Recent advances in understanding and managing diverticulitis

Concomitant diverticulosis among patients undergoing liver transplantation. Does it influence the length of hospitalization after the procedure?

Aim of the study

We tried to assess the influence of concomitant diverticulosis and other factors, e.g., Child-Pugh (C-P) and MELD scores, viral etiology, and presence of alcoholic disease, on short-term results of liver transplantation (LT) with an emphasis on duration of patient's hospitalization.

Material and methods

This prospective study was performed on 206 cirrhotic patients who were selected for LT. In order to assess the presence of diverticculosis we performed colonoscopy.

Results

The duration of hospitalization after LT did not differ significantly between patients with and without diverticulosis (27.5 [21.0-33.5] vs. 24.0 [18.0-32.0] days, p = 0.28). Patients with C-P class C were hospitalized longer in comparison to the class B patients. It is reflected in the positive correlation between C-P score and days of hospitalization (r = 0.22, p = 0.002). Patients with diverticulosis were significantly older (59.6 [51.1-63.3] vs. 52.9 [43.8-59.2] years, p = 0.03). Alcoholic liver disease (ALD) was associated with a greater risk of diverticulosis (OR = 3.89, 95% CI [1.13-15.87], p = 0.04).

Conclusions

Presence of diverticulosis among subjects undergoing LT did not influence the duration of hospitalization after the procedure. Significantly longer hospitalization was observed in patients with the most advanced liver disease according to C-P score. To determine the exact impact of diverticulosis on short-term results of LT additional studies are required.

Diverticular Disease Worsening Is Associated with Increased Oxidative Stress and Gut Permeability: New Insights by Circulating Biomarkers

Diverticular disease (DD) management is impaired by its pathogenesis, which is still not completely defined, with an unmet clinical need for improved therapies. Ex vivo DD human models demonstrated the presence of a transmural oxidative imbalance that supports an ischemic pathogenesis. This study aimed to assess, with the use of circulating biomarkers, insights into DD pathogenesis and possible therapeutic targets. Nox2-derived peptide, H2O2, antioxidant capacity, isoprostanes, thromboxanes, TNF-α, LPS and zonulin were evaluated by ELISA in healthy subjects (HS) and asymptomatic and symptomatic DD patients. Compared to HS, DD patients presented low antioxidant capacity and increase in sNox2-dp, H2O2 and isoprostanes paralleled to a TNFα increase, lower than that of oxidative markers. TxB2 production correlated to Nox2 and isoprostanes, suggesting platelet activation. An increase in zonulin and LPS highlighted the role of gut permeability and LPS translocation in DD pathogenesis. The increase of all the markers statistically correlated with DD severity. The present study confirmed the presence of a main oxidative imbalance in DD and provides evidence of platelet activation driven by LPS translocation. The use of circulating biomarkers could represent a new clinical tool for monitoring disease progression and validate therapeutic strategies never tested in DD as antioxidant supplementation.

Analysis of the Epidemiological Trends on Inpatient Diverticulosis Admissions in the US: A Longitudinal Analysis From 1997-2018

Background Diverticulosis of the colon is characterized by outpouchings of mucosa and serosa through the muscular layer of the large intestinal wall. It is classically associated with increasing age with older individuals having a higher prevalence and greater density of diverticula secondary to its progressive disease nature. Also, diverticular disease is associated with dietary habits, low fiber intake in western society as well as obesity. The aim of this study was to investigate the epidemiological trends associated with diverticular disease in the United States in a 21-year interval from 1997 to 2018. Methods Using the Nationwide Inpatient Sample, all hospitalizations between 1997 and 2018 were analyzed. We examined annual data for hospitalization rate, the average length of stay (LOS), mean age and interval age groups, and hospital charges for inpatient admissions for diverticular disease (diverticulitis and diverticulosis). Results Between 1997 and 2018, the number of hospitalizations for patients with a primary discharge diagnosis of diverticular disease (diverticulosis and diverticulitis) increased 32% from 220,896 to 293,530 with 89.7 discharges per 100,000 persons in 2018 versus 81.0 discharges per 100,000 persons in 1997. Overall, the average age of patients decreased from 67.55 ± 0.15 years in 1997 to 64.59 ±0.08 in 2018, [t-value (t) 12.56, degrees of freedom (df) 514424, 95% confidence interval (CI) 2.497-3.423, P<0.0001]. On further evaluation, the mean average age in males decreased from 63.16±0.21 years in 1997 to 61.31±0.12 years in 2018, (t 8.16, df 217981, 95% CI 1.404-2.295 P<0.0001), while in females it decreased from 70.53±0.14 years to 67.15±0.10 years, (t 20.13, df 296422, 95% CI 3.050-3.709 P<0.0001), in the same interval time. While evaluating different subgroups of age in this time interval, the prevalence rate of diverticular disease diagnosis per 100,000 persons increased in the interval age between 18-44 years from 20.1 to 29.8, [relative risk (RR) 0.848, CI 95% 0.834-0.863, P< 0.0001) and 45-64 years from 107.1 to 125.3, (RR 0.761, CI 95% 0.754-0.769 P<0.0001) while it decreased in the interval age between 65-84 years from 357.6 to 259.7, (RR 1.211, CI 95% 1.206-1.226, P<0.0001) as well as > 85 years from 746.2 to 523.6, (RR 1.130, CI 95% 1.112-1.147, P<0.0001) The length of stay (LOS) mean average in days decreased from 5.8 ± 0.04 days in 1997 to 4.4±0.021 days in 2018, (t 33.08 df 514424, 95%CI 1.316-1.483, P< 0.0001). Hospital Inpatient National Statistics data over hospital mean charges, available from the period between 1997 to 2015, shows that the mean hospital charges in US dollars increased over 100%, from $19,735.17 in 1997 to $39,575 in 2015 (P<0.001) even after adjusting values to 2015 inflation. Conclusion There is an overall trend of decreased mean age of patients admitted with diverticular disease in the US over the past 21 years with a respective significant increased rate of disease in younger age groups. We postulate that these changes may be associated with poor dietary habits and obesity epidemics worsened in the last two decades in the US. In addition, despite the decreased length of stay over the same time period, the mean hospital charges more than double likely reflecting the increased access to expensive diagnostic methods such as computed tomography and colonoscopies.

Oxidative imbalance and muscular alterations in diverticular disease

BACKGROUND

It is still a matter of debate if neuromuscular alterations reflect a primary event in diverticular disease (DD).

AIMS

This study aimed to assess colonic wall layers from both stenotic and non-stenotic complicated DD, bio-phenotypic alterations, inflammatory and oxidative status.

METHODS

A systematic analysis of colonic specimens obtained from stenotic and non-stenotic DD specimens was conducted and compared with controls. Biological activity and qPCR analysis were performed on longitudinal and circular muscles. Western blot analysis was performed throughout colonic wall layers to quantify oxidative and inflammatory markers.

RESULTS

A homogenous increase in oxidative stress was observed through all the layers, which were more sharpened in the longitudinal muscle for a loss in antioxidant defenses. In both stenotic and non-stenotic colon, the longitudinal muscle presented an impaired relaxation and a cellular phenotypic switch driven by transforming growth factor-β with an increase in mRNA expression of collagen Iα and a decrease in myosin heavy chain. The circular muscle, as the mucosa, was less affected by molecular alterations. No peculiar increase in inflammatory markers was observed.

CONCLUSION

A longitudinal colonic myopathy is present in DD, independently from the disease stage associated with an oxidative imbalance that could suggest new therapeutic strategies.

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

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

Diagnostic Imaging and Medical Management of Acute Left-Sided Colonic Diverticulitis : A Systematic Review

BACKGROUND

Clinicians need to better understand the value of computed tomography (CT) imaging and nonsurgical treatment options to manage acute left-sided colonic diverticulitis.

PURPOSE

To evaluate CT imaging, outpatient treatment of uncomplicated diverticulitis, antibiotic treatment, and interventional radiology for patients with complicated diverticulitis.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, CINAHL, and ClinicalTrials.gov from 1 January 1990 through 16 November 2020.

STUDY SELECTION

Existing systematic reviews of CT imaging accuracy, as well as randomized trials and adjusted nonrandomized comparative studies reporting clinical or patient-centered outcomes.

DATA EXTRACTION

6 researchers extracted study data and risk of bias, which were verified by an independent researcher. The team assessed strength of evidence across studies.

DATA SYNTHESIS

Based on moderate-strength evidence, CT imaging is highly accurate for diagnosing acute diverticulitis. For patients with uncomplicated acute diverticulitis, 6 studies provide low-strength evidence that initial outpatient and inpatient management have similar risks for recurrence or elective surgery, but they provide insufficient evidence regarding other outcomes. Also, for patients with uncomplicated acute diverticulitis, 5 studies comparing antibiotics versus no antibiotics provide low-strength evidence that does not support differences in risks for treatment failure, elective surgery, recurrence, posttreatment complications, and other outcomes. Evidence is insufficient to determine choice of antibiotic regimen (7 studies) or effect of percutaneous drainage (2 studies).

LIMITATIONS

The evidence base is mostly of low strength. Studies did not adequately assess heterogeneity of treatment effect.

CONCLUSION

Computed tomography imaging is accurate for diagnosing acute diverticulitis. For patients with uncomplicated diverticulitis, no differences in outcomes were found between outpatient and inpatient care. Avoidance of antibiotics for uncomplicated acute diverticulitis may be safe for most patients. The evidence is too sparse for other evaluated questions.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and American College of Physicians. (PROSPERO: CRD42020151246).

Excessive Body Weight and Diverticular Disease

BACKGROUND

The worldwide proportion of overweight adults almost doubled from 22% in 1975 to 39% in 2016. Comparably, for the USA and Germany in 2016, the proportion was 68 and 56.8%, respectively. In Olmsted County, Minnesota, the prevalence of diverticulitis also doubled between 1980 and 2007, from 19 to 40%. Obesity substantially increases the risk of multiple gastrointestinal (GI) diseases and non-GI diseases. In a narrative review, we examined the evidence on whether obesity also increases the risk for the development of diverticulosis or diverticular disease and its outcome.

SUMMARY

Evidence suggests that being overweight (body mass index ≥25 kg/m2) or obese (≥30 kg/m2), especially viscerally obese, is a risk factor for diverticulosis, diverticular disease and diverticulitis, diverticular bleeding, more severe or complicated disease, recurrent disease, and for worse outcomes after surgery.

KEY MESSAGES

There is a well-founded association between overweight and diverticular disease as well as diverticulosis. It is not clear whether overweight per se or confounders linked with it are responsible for the association. However, means to fight the overweight and obesity epidemic might also help to reduce the prevalence of morbidity and mortality from diverticular disease.

Microbiota and Probiotics: The Role of Limosilactobacillus Reuteri in Diverticulitis

The microbiota is the set of commensal microorganisms, residing in the organism, helping proper functioning of organs and systems. The role that the microbiota plays in maintaining the health of vertebrates is widely accepted, particularly in the gastrointestinal system, where it is fundamental for immunity, development, and conversion of nutrients. Dysbiosis is an alteration of the microbiota which refers to a disturbed balance, which can cause a number of pathologies. Probiotics have proven to be effective in modulating the microbiota of the gastrointestinal system and, therefore, in promoting the health of the individual. In particular, Lactobacilli are a group of Gram-positive bacteria, which are able to produce lactic acid through glucose metabolism. They are present in different microenvironments, ranging from the vagina, to the mouth, to different tracts of the small intestine. In the present review, we will discuss the use of Limosilactobacillus in human health in general and more specifically in diverticulitis. In particular we analyze the role of Limosilactobacillus reuteri and its anti-inflammatory action. For this review, articles were identified using the electronic PubMed database through a comprehensive search, conducted by combining key terms such as "diverticulitis", "Limosilactobacillus reuteri", "human health and disease", "probiotics". We selected all the articles published in the last 10 years and screened 1017 papers. Articles referenced in the screened papers were evaluated if considered interesting for our topic. Probiotics have proven to be effective in modulating the microbiota of the gastrointestinal system and, therefore, in promoting the health of the individual. The importance of probiotics in treating diverticular disease and acute diverticulitis can be further understood if taking into consideration some pathophysiological aspects, associated to the microbiota. L. reuteri plays an important role in human health and disease. The effectiveness of L. reuteri in stimulating a correct bowl motility partly explains its effectiveness in treating diverticulitis. The most important action of L. reuteri is probably its immunomodulating activity. Levels of IL-6, IL-8, and Tumor necrosis factor (TNF-alpha) are reduced after supplementation with different strands of Lactobacilli, while T-regulatory cells increase in number and activity. Anyway, new mechanisms of action of probiotics come to light from the many investigations currently taking place in numerous centres around the world and to improve how exactly probiotic administration could make the difference in the management of diverticular disease and acute diverticulitis.

Gut Microbiota and Acute Diverticulitis: Role of Probiotics in Management of This Delicate Pathophysiological Balance

How can the knowledge of probiotics and their mechanisms of action be translated into clinical practice when treating patients with diverticular disease and acute diverticulitis? Changes in microbiota composition have been observed in patients who were developing acute diverticulitis, with a reduction of taxa with anti-inflammatory activity, such as Clostridium cluster IV, Lactobacilli and Bacteroides. Recent observations supported that a dysbiosis characterised by decreased presence of anti-inflammatory bacterial species might be linked to mucosal inflammation, and a vicious cycle results from a mucosal inflammation driving dysbiosis at the same time. An alteration in gut microbiota can lead to an altered activation of nerve fibres, and subsequent neuronal and muscular dysfunction, thus favoring abdominal symptoms' development. The possible role of dysbiosis and mucosal inflammation in leading to dysmotility is linked, in turn, to bacterial translocation from the lumen of the diverticulum to perivisceral area. There, a possible activation of Toll-like receptors has been described, with a subsequent inflammatory reaction at the level of the perivisceral tissues. Being aware that bacterial colonisation of diverticula is involved in the pathogenesis of acute diverticulitis, the rationale for the potential role of probiotics in the treatment of this disease becomes clearer. For this review, articles were identified using the electronic PubMed database through a comprehensive search conducted by combining key terms such as "gut microbiota", "probiotics and gut disease", "probiotics and acute diverticulitis", "probiotics and diverticular disease", "probiotics mechanism of action". However, the amount of data present on this matter is not sufficient to draw robust conclusions on the efficacy of probiotics for symptoms' management in diverticular disease.