likely to be diagnosed later with IBS (95% confidence interval [CI], 1.6-14.0; P = .006), 2.4-fold more likely to be diagnosed later with a functional bowel disorder (95% CI, 1.6-3.6; P < .001), and 2.2-fold more likely to develop a mood disorder (CI, 1.4-3.5; P < .001) than controls.

CONCLUSIONS

Patients with diverticulitis could be at risk for later development of IBS and functional bowel disorders. We propose calling this disorder postdiverticulitis IBS. Diverticulitis appears to predispose patients to long-term gastrointestinal and emotional symptoms after resolution of inflammation; in this way, postdiverticulitis IBS is similar to postinfectious IBS.

Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights

Diverticular disease imposes a significant burden on Western and industrialized societies. The traditional pathogenesis model posits that low dietary fiber predisposes to diverticulosis, and fecalith obstruction prompts acute diverticulitis that is managed with broad-spectrum antibiotics or surgery. However, a growing body of knowledge is shifting the paradigm of diverticular disease from an acute surgical illness to a chronic bowel disorder composed of recurrent abdominal symptoms and considerable psychosocial impact. New research implicates a role for low-grade inflammation, sensory-motor nerve damage, and dysbiosis in a clinical picture that mimics irritable bowel syndrome (IBS) and even inflammatory bowel disease (IBD). Far from being an isolated event, acute diverticulitis may be the catalyst for chronic symptoms including abdominal pain, cramping, bloating, diarrhea, constipation, and "post-diverticulitis IBS." In addition, studies reveal lower health-related quality of life in patients with chronic diverticular disease vs. controls. Health-care providers should maintain a high index of suspicion for the multifaceted presentations of diverticular disease, and remain aware that it might contribute to long-term emotional distress beyond traditional diverticulitis attacks. These developments are prompting a shift in therapeutic approaches from widespread antimicrobials and supportive care to the use of probiotics, mesalamine, and gut-directed antibiotics. This review addresses the emerging literature regarding epidemiology, pathophysiology, and management of chronic, symptomatic diverticular disease, and provides current answers to common clinical questions.

Clinical features of symptomatic uncomplicated diverticular disease: a multicenter Italian survey

PURPOSE

Clinical features of symptomatic uncomplicated diverticular disease are poorly investigated. Abdominal symptoms may be similar to those of irritable bowel syndrome. This survey aimed to assess clinical features associated with symptomatic uncomplicated diverticular disease.

METHODS

This multicenter survey included consecutive outpatients with symptomatic uncomplicated diverticular disease to whom a detailed clinical questionnaire regarding demographic, lifestyle, and clinical features was administered. Diagnosis was based on the presence of diverticula and abdominal pain/discomfort. Irritable bowel syndrome and functional dyspepsia were assessed according to Rome III criteria.

RESULTS

A total of 598 patients (50 % female, age 69 years), 71 % with newly diagnosed symptomatic uncomplicated diverticular disease and 29 % with history of colonic diverticula, were recruited. Diverticula were localized in the left colon in 78 % of the patients. Recurrent short-lived abdominal pain (<24 h) was present in 70 % (relieved by evacuation in 73 %), prolonged abdominal pain (>24 h) in 27 %, and recurrent abdominal bloating in 61 % of the patients. Normal, loose, or hard stools were reported by 58, 29, and 13 % of patients, respectively. Irritable bowel syndrome (IBS)-like and functional dyspepsia-like symptoms were recorded in 59 and 7 % of patients, respectively. IBS-like symptoms (odds ratio, 4.3) were associated in patients with prolonged abdominal pain.

CONCLUSIONS

Symptomatic uncomplicated diverticular disease is associated with a gender ratio of 1:1 and an unspecific clinical picture mainly characterized by normal stools, short-lived abdominal pain, abdominal bloating, IBS-like symptoms, while functional dyspepsia-like symptoms are not commonly present. These findings suggest that symptomatic uncomplicated diverticular disease often shows similar findings rather than overlaps IBS.

Colonic diverticular disease: abnormalities of neuromuscular function

Although diverticular disease of the colon (diverticulosis) is a frequent finding in Western countries, its pathophysiologic grounds are still only partially understood. Traditionally considered as an age-related condition, colonic diverticulosis is probably the final result of several factors concurring together to determine the anatomo-functional abnormalities eventually causing outpouching of the viscus' mucosa. Among these factors, a relevant role seems to be played by an abnormal neuromuscular function of the large bowel, as shown by abnormal myoelectrical and motor function repeatedly described in these patients, as well as by altered visceral perception. These anomalies might be related to the recent demonstration of derangement of enteric innervation (especially involving interstitial cells of Cajal and enteric glial cells), mucosal neuropeptides, and mucosal inflammation. The latter may have a role of paramount importance in the development of visceral hypersensitivity, responsible for abdominal pain in a subset of patients.

Perception and the origin of symptoms in diverticular disease

Colonic diverticulosis is a common condition and although the majority of patients are asymptomatic up to 20% experience altered bowel habit and abdominal pain. The mechanisms underlying these symptoms are unclear but several theories now exist. This article briefly outlines a model of GI perception and then highlights past and current theories that may explain the development of symptoms in patients with diverticulosis.