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Cicio A, Aloi N, Sut S, Longo V, Terracina F, Dall’Acqua S, Zizzo MG, Bruno M, Ilardi V, Colombo P, Luparello C, Serio R. Chemical Characterization, Free Radical Scavenging, and Cellular Antioxidant Properties of the Egadi Island Endemic Brassica macrocarpa Guss Leaf Extract. Biomolecules 2024; 14:636. [PMID: 38927041 PMCID: PMC11201591 DOI: 10.3390/biom14060636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
The genus Brassica is an important source of food in the Mediterranean diet with documented nutritional and medicinal properties. However, few studies have investigated the phytochemical composition and the biological activity of wild Sicilian taxa. Thus, we aimed to study the chemical profile and the antioxidant potential, in vitro and in LPS-stimulated RAW 264.7 cells, of a methanolic extract of leaves of wild Brassica macrocarpa Guss (B. macrocarpa) (Egadi Islands; Sicily-Italy). B. macrocarpa methanolic extract showed a large amount of glucosinolates and different phenolic compounds. It exhibited antioxidant activity in the DPPH assay and in LPS-stimulated RAW 264.7 cells, being able to reduce NO and ROS levels and NOS2 mRNA expression. Our study demonstrated that Sicilian B. macrocarpa methanolic extract, in LPS-stimulated macrophages, efficiently counteracts oxidative stress and displays radical scavenging activity. Future studies are required to identify the contribution of the single phytocomponents, to characterize the action mechanism, and to reveal possible applications in human health.
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Affiliation(s)
- Adele Cicio
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
| | - Noemi Aloi
- Institute for Biomedical Research and Innovation, National Research Council of Italy (IRIB-CNR), Via Ugo la Malfa 153, 90146 Palermo, Italy; (N.A.); (V.L.); (P.C.)
| | - Stefania Sut
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Via F. Marzolo 5, 35131 Padova, Italy; (S.S.); (S.D.)
| | - Valeria Longo
- Institute for Biomedical Research and Innovation, National Research Council of Italy (IRIB-CNR), Via Ugo la Malfa 153, 90146 Palermo, Italy; (N.A.); (V.L.); (P.C.)
| | - Francesca Terracina
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
| | - Stefano Dall’Acqua
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, Via F. Marzolo 5, 35131 Padova, Italy; (S.S.); (S.D.)
| | - Maria Grazia Zizzo
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
- ATeN (Advanced Technologies Network) Center, Viale delle Scienze, University of Palermo, 90128 Palermo, Italy
- NBFC—National Biodiversity Future Center, University of Palermo, 90133 Palermo, Italy
| | - Maurizio Bruno
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
- NBFC—National Biodiversity Future Center, University of Palermo, 90133 Palermo, Italy
| | - Vincenzo Ilardi
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
| | - Paolo Colombo
- Institute for Biomedical Research and Innovation, National Research Council of Italy (IRIB-CNR), Via Ugo la Malfa 153, 90146 Palermo, Italy; (N.A.); (V.L.); (P.C.)
| | - Claudio Luparello
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
- NBFC—National Biodiversity Future Center, University of Palermo, 90133 Palermo, Italy
| | - Rosa Serio
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), Università degli Studi di Palermo, Viale delle Scienze, 90128 Palermo, Italy (F.T.); (M.B.); (C.L.); (R.S.)
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Coakley KM, Davis BR, Kasten KR. Complicated Diverticular Disease. Clin Colon Rectal Surg 2020; 34:96-103. [PMID: 33642949 DOI: 10.1055/s-0040-1716701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.
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Affiliation(s)
- Kathleen M Coakley
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Bradley R Davis
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Kevin R Kasten
- Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
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O’Grady M, Clarke L, Turner G, Doogue M, Purcell R, Pearson J, Frizelle F. Statin use and risk of acute diverticulitis: A population-based case-control study. Medicine (Baltimore) 2020; 99:e20264. [PMID: 32443369 PMCID: PMC7253659 DOI: 10.1097/md.0000000000020264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The goal of the study was to examine the association between statin use and the development of acute diverticulitis requiring hospital admission.Acute diverticulitis is a common and costly gastrointestinal disorder. Although the incidence is increasing its pathophysiology and modifiable risk factors are incompletely understood. Statins affect the inflammatory response and represent a potential risk reducing agent.A retrospective, population-based, case-control study was carried out on a cohort of adults, resident in Canterbury, New Zealand. All identified cases were admitted to hospital and had computed tomography confirmed diverticulitis. The positive control group comprised patients on non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs), and the negative control group were patients on selective serotonin reuptake inhibitors (SSRIs). Medicine exposure was obtained from the Pharmaceutical Management Agency of New Zealand. Subgroup analysis was done by age and for complicated and recurrent diverticulitis.During the study period, there were 381,792 adults resident in Canterbury. The annual incidence of diverticulitis requiring hospital presentation was 18.6 per 100,000 per year. Complicated disease was seen in 37.4% (158) of patients, and 14.7% (62) had recurrent disease. Statins were not found to affect the risk of developing acute diverticulitis, nor the risk of complicated or recurrent diverticulitis. Subgroup analysis suggested statin use was associated with a decreased risk of acute diverticulitis in the elderly (age >64 years). NSAIDs were associated with a decreased risk of acute diverticulitis (risk ratio = 0.65, confidence interval: 0.26-0.46, P < .01), as were SSRIs (risk ratio = 0.37, confidence interval: 0.26-0.54, P < .01).This population-based study does not support the hypothesis that statins have a preventative effect on the development of diverticulitis, including complicated disease. We also found a decreased risk of diverticulitis associated with NSAID and SSRI use.
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Affiliation(s)
| | | | | | - Matt Doogue
- University of Otago, Christchurch, New Zealand
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4
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Abstract
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.
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Affiliation(s)
- Mona Rezapour
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Neil Stollman
- Alta Bates Summit Medical Center, East Bay Center for Digestive Health, 300 Frank H Ogawa Plaza, Suite 450, Oakland, CA, 94612, USA.
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Gill D, Georgakis MK, Koskeridis F, Jiang L, Feng Q, Wei WQ, Theodoratou E, Elliott P, Denny JC, Malik R, Evangelou E, Dehghan A, Dichgans M, Tzoulaki I. Use of Genetic Variants Related to Antihypertensive Drugs to Inform on Efficacy and Side Effects. Circulation 2019; 140:270-279. [PMID: 31234639 PMCID: PMC6687408 DOI: 10.1161/circulationaha.118.038814] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/02/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Drug effects can be investigated through natural variation in the genes for their protein targets. The present study aimed to use this approach to explore the potential side effects and repurposing potential of antihypertensive drugs, which are among the most commonly used medications worldwide. METHODS Genetic proxies for the effect of antihypertensive drug classes were identified as variants in the genes for the corresponding targets that associated with systolic blood pressure at genome-wide significance. Mendelian randomization estimates for drug effects on coronary heart disease and stroke risk were compared with randomized, controlled trial results. A phenome-wide association study in the UK Biobank was performed to identify potential side effects and repurposing opportunities, with findings investigated in the Vanderbilt University biobank (BioVU) and in observational analysis of the UK Biobank. RESULTS Suitable genetic proxies for angiotensin-converting enzyme inhibitors, β-blockers, and calcium channel blockers (CCBs) were identified. Mendelian randomization estimates for their effect on coronary heart disease and stroke risk, respectively, were comparable to results from randomized, controlled trials against placebo. A phenome-wide association study in the UK Biobank identified an association of the CCB standardized genetic risk score with increased risk of diverticulosis (odds ratio, 1.02 per standard deviation increase; 95% CI, 1.01-1.04), with a consistent estimate found in BioVU (odds ratio, 1.01; 95% CI, 1.00-1.02). Cox regression analysis of drug use in the UK Biobank suggested that this association was specific to nondihydropyridine CCBs (hazard ratio 1.49 considering thiazide diuretic agents as a comparator; 95% CI, 1.04-2.14) but not dihydropyridine CCBs (hazard ratio, 1.04; 95% CI, 0.83-1.32). CONCLUSIONS Genetic variants can be used to explore the efficacy and side effects of antihypertensive medications. The identified potential effect of nondihydropyridine CCBs on diverticulosis risk could have clinical implications and warrants further investigation.
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Affiliation(s)
- Dipender Gill
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, United Kingdom (D.G., P.E., E.E., A.D., I.T.)
| | - Marios K. Georgakis
- Institute for Stroke and Dementia Research, University Hospital (M.K.G., R.M., M.D.), Ludwig-Maximilians-Universität LMU, Munich, Germany
- Graduate School for Systemic Neurosciences (M.K.G.), Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Fotios Koskeridis
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Greece (F.K., E.E., I.T.)
| | - Lan Jiang
- Division of Clinical Pharmacology, Department of Medicine (L.J., Q.F.), Vanderbilt University Medical Center, Nashville, TN
| | - Qiping Feng
- Division of Clinical Pharmacology, Department of Medicine (L.J., Q.F.), Vanderbilt University Medical Center, Nashville, TN
| | - Wei-Qi Wei
- Department of Biomedical Informatics (W.-Q.W., J.C.D.), Vanderbilt University Medical Center, Nashville, TN
| | - Evropi Theodoratou
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (E.T.)
| | - Paul Elliott
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, United Kingdom (D.G., P.E., E.E., A.D., I.T.)
- Medical Research Council-Public Health England Centre for Environment, School of Public Health, Imperial College London, United Kingdom (P.E., A.D., I.T.)
- Imperial Biomedical Research Centre, Imperial College London and Imperial College NHS Healthcare Trust, UK (P.E.)
- UK Dementia Research Institute at Imperial College London, UK (P.E., A.D., I.T.)
- Health Data Research UK-London (P.E.)
| | - Joshua C. Denny
- Department of Biomedical Informatics (W.-Q.W., J.C.D.), Vanderbilt University Medical Center, Nashville, TN
| | - Rainer Malik
- Institute for Stroke and Dementia Research, University Hospital (M.K.G., R.M., M.D.), Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Evangelos Evangelou
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, United Kingdom (D.G., P.E., E.E., A.D., I.T.)
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Greece (F.K., E.E., I.T.)
| | - Abbas Dehghan
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, United Kingdom (D.G., P.E., E.E., A.D., I.T.)
- Medical Research Council-Public Health England Centre for Environment, School of Public Health, Imperial College London, United Kingdom (P.E., A.D., I.T.)
- UK Dementia Research Institute at Imperial College London, UK (P.E., A.D., I.T.)
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, University Hospital (M.K.G., R.M., M.D.), Ludwig-Maximilians-Universität LMU, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
- German Center for Neurodegenerative Diseases (DZNE, Munich), Germany (M.D.)
| | - Ioanna Tzoulaki
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, United Kingdom (D.G., P.E., E.E., A.D., I.T.)
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Greece (F.K., E.E., I.T.)
- Medical Research Council-Public Health England Centre for Environment, School of Public Health, Imperial College London, United Kingdom (P.E., A.D., I.T.)
- UK Dementia Research Institute at Imperial College London, UK (P.E., A.D., I.T.)
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Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology 2019; 156:1282-1298.e1. [PMID: 30660732 PMCID: PMC6716971 DOI: 10.1053/j.gastro.2018.12.033] [Citation(s) in RCA: 207] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 02/06/2023]
Abstract
Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Approximately 20% of patients with incident diverticulitis have at least 1 recurrence. Complications of diverticulitis, such as abdominal sepsis, are less likely to occur with subsequent events. Several risk factors, many of which are modifiable, have been identified including obesity, diet, and physical inactivity. Diet and lifestyle factors could affect risk of diverticulitis through their effects on the intestinal microbiome and inflammation. Preliminary studies have found that the composition and function of the gut microbiome differ between individuals with vs without diverticulitis. Genetic factors, as well as alterations in colonic neuromusculature, can also contribute to the development of diverticulitis. Less-aggressive and more-nuanced treatment strategies have been developed. Two multicenter, randomized trials of patients with uncomplicated diverticulitis found that antibiotics did not speed recovery or prevent subsequent complications. Elective surgical resection is no longer recommended solely based on number of recurrent events or young patient age and might not be necessary for some patients with diverticulitis complicated by abscess. Randomized trials of hemodynamically stable patients who require urgent surgery for acute, complicated diverticulitis that has not improved with antibiotics provide evidence to support primary anastomosis vs sigmoid colectomy with end colostomy. Despite these advances, more research is needed to increase our understanding of the pathogenesis of diverticulitis and to clarify treatment algorithms.
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Affiliation(s)
- Lisa L Strate
- Division of Gastroenterology, University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington.
| | - Arden M Morris
- S-SPIRE Center and Department of Surgery, Stanford University, Stanford, California
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Dumic I, Nordin T, Jecmenica M, Stojkovic Lalosevic M, Milosavljevic T, Milovanovic T. Gastrointestinal Tract Disorders in Older Age. Can J Gastroenterol Hepatol 2019; 2019:6757524. [PMID: 30792972 PMCID: PMC6354172 DOI: 10.1155/2019/6757524] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 12/11/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.
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Affiliation(s)
- Igor Dumic
- 1Division of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- 2Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
| | - Terri Nordin
- 2Mayo Clinic College of Medicine and Sciences, Rochester, MN, USA
- 3Department of Family Medicine, Mayo Clinic Health System, Eau Claire WI, USA
| | - Mladen Jecmenica
- 4Gastroenterology Fellowship Program, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | | | - Tomica Milosavljevic
- 5Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- 6School of Medicine, Belgrade University, Belgrade, Serbia
| | - Tamara Milovanovic
- 5Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
- 6School of Medicine, Belgrade University, Belgrade, Serbia
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Abstract
Inflammation of diverticula, or outpouchings of the colonic mucosa and submucosa through the muscularis layer, leads to diverticulitis. The development of diverticular disease, encompassing both diverticulosis and diverticulitis, is a result of genetic predisposition, lifestyle, and environmental factors, including the microbiome. Areas covered: Previous reports implicated genetic predisposition, environmental factors, and colonic dysmotility in diverticular disease. Recent studies have associated specific host immune responses and the microbiome as contributors to diverticulitis. To review pertinent literature describing pathophysiological factors associated with diverticulosis or diverticulitis, we searched the PubMed database (March 2018) for articles considering the role of colonic architecture, genetic predisposition, environment, colonic motility, immune response, and the microbiome. Expert commentary: In the recent years, research into the molecular underpinnings of diverticular disease has enhanced our understanding of diverticular disease pathogenesis. Although acute uncomplicated diverticulitis is treated with broad spectrum antibiotics, evaluation of the microbiome has been limited and requires further comprehensive studies. Evidence suggests that a deregulation of the host immune response is associated with both diverticulosis and diverticulitis. Further examining these pathways may reveal proteins that can be therapeutic targets or aid in identifying biological determinants of clinical or surgical decision making.
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Affiliation(s)
- Kathleen M Schieffer
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Bryan P Kline
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Gregory S Yochum
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA.,b Department of Biochemistry & Molecular Biology , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
| | - Walter A Koltun
- a Department of Surgery, Division of Colon and Rectal Surgery , The Pennsylvania State University, College of Medicine , Hershey , PA , USA
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Reichert MC, Krawczyk M, Appenrodt B, Casper M, Friesenhahn-Ochs B, Grünhage F, Jüngst C, Zimmer V, Lammert F, Dauer M. Selective association of nonaspirin NSAIDs with risk of diverticulitis. Int J Colorectal Dis 2018; 33:423-430. [PMID: 29411119 DOI: 10.1007/s00384-018-2968-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to investigate the association of intake of nonsteroidal anti-inflammatory drugs (NSAIDs) and in particular nonaspirin NSAIDs and compare it with other risk factors for the progression of diverticulosis to diverticulitis in patients who underwent colonoscopy. METHODS A total of 194 patients who underwent complete colonoscopy in our center between 2012 and 2016 were recruited: 144 with diverticulosis without prior diverticulitis (median age 71 years, 59.7% men) and 50 with diverticulitis (median age 64 years, 54.0% men). Data concerning current and previous medication as well as concomitant diseases were collected using a structured questionnaire and by revision of patients medical charts. RESULTS Patients with diverticulitis were significantly (p < 0.001) younger as compared to individuals with plain diverticulosis (median age 64 versus 71 years, respectively). The intake of NSAIDs significantly (p = 0.002) increased the risk of prior diverticulitis (OR 3.2, 95% CI 1.5-6.9). In the multivariate model, both age (p < 0.001) and NSAIDs (p = 0.03) proved to be independent determinants of diverticulitis. When analyzing aspirin intake, it was not associated with diverticulitis. CONCLUSIONS Our study demonstrates, in line with previous reports, that intake of NSAIDs is associated with diverticulitis. We show in particular that nonaspirin NSAIDs might be selectively associated with diverticulitis. These results point to divergent role of aspirin and nonaspirin NSAIDs in the development of diverticulitis.
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Affiliation(s)
- Matthias C Reichert
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany.
| | - Marcin Krawczyk
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
- Laboratory of Metabolic Liver Diseases, Centre for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Beate Appenrodt
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Markus Casper
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | | | - Frank Grünhage
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Christoph Jüngst
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Vincent Zimmer
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Marc Dauer
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
- Department Medicine 2, Klinikum St. Marien, Amberg, Germany
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Severi C, Carabotti M, Cicenia A, Pallotta L, Annibale B. Recent advances in understanding and managing diverticulitis. F1000Res 2018; 7:F1000 Faculty Rev-971. [PMID: 30026920 PMCID: PMC6039950 DOI: 10.12688/f1000research.14299.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 02/05/2023] Open
Abstract
In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single 'causa prima' will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies.
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Affiliation(s)
- Carola Severi
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Alessia Cicenia
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Lucia Pallotta
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
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Abstract
Diverticular disease is common and accounts for substantial health care utilization in the USA. Recent publications in the areas of diverticulosis and diverticular disease have highlighted several notable advances that are now changing practice. Despite colonic diverticula being common, only 1-4 % of individuals with colonic diverticula will develop diverticulitis. After a first occurrence of acute diverticulitis, the risk of recurrence is 20 % at 5 years. Complications most commonly occur with the first occurrence of acute diverticulitis and not with recurrent episodes. After an episode of diverticulitis, many patients continue to experience chronic gastrointestinal symptoms. Prophylactic surgery is an option to reduce the risk of recurrence and its negative impact on quality of life. Importantly, the rationale for surgery is no longer to prevent complications because this risk is low. The review concludes with practical recommendations for patients with diverticulosis and diverticular disease.
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Affiliation(s)
- Anne F Peery
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Bioinformatics Building, CB # 7080, 130 Mason Farm Road, Chapel Hill, NC, 27599-7555, USA.
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Humes D, Spiller RC. Colonic diverticular disease: medical treatments for acute diverticulitis. BMJ CLINICAL EVIDENCE 2016; 2016:0405. [PMID: 26854496 PMCID: PMC4745836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Diverticula (mucosal outpouchings through the wall of the colon) are rare before the age of 40 years, after which prevalence increases steadily and reaches over 25% by 60 years. However, only 10% to 25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses. METHODS AND OUTCOMES We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of medical treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS At this update, searching of electronic databases retrieved 193 studies. After deduplication and removal of conference abstracts, 75 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 37 studies and the further review of 38 full publications. Of the 38 full articles evaluated, four systematic reviews and one RCT were added at this update. We performed a GRADE evaluation for two PICO combinations CONCLUSIONS In this systematic overview, we categorised the efficacy for one comparison based on information about the effectiveness and safety of medical treatment (mesalazine, antibiotics [any] only) versus placebo or no treatment.
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Affiliation(s)
- David Humes
- Department of Surgery, University of Nottingham, Nottingham, UK
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13
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Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute Technical Review on the Management of Acute Diverticulitis. Gastroenterology 2015; 149:1950-1976.e12. [PMID: 26453776 DOI: 10.1053/j.gastro.2015.10.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lisa L Strate
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Anne F Peery
- Division of Gastroenterology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ignacio Neumann
- Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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14
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Böhm SK. Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking. VISZERALMEDIZIN 2015; 31:84-94. [PMID: 26989377 PMCID: PMC4789955 DOI: 10.1159/000381867] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding. Methods A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed. Results Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities. Conclusion Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.
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Affiliation(s)
- Stephan K Böhm
- Medizinische Universitätsklinik, Kantonsspital Baselland, Bruderholz, Switzerland
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Vaidya KK, Floch MH. Diverticular Disease: Paradigm Shifts in Pathogenesis and Treatment. ACTA ACUST UNITED AC 2015; 13:143-55. [DOI: 10.1007/s11938-014-0045-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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Bugiantella W, Rondelli F, Longaroni M, Mariani E, Sanguinetti A, Avenia N. Left colon acute diverticulitis: an update on diagnosis, treatment and prevention. Int J Surg 2014; 13:157-164. [PMID: 25497007 DOI: 10.1016/j.ijsu.2014.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy.
| | - Maurizio Longaroni
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
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Espín F, Rofes L, Ortega O, Clavé P, Gallego D. Nitrergic neuro-muscular transmission is up-regulated in patients with diverticulosis. Neurogastroenterol Motil 2014; 26:1458-68. [PMID: 25109425 DOI: 10.1111/nmo.12407] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 07/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neuro-transmission impairment could be associated to motility changes observed in patients with diverticular disease. Therefore, the objective was to characterize the inhibitory neuro-muscular transmission and gene expression changes of the enteric inhibitory pathways in patients with diverticulosis (DS). METHODS Circular muscle strips from sigmoid colon of patients with DS and controls were studied using the organ bath technique to evaluate spontaneous contractility and enteric motor neurons stimulated by electrical field and qRT-PCR to assess the expression of nNOS, iNOS, P2Y1 R and PGP9.5. KEY RESULTS Patients with DS presented decreased spontaneous rhythmic contractions (SRC) that were significantly enhanced after incubation with L-NNA (1 mM) and TTX (1 μM), and unaffected by the P2Y1 antagonist MRS2500 (1 μM). Stimulation on enteric motor neurons caused an increased duration of the latency of OFF-contractions in DS group (p < 0.001), antagonized by L-NNA and slightly affected by MRS2500 (1 μM). No differences in the IC50 between controls and DS patients were observed on inhibition of SRC for the NO-donor sodium nitroprusside (SNP) and the preferential P2Y agonist ADPβS. Moreover, nNOS relative expression was also up-regulated 2.3-fold in the DS group (p < 0.05) whereas there was no significant difference in relative expression of iNOS, P2Y1 R and the neuronal marker PGP9.5 between groups. CONCLUSIONS & INFERENCES Patients with DS presented an over-expression of nNOS with increased endogenously NO-mediated responses suggesting enhanced NO-release. Up-regulation in the nitrergic pathway in early stages of the disease might play a role in colonic motor disorders associated to diverticular disease.
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Affiliation(s)
- F Espín
- Department of Surgery, Gastrointestinal Physiology Laboratory, Hospital de Mataró, Mataró, Barcelona, Spain
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18
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Diverticular disease is associated with increased risk of subsequent arterial and venous thromboembolic events. Clin Gastroenterol Hepatol 2014; 12:1695-701.e1. [PMID: 24316104 DOI: 10.1016/j.cgh.2013.11.026] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/26/2013] [Accepted: 11/12/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diverticular disease and cardiovascular disease share several risk factors. Inflammation associated with diverticular disease could predispose to cardiovascular disease. We assessed the association between a diagnosis of diverticular disease and subsequent arterial and venous thromboembolic events, adjusting for related comorbidities to explore a possible causal relationship. METHODS We identified 77,065 incident cases of diverticular disease from 1980-2011 from Danish nationwide medical registries; these were matched for age and sex with 302,572 population comparison cohort members. Individuals with a history of cardiovascular disease were excluded. We used Cox proportional hazards regression to compute incidence rate ratios, comparing the incidence of acute myocardial infarction, stroke, venous thromboembolism, and subarachnoid hemorrhage in patients with diverticular disease with those of the population cohort members, adjusting for age, sex, obesity, diabetes, hyperlipidemia, chronic obstructive pulmonary disease, connective tissue disease, renal disease, and treatments and medications. RESULTS The adjusted incidence rate ratios for patients with diverticular disease, compared with population cohort members, were 1.11 (95% confidence interval [CI], 1.07-1.14) for acute myocardial infarction, 1.11 (95% CI, 1.08-1.15) for overall stroke, 1.36 (95% CI, 1.30-1.43) for overall venous thromboembolism, and 1.27 (95% CI, 1.09-1.48) for subarachnoid hemorrhage. The relative risk of each event remained increased after we adjusted for changes in aspirin use or for endoscopy or colorectal surgery after the diagnosis of diverticular disease. These findings also held after excluding the first year of follow-up and limiting the analysis to patients with diverticulitis. CONCLUSIONS On the basis of an analysis of Danish medical registries, a diagnosis of diverticular disease is associated with a modest increase in risk of arterial and venous thromboembolic events after adjustment for related disorders.
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Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Colorectal Dis 2014; 16:O189-96. [PMID: 24320820 DOI: 10.1111/codi.12516] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/11/2013] [Indexed: 02/08/2023]
Abstract
AIM Complications of colonic diverticula, perforation and bleeding are a source of morbidity and mortality. A variety of drugs have been implicated in these complications. We present a systemic review and meta-analysis of the literature to assess the importance of this relationship. METHOD A systematic review of articles in PubMed, Cochrane Reviews, Embase and Google Scholar was undertaken in February 2013. An initial literature search yielded 2916 results that were assessed for study design and topicality. Twenty-three articles were included in the review. A qualitative data synthesis was conducted using forest plots of studies comparing single medication with complications. RESULTS Individual studies demonstrated the odds of perforation and abscess formation with nonsteridal anti-inflammatory drugs (NSAIDs) (1.46-10.30), aspirin (0.66-2.40), steroids (2.17-31.90) and opioids (1.80-4.51) and the odds of bleeding with NSAIDs (2.01-12.60), paracetamol (0-3.75), aspirin (1.14-3.70) and steroids (0.57-5.40). Pooled data showed significantly increased odds of perforation and abscess formation with NSAIDs (OR = 2.49), steroids (OR = 9.08) and opioids (OR = 2.52). They also showed increased odds of diverticular bleeding from NSAIDs (OR = 2.69), aspirin (OR = 3.24) and calcium-channel blockers (OR = 2.50). Most studies did not describe the duration or dosage of medication used and did not systematically describe the severity of diverticular complications. CONCLUSION Various common medications are implicated in complications of diverticular disease.
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Affiliation(s)
- C L Kvasnovsky
- Department of Colorectal Surgery, King's College Hospital, London, UK
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Gravante G, Yahia S. Medical influences, surgical outcomes: Role of common medications on the risk of perforation from untreated diverticular disease. World J Gastroenterol 2013; 19:5947-5952. [PMID: 24106394 PMCID: PMC3785615 DOI: 10.3748/wjg.v19.i36.5947] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/06/2013] [Accepted: 08/13/2013] [Indexed: 02/06/2023] Open
Abstract
Numerous drugs, largely used in the wards or at home, have a significant influence on patients with untreated diverticular disease. The consequences can be disastrous, may require an emergency operation, postoperative intensive care, and overall influence the patient’s length of stay and the final outcomes. Bearing these considerations in mind the routine or chronic administration of pain-killers, steroids and non-steroidal anti-inflammatory should be balanced in patients with known diverticular disease as it normally happens with other conditions potentially affected by these drugs (i.e., peptic ulcer disease or chronic obstructive pulmonary disease). This is even more important in the old and frail patient where an eventual surgical treatment may not always be possible.
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Boynton W, Floch M. New strategies for the management of diverticular disease: insights for the clinician. Therap Adv Gastroenterol 2013; 6:205-13. [PMID: 23634185 PMCID: PMC3625022 DOI: 10.1177/1756283x13478679] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Diverticulosis is one of the most common gastrointestinal conditions affecting the general population in the Western world. It is estimated that over 2.5 million people are affected by diverticular disease in the United States. The spectrum of clinical manifestations of diverticulosis ranges from asymptomatic diverticulosis to complicated diverticulitis. Treatment for symptomatic diverticular disease is largely based on symptoms. Traditional therapy includes fiber, bowel rest, antibiotics, pain control and surgery for selected cases. This review discusses recent advances in the medical treatment of diverticular disease such as the use of mesalamine, rifaximin and probiotics as our understanding of the disease evolves.
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Affiliation(s)
- Wen Boynton
- Section of Digestive Diseases, Yale University School of Medicine, PO Box 208033, New Haven, CT 06520-8033, USA
| | - Martin Floch
- Digestive Disease Section, Yale University School of Medicine, New Haven, CT, USA
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Abstract
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.
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Abstract
BACKGROUND A recurrent episode of diverticulitis is a new distinct episode of acute inflammation after a period of complete remission of symptoms. Outdated literature suggested a high recurrence rate (>40%) and a worse clinical presentation with less chance of conservative treatment. More recent studies showed a more benign course with no need toward an aggressive policy of treatment. METHODS We report data from revised literature and from our study: a 4-year multicenter retrospective and prospective database analysis of 743 patients hospitalized for acute diverticulitis (AD) treated medically or surgically and then followed for a minimum of 9 years. RESULTS The literature showed a recurrence rate of 25-35% at 5 years of follow-up, with a reduced risk of severe complications (i.e. perforations), a risk of subsequent emergency surgery of 2-14% and a risk of stoma and related death of 0-2.7%. Several risk factors of recurrence have been advocated: family history, abscess, severe CT stage, comorbidities (renal failure, collagen vascular disease) and nonsteroidal anti-inflammatory drugs. Young age is still a matter of debate. These studies have different limitations: retrospective, lack of definition of AD, small number of patients, long recruiting time, short follow-up, study population or hospital-system based. In our study of 320 followed-up, medically treated patients, 61% were asymptomatic and 22% complained of chronic symptoms: the 12-year actuarial risk of recurrence, emergency surgery, stoma and death was 21.2, 8.3, 1 and 0%, respectively. Recurrence was related to very young age (<40 years) and more than 3 previous episodes of AD. CONCLUSION This study confirms the benign course of diverticulitis treated conservatively, with a low long-term risk of serious complications and death, and does not support an aggressive surgical policy to prevent them.
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Abstract
The traditional view that recurrent episodes of diverticulitis lead to progressively complicated disease resulting in a disadvantageous course, more difficult, complicated operations and lethal outcomes did not stand the test of evidence. Only a minority of patients with acute diverticulitis will ever require surgery, and if so, this occurs during or early after the first episode. Complications and recurrence of disease after surgery are enumerable. Strong indicators favoring sigmoid colectomy are major abscess, free air, and fistula, i.e. perforating disease. This occurs predominantly at the initial presentation, frequently in younger or immunosuppressed patients. Important differential diagnoses must be considered both for initial diagnosis of diverticulitis and for recurrent episodes. Conservative management of recurrent diverticulitis is safe and best guided by gastroenterological expertise. Sophisticated ultrasound experience as a part of this competence allows detailed evaluation of the local status and the best evidence in the literature for diagnosing diverticulitis is on US. In practice, however, the question of perforating diverticulitis is adequately answered by subtle CT scan. Medical therapy is usually the treatment of choice for recurrent diverticulitis. Avoidance of drugs bearing the hazard of perforation (e.g. NSAIDs) is emphasized, and smoking is strongly discouraged. A mathematical model based on published data shows that patients with recurrent diverticulitis overall (only) profit from surgery if they are hit by four episodes during the course of disease. This is where theory and reality (should) meet.
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Affiliation(s)
- Bernhard Lembcke
- Department of Internal Medicine and Gastroenterology, KKEL, St. Barbara-Hospital Gladbeck, Gladbeck, Germany.
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Sopeña F, Lanas A. Management of colonic diverticular disease with poorly absorbed antibiotics and other therapies. Therap Adv Gastroenterol 2011; 4:365-74. [PMID: 22043229 PMCID: PMC3187681 DOI: 10.1177/1756283x11412820] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Colonic diverticular disease is common in Western countries and its prevalence increases with age. The large majority of patients (80-85%) will remain entirely asymptomatic throughout their life. In symptomatic cases, most patients will have diverticulosis without inflammation while the remainder will have diverticulitis with or without complications. About 1-2% will require hospitalization and 0.5% will require surgery. Factors predicting the development of symptoms remain to be identified. However, it is generally recognized that diverticular disease is probably related to complex interactions between colon structure, intestinal motility, diet, and genetic features. Epidemiologic studies have demonstrated an association between diverticulosis and diets that are low in fiber and high in refined carbohydrates. Although the causes of symptom development are still unclear, it is thought that previous episodes of intestinal inflammation may play a role. Changes in intestinal microflora could be one of the putative mechanisms responsible for low-grade inflammation. In patients with uncomplicated diverticulosis, a diet abundant in fruit and vegetables is recommended. The current therapeutic approaches in preventing recurrence of symptoms are based on nonabsorbable antibiotics, mesalazine, and/or probiotics. Cyclic rifaximin administration seems to be an adequate approach to relieving symptoms and preventing acute diverticulitis in patients with symptomatic diverticulosis.
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Affiliation(s)
- Federico Sopeña
- University of Zaragoza School of Medicine, University Hospital Lozano Blesa, Zaragoza, Spain
| | - Angel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, c/Sn Juan Bosco 15, 50009 Zaragoza, Spain
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Humes D, Smith JK, Spiller RC. Colonic diverticular disease. BMJ CLINICAL EVIDENCE 2011; 2011:0405. [PMID: 21401970 PMCID: PMC3275154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Diverticula (mucosal outpouching through the wall of the colon) are rare before the age of 40 years, after which prevalence increases steadily and reaches over 25% by 60 years. However, only 10% to 25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: treatments for uncomplicated diverticular disease; treatments to prevent complications; and treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 16 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodics, elective surgery, increasing fibre intake with bran or ispaghula husk, lactulose, medical treatment, mesalazine, methylcellulose, rifaximin, and surgery.
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Affiliation(s)
- David Humes
- Department of Surgery, University of Nottingham, Nottingham, UK
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Effets pharmacodynamiques d’un extrait hydroalcoolique de Curcuma longa Linné (Zingiberaceae) sur le système cardiovasculaire, la respiration et l’activité mécanique intestinale de mammifères. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s10298-010-0600-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gomes-Filho IS, Cruz SS, Costa MDCN, Passos JS, Cerqueira EM, Sampaio FP, Pereira EC, Miranda LF. Periodontal Therapy and Low Birth Weight: Preliminary Results From an Alternative Methodologic Strategy. J Periodontol 2010; 81:1725-33. [DOI: 10.1902/jop.2010.100041] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Piekarek K, Israelsson LA. Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers. Int J Colorectal Dis 2008; 23:1193-7. [PMID: 18679693 DOI: 10.1007/s00384-008-0555-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2008] [Indexed: 02/04/2023]
Abstract
PURPOSE Perforated colonic diverticular disease is associated with a high rate of late sequel and mortality. The risk of colonic perforation may relate to intracolonic pressure and mucosal barrier function in the wall of diverticula. The use of substances affecting these parameters may therefore be associated with the risk of developing a perforation. The aim was to study the effect of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, calcium channel blockers, and antimuscarinics on perforation in diverticular disease. MATERIALS AND METHODS A review of 54 patients with colonic diverticular perforation-forming the case group-and 183 patients with verified colonic diverticular disease-forming the control group-was done. Patient characteristics and drug use was registered. RESULTS Case group and control group were comparable with respect to sex, age, and comorbidity. In multivariate analysis, the use of NSAIDs (OR 3.56; 95% CI 1.50-8.43), opioids (OR 4.51; 95% CI 1.67-12.18), and corticosteroids (OR 28.28; 95% CI 4.83-165.7) were significantly associated with perforated diverticular disease. Acetylsalicylic acid in cardiologic dose did not affect the rate of perforation (OR 0.66; 95% CI 0.27-1.61). The use of calcium channel blockers was associated with a reduced rate of diverticular complications (OR 0.14; 95% CI 0.02-0.95). CONCLUSIONS The administration of NSAIDs, opioids, and corticosteroids are associated with an increased risk of colonic diverticular perforation. Acetylsalicylic acid in cardiologic dose does not affect the risk of perforation. Calcium channel blockers are associated with a reduced risk of perforation.
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Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008; 300:907-14. [PMID: 18728264 PMCID: PMC2643269 DOI: 10.1001/jama.300.8.907] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT Patients with diverticular disease are frequently advised to avoid eating nuts, corn, popcorn, and seeds to reduce the risk of complications. However, there is little evidence to support this recommendation. OBJECTIVE To determine whether nut, corn, or popcorn consumption is associated with diverticulitis and diverticular bleeding. DESIGN AND SETTING The Health Professionals Follow-up Study is a cohort of US men followed up prospectively from 1986 to 2004 via self-administered questionnaires about medical (biennial) and dietary (every 4 years) information. Men reporting newly diagnosed diverticulosis or diverticulitis were mailed supplemental questionnaires. PARTICIPANTS The study included 47,228 men aged 40 to 75 years who at baseline were free of diverticulosis or its complications, cancer, and inflammatory bowel disease and returned a food-frequency questionnaire. MAIN OUTCOME MEASURES Incident diverticulitis and diverticular bleeding. RESULTS During 18 years of follow-up, there were 801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding. We found inverse associations between nut and popcorn consumption and the risk of diverticulitis. The multivariate hazard ratios for men with the highest intake of each food (at least twice per week) compared with men with the lowest intake (less than once per month) were 0.80 (95% confidence interval, 0.63-1.01; P for trend = .04) for nuts and 0.72 (95% confidence interval, 0.56-0.92; P for trend = .007) for popcorn. No associations were seen between corn consumption and diverticulitis or between nut, corn, or popcorn consumption and diverticular bleeding or uncomplicated diverticulosis. CONCLUSIONS In this large, prospective study of men without known diverticular disease, nut, corn, and popcorn consumption did not increase the risk of diverticulosis or diverticular complications. The recommendation to avoid these foods to prevent diverticular complications should be reconsidered.
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Affiliation(s)
- Lisa L Strate
- University of Washington School of Medicine, Seattle, USA.
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Humes D, Simpson J, Spiller RC. Colonic diverticular disease. BMJ CLINICAL EVIDENCE 2007; 2007:0405. [PMID: 19454119 PMCID: PMC2943810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Diverticula (mucosal outpouching through the wall of the colon) affect over 5% of adults aged 40 years and older, but only 10-25% of affected people will develop symptoms such as lower abdominal pain. Recurrent symptoms are common, and 5% of people with diverticula eventually develop complications such as perforation, obstruction, haemorrhage, fistulae, or abscesses. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of: treatments for uncomplicated diverticular disease; treatments to prevent complications; and treatments for acute diverticulitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to July 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 13 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antispasmodics, bran, elective surgery, increasing fibre intake, ispaghula husk, lactulose, medical treatment, mesalazine, methylcellulose, rifaximin, surgery.
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Affiliation(s)
- David Humes
- Department of Surgery, University of Nottingham, Nottingham, UK
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Affiliation(s)
- Simon E J Janes
- Colorectal Unit, Department of Surgery, Christchurch Hospital, PO Box 4345, Christchurch, New Zealand
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Tursi A. Preventive therapy for complicated diverticular disease of the colon: looking for a correct therapeutic approach. Gastroenterology 2004; 127:1865-6. [PMID: 15578538 DOI: 10.1053/j.gastro.2004.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Buckley O, Geoghegan T, O'Riordain DS, Lyburn ID, Torreggiani WC. Computed tomography in the imaging of colonic diverticulitis. Clin Radiol 2004; 59:977-83. [PMID: 15488845 DOI: 10.1016/j.crad.2004.05.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2003] [Revised: 04/13/2004] [Accepted: 05/04/2004] [Indexed: 02/08/2023]
Abstract
Colonic diverticulitis occurs when diverticula within the colon become infected or inflamed. It is becoming an increasingly common cause for hospital admission, particularly in western society, where it is linked to a low fibre diet. Symptoms of diverticulitis include abdominal pain, diarrhoea and pyrexia, however, symptoms are often non-specific and the clinical diagnosis may be difficult. In addition, elderly patients and those taking corticosteroids may have limited findings on physical examination, even in the presence of severe diverticulitis. A high index of suspicion is required in such patients in order to avoid a significant delay in arriving at the correct diagnosis. Imaging plays an important role in establishing an early and correct diagnosis. In the past, contrast enema studies were the principal imaging test used to make the diagnosis. However, such studies lack sensitivity and have limited success in identifying abscesses that may require drainage. Conversely computed tomography (CT) is both sensitive and specific in making a diagnosis of diverticulitis. In addition, it is the imaging technique of choice in depicting complications such as perforation, abscess formation and fistulae. CT-guided drainage of diverticular abscesses helps to reduce sepsis and to permit a one-stage, rather than two-stage, surgical operation. The purpose of this review article is to discuss the role of CT in the imaging of diverticulitis, describe the CT imaging features and complications of this disease, as well as review the impact and rationale of CT imaging and intervention in the overall management of patients with diverticulitis.
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Affiliation(s)
- O Buckley
- Department of Surgery, Adelaide and Meath Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland
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Abstract
Diverticulosis is the most common structural abnormality of the colon. Although most people with colonic diverticula remain asymptomatic, a significant proportion of those affected develop symptoms and may suffer from complications. Whereas early research in diverticular disease addressed the pathogenesis of the condition, recent work has focused on symptomatic or complicated disease. Recent epidemiologic studies have attempted to identify patients who are at increased risk of perforated diverticular disease, and developing knowledge in neurogastroenterology has suggested mechanisms responsible for underlying chronically symptomatic disease. Further research in these areas has the potential to provide targeted therapeutic strategies for people with colonic diverticula.
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Affiliation(s)
- John Simpson
- Department of Surgery, University Hospital, E Floor, West Block, Nottingham NG7 2UH, UK.
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