Clinical outcomes of diverticular disease in young adults: results from a tertiary referral center

Introduction

Diverticular disease (DD), commonly associated with the elderly, is becoming more prevalent among younger individuals. This retrospective study aimed to evaluate the differences in the natural history and outcomes between young and old patients with DD.

Methods

Adult patients with DD diagnosed between 2010 and 2022 at an Italian tertiary referral center were enrolled, and their demographic and clinical data were retrieved. The patients were categorized as young or old based on the 25th percentile of the population's age at diagnosis. Univariate and multivariate analyses were performed to assess the association between the collected variables and the age of disease presentation. Additionally, survival analyses were conducted to evaluate the association between the age of diagnosis and clinical outcomes at follow-up, including disease recurrence, hospital access, surgery, and death.

Results

A total of 220 DD patients (with a median age of 66 years, IQR 55-74, and a female-to-male ratio of 1.4:1) were included in the study, comprising 54 patients receiving a diagnosis before the age of 49 years (young DD patients) and 166 patients diagnosed after the age of 49 years (old DD patients). Male sex (57 vs. 36%, p < 0.01), smoking (38 vs. 14%, p < 0.01), and alcohol consumption (54 vs. 38%) were highly prevalent in young patients. The complications at the time of diagnosis, particularly abscesses and free perforations, occurred more frequently in younger patients (p = 0.04). Moreover, young DD patients experienced a higher rate of hospitalization and surgical intervention (p = 0.01 and p = 0.04, respectively) over a median follow-up period of 5 years.

Conclusion

Preventive strategies and prompt diagnosis are crucial in young patients with DD for achieving better disease outcomes and preventing complications.

Small Bowel Diverticulitis: An Unusual Cause of Abdominal Pain

Teaching point: Small bowel diverticulitis, much less common than its colonic counterpart, is a diagnosis that must be considered in the presence of abdominal pain, especially in an elderly person.

Right Upper Quadrant Pain: A Rare Presentation of Diverticulitis

Acute diverticulitis is a prevalent medical condition with increasing incidence rates. While the sigmoid colon is the most commonly affected part of the large intestine, there have been occurrences of right-sided diverticulitis although uncommon. We present a case report highlighting the atypical presentation of diverticulitis in a 27-year-old female patient. The patient experienced right upper and epigastric pain and was ultimately diagnosed with right-sided diverticulitis, supported by her CT imaging findings. This uncommon presentation underscores the importance of considering diverse clinical manifestations when diagnosing and managing diverticulitis.

Sensitivity of urine cytology in detecting high-grade urothelial carcinoma in patients with neoplastic urinary bladder diverticula: A major cancer center experience

BACKGROUND

Bladder diverticula are herniations of bladder urothelium and mucosa through the muscularis propria. The reported incidence of neoplasia arising in bladder diverticula is widely variable. The authors' objective was to study the characteristics and sensitivity of urine cytology in these patients with emphasis on primary intradiverticular bladder cancer (IDBC).

METHODS

A 17-year, retrospective review of all resected bladder diverticula associated with bladder carcinoma was performed. Cases that had complete diverticular resections and preresection urine samples were included in this study. The cases were divided into either primary IDBC or primary extradiverticular bladder cancer (EDBC). Demographic data and urine cytology characteristics were recorded, and sensitivity was calculated. For IDBC, a comparison between voided and cystoscopic urines was done for cases that had both collection methods performed.

RESULTS

Of 70 patients with IDBC, 47 patients had urine cytology results that were either positive for high grade-urothelial carcinoma (HG-UC) or suspicious for HG-UC. The sensitivity for HG-UC in IDBC samples was 80%, compared with 82% in EDBC samples (p > .05). Also, 28 patients in the IDBC group had both voided and cystoscopic urine samples for comparisons; in seven patients, the voided urine sample yielded a more definitive diagnosis; in 10 patients, the cystoscopic urine sample yielded a more definitive diagnosis; and, in 11 patients, both samples were equally diagnostic (p > .05).

CONCLUSIONS

The characteristics and sensitivity of urine cytology in bladder diverticula were investigated in association with neoplasia, with an emphasis on primary intradiverticular bladder cancer. The results indicated that urine cytology remains a reliable screening and diagnostic test for detecting IDBC, with sensitivity similar to that for detecting EDBC, and no significant difference was noted between voided and cystoscopic samples.

Different clinical diagnosis end up in the same pathological diagnosis of intravascular leiomyomatosis: Two case reports

RATIONALE

Intravascular/intravenous leiomyomatosis (IVL) is a peculiar variant of uterine leiomyoma that is classified as a histologically benign smooth muscle tumor with a biological behavior similar to that of a malignant tumor. It is characterized by the proliferation of leiomyomas spreading along the uterine and extrauterine venous circulation.

PATIENT CONCERNS

Herein, we present 2 cases of IVL who had completely different clinical manifestations to stress the need for constant vigilance of IVL diagnosis and the understanding of uterine leiomyoma heterogenicity. Case 1 was registered for fever without specific triggering factors, irregular menstruation and clinically diagnosed uterine diverticula, while no information about fibroids was mentioned. Case 2 was characterized by an aggressively growing abdominal mass. With a large space-occupying lesion in the right abdominopelvic cavity and no imaging evidence of involvement of the iliac vein or above vein, the patient was initially diagnosed with multiple myomata.

DIAGNOSES

Both patients' diagnoses were confirmed as IVL by histopathology. To our knowledge, the mass of case 1 is the minimum IVL in the English literature.

INTERVENTIONS

Subtotal hysterectomy with bilateral salpingectomy was performed on the former, while total hysterectomy with bilateral salpingectomy was performed on the latter.

OUTCOMES

Both patients were comfortable, and no relapse occurred.

LESSONS

Two cases in the study showed 2 different proceeding stages of the same disease and corroborated multiple pathogeneses, which have been mentioned in the available literature on IVL. Our work provides both supplement for clinical data to facilitate further research and better understanding of special types of fibroids to clinicians.

Prenatal features and postnatal follow-up of congenital ventricular outpouching: A retrospective study of two centers in China

OBJECTIVES

Congenital ventricular outpouching (CVO) is a rare cardiac malformation that can manifest as congenital ventricular aneurysm (CVA) and/or congenital ventricular diverticula (CVD). In this study, we describe the prenatal features and postnatal follow-up of 27 cases of CVO.

METHODS

The clinical data of 27 patients with CVO who attended Sir Run Run Shaw Hospital Affiliated to the Medical College of Zhejiang University (Zhejiang Province, China) and Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University (Zhejiang Province, China) from April 2013 to October 2022 were retrospectively analyzed. The patients were also followed up by telephone. The prenatal characteristics and postnatal outcomes of the patients with CVO were evaluated.

RESULTS

CVO was detected in 26 cases prenatally, 14 (51.85%) were diagnosed with CVA, nine (33.33%) were diagnosed with CVD, three (11.11%) were equivocal for CVA/CVD, and one (3.70%) was detected with CVA postnatally. Six patients underwent follow-up fetal echocardiography approximately 4 weeks after the initial echocardiography examination, and a significant difference in CVO size was observed between the two examinations (P = .02). Eight patients (29.63%) demonstrated cardiovascular dysfunction, and the median CVO size in fetuses with and without cardiovascular dysfunction was 205 (range: 169-396) mm2 and 124 (range: 92-154.5) mm2 , respectively (P = .01). Correlation was found between CVO size and fetal cardiac dysfunction (p = .000, r = .778). Eight patients (29.63%) had cardiac/extracardiac defects. Thirteen patients were live born, 12 were terminated pregnancies, and two were lost to follow-up. The postpartum size of the CVOs remained stable in six patients, decreased in two patients, dissolved in three patients, and were surgically removed in two patients. With the exception of one patient with CVA complicated with complex congenital cardiac malformation who underwent surgical treatment after birth and who had postoperative left ventricular dysfunction (Case 1), the prognosis of all of the patients was good.

CONCLUSION

CVO is often associated with cardiac malformations. The size of prenatal CVOs can increase with gestational development, and cardiovascular dysfunction is significantly related to CVO size. The postpartum prognosis of patients with CVO is good. Echocardiography plays a key role in the diagnosis of congenital ventricular outpouching. Prenatal counseling should be cautious regarding the diagnosis and the prognosis although our cases had a favorable prognosis.

Diverticulosis and Diverticulitis: Epidemiology, Pathophysiology, and Current Treatment Trends

Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.

Aurora rings may not always indicate an inverted colonic diverticulum: Report of a rare case of colonic lipoma

Aurora rings are prominent endoscopic features of the inverted colonic diverticulum (ICD), and their appearance alongside a colonic lipoma is an unprecedented phenomenon. The present study reports a case of colonic lipoma with Aurora rings, contradicting the assumption that Aurora rings are indicative of ICD. A 52-year-old male patient presented with left-sided abdominal pain for >1 year, associated with constipation in the form of the decreased frequency of bowel motions every 4 to 5 days. A physical examination revealed an obese, protuberant abdomen and a mildly tender left iliac fossa region without other notable findings. A transabdominal ultrasonography revealed a thickening of the large bowel wall (<7 mm) with a suspected inflammatory lesion on the left side of the colon. During an ileocolonoscopy, multiple diffuse diverticula of various sizes were observed, affecting the entire colonic mucosa. Furthermore, a large (1.5 cm) pedunculated polyp with a thick stalk was found in the sigmoid colon, exhibiting positive Aurora rings. A polypectomy was conducted with the deployment of two hemoclips at the polyp base to prevent perforation. The histopathological examination of the specimen, a 1.3 cm polyp, revealed the presence of a colonic lipoma, rather than an ICD. The identification of Aurora rings has emerged as a significant endoscopic feature in the diagnosis of ICD; nevertheless, the underlying etiology of these rings remains elusive. Based on an extensive search of the literature, no study was found mentioning the appearance of Aurora rings in an endoscopic screening of other colonic conditions other than ICD. The appearance of Aurora rings alongside a colonic lipoma has not previously been mentioned, at least to the best of our knowledge, which renders the differentiation of ICD from lipomas and polyps more challenging.

A computed tomography-based survey of paramedullary diverticula in extant Aves

Avian respiratory systems are comprised of rigid lungs connected to a hierarchically organized network of large, regional air sacs, and small diverticula that branch from them. Paramedullary diverticula are those that rest in contact with the spinal cord, and frequently invade the vertebral canal. Here, we review the historical study of these structures and provide the most diverse survey to date of paramedullary diverticula in Aves, consisting of observations from 29 taxa and 17 major clades. These extensions of the respiratory system are present in nearly all birds included in the study, with the exception of falconiforms, gaviiforms, podicipediforms, and piciforms. When present, they share connections most commonly with the intertransverse and supravertebral diverticula, but also sometimes with diverticula arising directly from the lungs and other small, more posterior diverticula. Additionally, we observed much greater morphological diversity of paramedullary airways than previously known. These diverticula may be present as one to four separate tubes (dorsal, lateral, or ventral to the spinal cord), or as a single large structure that partially or wholly encircles the spinal cord. Across taxa, paramedullary diverticula are largest and most frequently present in the cervical region, becoming smaller and increasingly absent moving posteriorly. Finally, we observe two osteological correlates of paramedullary diverticula (pneumatic foramina and pocked texturing inside the vertebral canal) that can be used to infer the presence of these structures in extinct taxa with similar respiratory systems.

Otopathologic and Computed Tomography Correlation of Internal Auditory Canal Diverticula in Otosclerosis

INTRODUCTION

Internal auditory canal (IAC) diverticula, also known as IAC cavitary lesions or anterior cupping of the IAC, observed in otopathologic specimens and high-resolution computed tomography (CT) scans of the temporal bone are thought to be related to otosclerosis. Herein, we examined the usefulness of CT scans in identifying diverticula and determined whether IAC diverticula are associated with otosclerosis on otopathology.

METHODS

One hundred five consecutive specimens were identified from the National Temporal Bone Hearing and Balance Pathology Resource Registry. Inclusion criteria included the availability of histologic slides and postmortem specimen CT scans. Exclusion criteria included cases with severe postmortem changes or lesions causing bony destruction of the IAC.

RESULTS

Ninety-seven specimens met criteria for study. Of these, 42% of the specimens were from male patients, and the average age of death was 77 years (SD = 18 yr). IAC diverticula were found in 48 specimens, of which 46% were identified in the CT scans. The mean area of the IAC diverticula was 0.34 mm 2 . The sensitivity and specificity of detecting IAC diverticula based on CT were 77% and 63%, respectively. Overall, 27% of specimens had otosclerosis. Histologic IAC diverticula were more common in specimens with otosclerosis than those without (37.5% versus 16%; p = 0.019). Cases with otosclerosis had a greater mean histologic diverticula area compared with nonotosclerosis cases (0.69 mm 2 versus 0.14 mm 2 ; p = 0.001).

CONCLUSION

IAC diverticula are commonly found in otopathologic specimens with varied etiologies, but larger diverticula are more likely to be associated with otosclerosis. The sensitivity and specificity of CT scans to detect IAC diverticula are limited.

Characterization of urethral diverticula in males

INTRODUCTION

Urethral diverticulum in a male is a rare entity and the literature is limited to case reports and small case series. The aim of our study is to characterize this disease in patients from three Mayo Clinic locations.

MATERIALS AND METHODS

Chart analysis was performed of patients across all three Mayo Clinic sites that had International Classification of Diseases (ICD) codes corresponding to urethral diverticulum or urethral diverticulectomy via CPT code. Data were available for patients that were seen from 6/1/2003 through 10/5/2018. Patients were classified by age, etiology, presenting symptomatology, location, treatment, pathology, and postoperative outcomes.

RESULTS

A total of 87 men met the initial search criteria with 52 having documented urethral diverticula. The most common presenting complaint in these men was incontinence (37%). The majority of diverticula (83%) were within the anterior urethra. The most common diagnostic modalities were retrograde urethrogram (46%) and cystoscopy (50%). Most diverticula were iatrogenic (77%). Of the men that were diagnosed, 42% went on to have diverticulectomy. Median follow up was 1.5 years. Eighteen percent of patients had persistent urinary symptoms following diverticulectomy with incontinence being the most common finding. Postoperative complications were experienced by 26% patients with the most prevalent complication being urethrocutaneous fistula. The patients who did not undergo diverticulectomy either had other surgical procedure to manage their coexisting conditions or were managed medically.

CONCLUSION

Urethral diverticulum in males is a rare yet important entity that requires special consideration, especially in those who have had prior surgery within the lower urinary tract.

An Unusual Case of Multiple Left Ventricular Aneurysms Masquerading as Diverticula in the Setting of Myocardial Infarction

The distinction between cardiac aneurysms and diverticula can be very difficult by angiography. Left ventricular (LV) aneurysms usually occur following transmural myocardial infarction. On the other hand, cardiac diverticula are most commonly congenital. They are commonly detected by cardiac CT with a prevalence of 2.2%. Here we present a case of a 60-year-old male with the incidental finding of multiple LV aneurysms masquerading as diverticula in the setting of myocardial infarction with near normal coronary arteries. Moreover, this case highlights the limitation of coronary angiography in the diagnosis of myocardial infarction with no obstructive atherosclerosis (MINOCA).

Duplication cyst and diverticulum of the stomach: A case report of an unusual association

Gastric duplication cysts are uncommon findings in adult patients. Accurate diagnosis of these cysts is difficult. Presenting symptoms are often non-specific, and complications are rare. We report an uncommon case of a non-communicating duplication cyst associated to a diverticula of the stomach in 38-year-old women.

Atretic Coronary Sinus Orifice and a Diverticulum of Coronary Sinus Associated with Persistent Left Superior Vena Cava and Accessory Pathway

Coronary orifice atresia and diverticula are considered rare congenital conditions. Our understanding of the coronary sinus (CS) and venous drainage anatomy plays a crucial role in performing interventions and surgical procedures required to improve treatment options and related prognosis for these patients. The case study described herein involves a 29-year-old female patient who was diagnosed with coronary orifice atresia and diverticula. The patient's electrocardiography revealed normal sinus rhythm, short PR interval, and delta wave. Transthoracic echocardiography results showed the subject also suffered from mild CS dilation associated with coronary orifice atresia and diverticula. Our clinical intervention included the use of agitated saline injection which was administered intravenously into the patient's left arm. Our clinical observations during the administration of agitated saline solution did not indicate the presence of any detectable air bubbles entering into the CS. The results of two-dimensional and color flow Doppler study showed that CS connection to the right atrium appeared to be atretic. During our examination, we were also successful in detecting a pulsatile free echo space which was connected through an isthmus to the CS. Electrophysiology study and coronary angiogram performed on the subject confirmed our clinical diagnosis and findings of CS atresia, diverticula, and left superior vena cava.

Interradicular Canals in 213 Mandibular and 235 Maxillary Molars by Means of Micro-computed Tomographic Analysis: An Ex Vivo Study

INTRODUCTION

Bacteria and/or toxin residuals in the furcation areas of mandibular and maxillary molars can be the cause of persistent periapical tissue inflammation before or after an endodontic treatment.

METHODS

The objective of this ex vivo study was to investigate the frequency of interradicular canals and diverticula in first and second mandibular and first and second maxillary molars by means of micro-computed tomographic imaging. Five hundred thirteen extracted molars, 211 mandibular molars and 302 maxillary molars, were included in this investigation. The area between the pulp chamber floor (PCF) and the furcation area was examined, and the data obtained were evaluated with imaging software that generated the corresponding 3-dimensional images. The results were analyzed by means of descriptive statistics.

RESULTS

Interradicular canals were observed in 2.8% and 0.3% of the mandibular and maxillary molars, respectively. The diverticula (blind-ended interradicular canals) originated either at the furcation area or at the PCF. The diverticula frequency observed in mandibular molars was 3.3% (PCF) and 4.3% (bifurcation). The maxillary molar diverticula frequency observed was 2.0% (trifurcation), with none of them originating at the PCF. Altogether (n = 513) diverticula originated more frequently from the PCF (59.1%) than from the furcation area (40.9%).

CONCLUSIONS

Although interradicular canals as well as diverticula were observed in a relatively small number of the investigated molars, practitioners should always be aware of their existence because without an adequate chemical debridement/disinfection of the pulp chamber root canal system, successful endodontic treatment could be compromised in up to 10% of the cases.

Barium esophagogram in various esophageal diseases: A pictorial essay

Recent years have seen a decline in number of barium procedures due to wider availability of cross sectional imaging modalities. Though use of barium esophagography/barium swallow has decreased in day to day clinical practice, it still remains a valuable test for structural and functional evaluation of esophagus. It can be performed as single or double contrast examination or as a multiphasic examination comprising upright double contrast views followed by prone single contrast views. This pictorial essay demonstrates imaging features of various esophageal diseases on barium esophagogram.

Diverticulum of mitral valve

Diverticulum arising from the heart is an uncommon finding. They are incidentally detected by echocardiography as masses arising from the cardiac valves. We present a case of an incidental finding of a diverticulum arising from the mitral valve. This was initially detected by Transthoracic echocardiography and later confirmed by transesophageal echocardiography and pathologic appearance.

Natural History of Ulcerative Colitis with Coexistent Colonic Diverticulosis

Ulcerative colitis (UC) and colonic diverticulosis can co-exist in some patients. However, the natural history of UC associated with colonic diverticulosis is not well known. We here compared the disease characteristics and outcome of UC patients with and without concomitant colonic diverticulosis. Medical records of 347 UC patients were included in an observational, retrospective, nested-matched case-control study. Cases were 92 patients with UC and concomitant colonic diverticulosis, while controls were 255 UC patients without concomitant colonic diverticulosis. A propensity score matching (PSM) was used to homogenate cases (n = 92) and controls (n = 153) for age. UC patients with concomitant colonic diverticulosis were less likely to have an extensive disease (25/92, 27.1%) and to experience steroid dependence (8/92, 8.6%) compared to patients without concomitant colonic diverticulosis (70/153, 45.7% and 48/153, 31.3%, respectively; p < 0.001). The use of immunosuppressants (9/92, 9.7% vs. 37/153, 24.1%; p = 0.007) or biologics (3/92, 3.2% vs. 26/153, 16.9%, p < 0.001) was significantly lower in UC patients with concomitant diverticulosis compared to the control group. On multivariate analysis, steroid dependence and extensive colitis were significantly less frequent in UC patients with concomitant colonic diverticulosis compared to UC patients without diverticula. UC patients with coexisting colonic diverticulosis are less likely to have an extensive disease and to be steroid-dependent.

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service

OBJECTIVE

Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service.

METHODS

We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention.

RESULTS

A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3).

CONCLUSIONS

Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

A multicentre prospective case-control study: the ALADDIN study

AIM

Connective tissue changes due to ageing or diseases leading to changes in the colonic wall are one theory for the development of diverticula. Alpha-1-antitrypsin (A1AT), a protease inhibitor that protects connective tissue, possibly plays a role in the aetiology of diverticulosis. The aim of this study was to explore associations between the development of diverticula and A1AT deficiency.

METHODS

This was a multicentre prospective case-control study. A total of 221 patients aged ≥ 60 years with acute abdominal pain undergoing abdominal CT were included and analysed. Patients with diverticula were defined as the research group, patients without diverticula as controls. Genotype analysis for A1AT deficiency was performed.

RESULTS

Twenty-six of 221 (11.8%) patients were diagnosed with (being a carrier of) A1AT deficiency. A non-significant difference in prevalence between patients with and without diverticula was found, 20 (13.9%) of 144 vs 6 (7.8%) of 77, respectively, with a crude OR of 1.9 (95% CI 0.7-5.0; P = 0.186) and after adjustment for confounders an adjusted OR of 1.5 (95% CI 0.5-4.0; P = 0.466). A non-significant difference in 30-day mortality rate from acute diverticulitis between A1AT deficient patients (or carriers) and those without was observed: two (22.2%) of nine patients with A1AT deficiency vs 1 (1.8%) of 55 without.

CONCLUSION

We found no convincing evidence that A1AT deficiency plays a role in the aetiology of diverticulitis, although deficient patients and carriers had a higher mortality when experiencing diverticulitis. Diverticulitis is a multifactorial disease and larger numbers may be needed to explore the role of A1AT deficiency among other contributing factors.

Comparative Analysis of the Bacterial and Fungal Communities in the Gut and the Crop of Aedes albopictus Mosquitoes: A Preliminary Study

The Asian tiger mosquito Aedes albopictus is a major pathogen vector and one of the world’s most invasive species. In recent years, the study of mosquito-associated microbiota has received growing interest for reducing transmission of mosquito-borne pathogens. Most of studies on mosquito microbiota mainly focused on the gut bacteria. However, microorganisms can also colonize other organs and are not restricted to bacteria. In mosquitoes, the crop is the primary storage organ for sugars from the nectar feeding before it is transferred into the midgut for digestion. No study has yet investigated whether this organ can harbor microorganisms in Ae. albopictus. By using high-throughput sequencing, this study is the first to describe the microbiota including both bacteria and fungi in sugar-fed Ae. albopictus males and females. The results showed the presence of diverse and rich bacterial and fungal communities in the crop of both sexes that did not strongly differ from the community composition and structure found in the gut. Altogether, our results provide a thorough description of the crop-associated microbiota in Ae. albopictus which can open new avenues for further studies on trophic interactions between the mosquito and its microbiota.

Epiphrenic diverticula: An added source of complexity in achalasia management

Epiphrenic (pulsion) esophageal diverticula can occur in the setting of underlying esophageal motility disorders such as achalasia and present a unique management challenge to the gastroenterologist. Asymptomatic diverticula do not require treatment, but symptomatic diverticula require therapy targeted to the underlying esophageal motility disorder, or else the diverticula will recur. Generally, laparoscopic or combined laparoscopic/thoracoscopic myotomy, diverticulectomy, and anterior fundoplication are required. However, therapeutic options for epiphrenic diverticula are evolving as peroral endoscopic myotomy (POEM) becomes more commonplace. We review two cases of achalasia complicated by epiphrenic diverticula at our institution. In the first case, type II achalasia was identified and the patient underwent laparoscopic myotomy. In the second case, type III achalasia was present and the patient underwent successful POEM. We discuss the presentation, pathophysiology, and management of epiphrenic diverticula as well as the expanding role for POEM in diverticula.

Novel swine model of colonic diverticulosis

The pathophysiology of colonic diverticulosis has not been completely understood. The development of appropriate animal models is essential to study diverticular disease. To date, no large animal models are available for this disease condition. The objective of this study was to develop a swine model by damaging the colon wall, combined with or without a low-fiber diet to mimic the pathogenesis of diverticulosis. To create a weakness on the colon wall, collagenase was applied in vivo to degrade the collagen in the colon wall. Three groups of Yucatan minipigs were included. Group 1 (n = 12) underwent collagenase injection (CI) with a low-fiber diet for 6 mo, group 2 (n = 8) underwent CI alone with a standard swine diet for 6 mo, and group 3 (n = 12) received a low-fiber diet alone for 6 mo. We found that diverticulosis occurred in 91.7% (11 of 12) of pigs in the CI + diet group and 100% (8 of 8) in CI-alone group. Moreover, around 30-75% of colon CI spots for each pig developed diverticular lesions. Diet alone for 6 mo did not induce diverticulosis. The endoscopic and histological examinations revealed the formation of multiple wide-mouthed diverticular lesions along the descending colon. Our results provide convincing evidence of the high efficacy of the reduced colon wall strength caused by CI in the development of a swine model of diverticulosis. Low-fiber diet consumption for 6 mo had no influence on the generation time or incidence rate of diverticulosis. In this model, digestion of the collagen in the colonic wall is sufficient to cause diverticulosis. NEW & NOTEWORTHY Effective large animal models of diverticulosis are currently lacking for the study of diverticular disease. This study marks the first time that a swine model of diverticulosis was developed by damaging colon wall structure, combined with or without a low-fiber diet. We found that a defect of colon wall could result in colon diverticular lesions within 6 mo in swine. This animal model mimicking the pathological process of diverticulosis is of great clinical value.

Small intestinal enterolith in a dog presenting for a suspected gastric foreign body

A 12-year-old Labrador Retriever presented for an acute onset of anorexia and vomiting. Abdominal ultrasound and abdominal radiographs were performed, and on the latter a large mineral opaque structure with concentric rings within the cranial abdomen was diagnosed as a gastric foreign body. Laparotomy revealed that the suspected gastric foreign body was a large enterolith within the small intestines. Enteroliths should be considered as one of the differential diagnoses for a large mineralized abdominal structure in a dog presented for gastrointestinal clinical signs.

Diverticular disease and posture during defecation : a prospective comparative study

BACKGROUND AND STUDY AIMS

Although several factors are thought to be responsible for the development of colonic diverticulosis (CD), the underlying pathogenesis is still obscure and needs clarification. The aim of this study was to determine the prevalence, location and clinical features of CD and especially to detect whether there is an association between CD and postures during defecation.

PATIENTS AND METHODS

This prospective study enrolled 757 patients. The subjects were divided into two groups as a diverticulosis group (D group, n:95) and non-diverticulosis group (non-D group, n:662).

RESULTS

The median patient age was 54.9±13.2 years. CD frequency was 12.5% (n:95). The most commonly involved part of the colon was the sigmoid colon (56.8%). Diverticula location was on the left in 45.3% (n:43), on the right in 24.2% (n:23) and on both sides of the colon in 30.5% (n:29). Patients in the D group were older (p<0.001) and were predominantly female (p:0.04). The frequency of sitting during defecation (Western type toilet) was higher in the D group compared to the non-D group (72.2% vs 53.5%; p:0.007). The use-time of a Western-type toilet was longer in the D group compared to the non-D group (p:0.04). In multivariable logistic regression analysis, age and toilet type were independent risk factors for the development of diverticulosis.

CONCLUSION

Sitting during defecation seems to increase the risk of CD.

Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature

Jejunal diverticulitis is a rare entity with a higher prevalence among patients between 60 and 70 years. Jejunal diverticula are most often considered an incidental finding, but, they can have complications such as diverticulitis, perforation, abscess, generalized peritonitis, fistula, obstruction and bleeding.Setting the diagnosis still remains challenging. Physicians should be aware of their existence and the clinical suspicion should be raised, especially in the setting of acute abdominal pain where jejunal diverticulitis should be included in the differential diagnosis. A small amount of free air adjacent to the small bowel can be confusing and easily misdiagnosed as small bowel perforation, but, it can actually be found as a result of the inflammation itself without macroperforation or complications.This fact can change the therapeutic strategy to less aggressive, conservative treatments. We present a case of a patient coming to the emergency department with acute abdominal pain, signs of peritonitis, a small amount of extraluminal air, and jejunal diverticulitis without perforation was diagnosed on laparotomy, and a review of the current literature.

Factors associated with diverticular bleeding and re-bleeding: A United States hospital study

OBJECTIVE:

Diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Arteriovascular disease, metabolic syndromes, non-steroidal anti-inflammatory drugs (NSAIDs), anti-thrombotics, and anticoagulants have been suggested as risk factors. There is a paucity of studies addressing factors associated with diverticular re-bleeding, especially in the United States. The aim of this study is to evaluate factors associated with colonic diverticular bleeding and re-bleeding in a US community-based hospital.

METHODS:

We conducted a retrospective case-control study to analyze the factors associated with diverticular bleeding. Between January 2010 and July 2011, 93 patients were admitted to our hospital with a primary diagnosis of acute diverticular bleeding. We compared them to 152 patients who were admitted with a primary diagnosis of diverticulitis in the same period. We collected data from the medical records of each patient in relation to the demographics, comorbidities, medications, social habits, location of diverticulosis, length of stay in the hospital, and re-bleeding rate within 2 years of the first bleeding episode.

RESULTS:

Factors such as cerebrovascular accident (p=0.009), coronary artery disease (p=0.037), diabetes mellitus (p=0.046), obstructive sleep apnea (p=0.033), NSAIDs (p=0.038), use of anti-thrombotics (p=0.001), anticoagulants (p=0.002) or calcium channel blockers (p=0.009), and bilateral diverticulosis (p=0.001) were significantly associated with diverticular bleeding as compared to diverticulitis. Recurrence of bleeding was noted in 26 out of 93 patients (28%) within 2 years of the first bleeding episode (p=0.001). Bilateral colonic involvement, anticoagulants, and elderly age (≥65 years) were found to have a closer relationship to diverticular re-bleeding, although it was not statistically significant.

CONCLUSION:

This study reveals that arteriovascular disease, diabetes mellitus, NSAIDs, the use of anti-thrombotics, anticoagulants or calcium channel blockers, and obstructive sleep apnea are factors that are significantly associated with diverticular bleeding. It also shows that bilateral colonic involvement, elderly age, and anticoagulants have a closer relationship to diverticular re-bleeding. More prospective studies in patients with diverticular bleeding should be conducted to shed light on the causality of these factors and the prevalence of diverticulitis.

Small Gut Volvulus, A Rare Twist, In The Setting Of An Even Rarer Entity; Multiple Giant Jejuno Ileal Diverticula

Small gut volvulus with multiple Jejuno-ileal diverticulosis is an unusual pathology of the small intestine with a scarce number of cases reported so far. It usually goes unnoticed because it is often asymptomatic but complications like diverticulitis, perforation, bleeding or intestinal obstruction can occur in 10-30% of the cases. Mechanical obstruction, if it occurs, can be caused by adhesions or stenosis due to diverticulitis, intussusception at the site of the diverticulum and volvulus of the segment containing the diverticula. Acute volvulus of the small bowel is a serious abdominal emergency that poses a difficulty in diagnosis and delayed operative intervention can lead to dire consequences. We herein report the case of a 42-yearold man presented at the emergency department with acute abdominal pain, absolute constipation and vomiting. Preoperative investigations followed by laparotomy revealed small gut volvulus and multiple giant jejunal and ileal diverticula.

Increased serological cancer-associated biomarker levels at large bowel endoscopy and risk of subsequent primary cancer (†)

BACKGROUND

Frequently, subjects offered colonoscopy due to symptoms of colorectal neoplasia are diagnosed with diverticula. The symptoms may, however, also be related to extra-colonic neoplasia. The present retrospective study evaluated a possible association between increased levels of predefined biomarkers in subjects diagnosed with diverticula and risk of developing a primary malignant disease.

METHODS

During 2004/2005, about 4509 subjects were included in a multicenter study with collection of blood samples before bowel endoscopy. The aim was to evaluate a relation between the protein biomarkers CEA, TIMP-1, CA19-9 and YKL-40 and findings at endoscopy. Diverticula were diagnosed in 1021 subjects. By 31 December 2012, subjects who had developed primary malignancy were identified retrospectively and relation between biomarker levels at endoscopy and risk of developing primary malignancy was calculated. The relation with the four biomarkers was divided into three groups: 0 = none increased; 1 = one increased and 2 = two or more increased.

RESULTS

In the observation period, 148 subjects developed a primary malignant disease. Univariable analyzes of the biomarker levels showed that CEA, TIMP-1 and CA19-9 were significantly associated with development of primary malignancy. A multivariable analysis showed that increased levels were associated with development of malignancy (p < 0.0001). The 1- and 5-year cumulative risks of being diagnosed with a primary malignancy were: group 0: 1.1%/5.5%; group 1: 4.2%/10.1% and group 2: 11.4%/18.8%, respectively.

CONCLUSION

Increased levels of CEA, TIMP-1 and CA19-9 at endoscopy with findings of diverticula were associated with a significantly increased risk of being diagnosed with a subsequent primary malignant disease.

Esophageal diverticula are associated with propagating peristalsis: a study utilizing high-resolution manometry

BACKGROUND

Esophageal diverticula have been associated with esophageal motility disorders, most commonly achalasia. We aimed to evaluate high-resolution manometry (HRM) motility diagnoses and pressurization patterns in patients with esophageal diverticula.

METHODS

Patients were retrospectively identified for distal esophageal diverticula and previously completed HRM. High-resolution manometries were analyzed according to the Chicago Classification, and the pressure slope of the compartmentalization phase (time between upper esophageal sphincter closure and the transition zone) of esophageal bolus transit was measured. Pressure slopes were also measured in 10 asymptomatic volunteers (controls) for comparison.

KEY RESULTS

Nineteen patients (ages 31-83) were included. Eight (42%) patients had normal motility, five (26%) had esophagogastric junction outflow obstruction, and two (11%) had jackhammer esophagus; four patients had other motility diagnoses including only one patient with achalasia. A total of six patients (32%) had at least one hypercontractile swallow. Greater compartmentalization phase pressure slopes were observed in patients at the mid-esophageal body in both supine (median [interquartile range]: 1.9 mmHg/s [0.9, 3.6]) and upright (1.1 [0.1, 3.1]) positions than in controls (supine: -1.3 [-2.4, -0.11], p = 0.001; upright; -0.71 [-2.1, -0.02], p = 0.005).

CONCLUSIONS & INFERENCES

Propagating peristalsis, often with hypercontractility, was commonly seen in our cohort of patients with esophageal diverticula. Abnormal compartmentalization phase pressurization may indicate a relationship of abnormal esophageal wall mechanics and/or compliance with diverticula; however whether these findings are causal or reactionary remains unclear.

Diverticula and Diverticulitis: Time for a Reappraisal

Colonic diverticula are very common and may be associated with symptoms or complicated by diverticulitis and its associated problems. Many of the traditional concepts relating to the pathophysiology, prevention, and management of these entities have been questioned recently based on findings from high-quality prospective studies. Although dietary fiber may protect against symptoms and complications, its impact on the formation of diverticula may be limited. It is now evident that the risk for an episode of diverticulitis in an individual with diverticula is lower than previously thought. Furthermore, the necessity for antibiotic use in uncomplicated diverticulitis has been questioned and serious doubt cast upon the belief that surgery should be performed when a second attack occurs. Although data are far from conclusive, there is some evidence to suggest that diverticulosis may be associated with chronic abdominal symptoms, with or without underlying chronic inflammatory changes in the involved segment of the colon. In addition, colonoscopy is not routinely required after an attack of acute uncomplicated diverticulitis, as the risk of cancer in this population is not much higher than in the general population.

Primary congenital bladder diverticula: Where does the ureter drain?

BACKGROUND

Primary congenital bladder diverticulum (PCBD) is related to a deficient detrusor layer allowing out-pouching of the bladder mucosa through the inadequate muscularis wall. We aimed to review our experience with symptomatic PCBD in order to correlate clinical findings with anatomical aspects and to present late outcome.

MATERIALS AND METHODS

We reviewed all patients operated in our institution since 2004. We evaluated the charts for complaints, radiological exams, method of treatment, complications and length of follow-up.

RESULTS

We treated 10 cases (11 renal units - [RU]), predominantly males (9/10), mean age at surgery of 5.3 years. All patients had significant urological complaints presenting either with antenatal hydronephrosis (4) or febrile urinary tract infection (5) and urinary retention in one. The ureter was found implanted inside the diverticulum in 8/11 RU. An extravesical psoas-hitch ureteroneocystostomy and diverticulum resection was performed in 10/11 cases, whereas 1 case was treated intravesically based on surgeon's preference without performing cystoscopy. Mean follow-up was 34.1 months (1-120) without complications.

CONCLUSIONS

PCBD is an uncommon diagnosis and has a high probability of drainage inside the diverticulum (72.7%). We recommend the extravesical approach associated with diverticulectomy and ureteroneocystostomy as the preferred technique to treat this abnormality.

A multi detector computed tomography survey of tracheal diverticulum

OBJECTIVE

Tracheal diverticulum (DV) is an incidental finding in thoracic computed tomography examinations. Tracheal DV may be associated with chronic cough and chronic obstructive pulmonary disease (COPD). A few studies have investigated the relationship between tracheal DV and COPD. There is still no consensus on the relationship. The purpose of this study was to determine the incidence of tracheal DV and its coexistence with bronchial DV and hyperaeration.

MATERIALS AND METHODS

For the study, 299 patients from a total number of 12 800 patients who underwent a thoracic computed tomography examination were included. Tracheal diverticula were evaluated for localization, size, contour, wall thickness and communication with the tracheal lumen. The association of tracheal DV with bronchial DV and hyperaeration was also noted. The relationship between tracheal DV and hyperaeration was analyzed.

RESULTS

Of the 299 patients, a total of 412 tracheal diverticula were observed. Out of these, 148 of the tracheal diverticula were in females, and 264 of the tracheal diverticula were in male patients. The incidence of tracheal DV was determined to be 2.38% in this study. In total, 400 of the tracheal diverticula (97.1%) were located at the right posterolateral aspect of the trachea, and 320 of the tracheal diverticula were associated with hyperaeration. There was no significant relation between the tracheal DV and hyperaeration. However, 84 of 412 tracheal diverticula had a bronchial DV, and 72 of 84 of these bronchial DV were associated with COPD. Statistical analysis indicated a significant correlation with COPD and bronchial DV (p<0.05).

CONCLUSION

Tracheal DV is often asymptomatic and mostly located in the right posterolateral aspect of the trachea. Tracheal DV is more common in men than in women. The incidence of tracheal DV was 2.38% in this study. Our data demonstrate that there was no significant association between tracheal DV and COPD. However, there was a significant association between subcarinal bronchial DV and COPD.

Carbon dioxide laser versus stapler-assisted endoscopic Zenker's diverticulotomy: a systematic review and meta-analysis

To evaluate outcomes following endoscopic management of Zenker's diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.

Case report and treatment options]

BACKGROUND

the presence of duodenal diverticula was first described in 1710 by Chromel. Duodenal diverticulum is the second most common site of diverticula in the digestive tract. Anatomically duodenal diverticula are located in 10 to 67% in the second portion of duodenum, and its finding in most cases incidental. About 90% of patients appear asymptomatic, manifesting symptoms mostly once established complications such as: gastrointestinal bleeding and perforation.

CLINICAL CASE

78-years-old woman who attended our Emergency department with dyspnea, moderate epigastralgia, abdominal bloating, constipation and difficulty to pass gas; Laparotomy was performed to identify duodenal diverticulum in the third portion of the duodenum with a perforation of 5 mm in its cupula. It proceeds with diverticulectomy.

CONCLUSIONS

The diagnosis of duodenal diverticulum as a cause of acute abdomen must be considered in our differential diagnosis in acute abdomen supported by imaging and endoscopy. The surgical management of duodenal diverticulum, in particular the resection of the diverticulum, remains as the recommendation for treatment with less morbidity and a good recovery.

Adult polycystic kidney disease: a disorder of connective tissue?

Adult polycystic kidney disease (APCKD) is one of the most common serious inherited disorders. Many affected patients succumb to the renal and non-renal manifestations of this autosomal dominant disease. The disease is characterized by cyst formation in several organs, most obvious of which is in the renal parenchyma. Other features associated with the disease include hepatic fibrosis, hepatic, pancreatic and splenic cyst formation, Berry aneurysms, colonic diverticulae, hernias and cardiac valvular disorders. Rupture of Berry aneurysm is a sudden and often fatal manifestation in some unsuspected cases of APCKD. We recently examined one surgically removed kidney from a 15-year-old male patient with APCKD. In addition to the classical cystic change, extensive changes in renal parenchymal matrix and vasculature are also present. The excessive and weak matrix may contribute to dilatations of both renal tubules giving rise to cysts and the blood vessels. Our findings suggest that APCKD may be a connective tissue disorder in which alteration of extracellular matrix may be a common denominator for the manifestations and organ pleotropism of APCKD.

Diverticular disease of the colon in Korea

This study is designed to determine the relative prevalence and characteristics of diverticular disease of the colon in Korea. We did a retrospective evaluation of 16,964 consecutive barium enemas performed at Koryo General Hospital between January 1971 and October 1986, and found 100 patients with diverticular disease of the colon. The results are as follows: 1) Colonic diverticula were found in 100 patients, and incidence of 0.59% in 16,964 consecutive barium enemas. The male to female ratio was 2.1:1. 2) Incidence rose with advancing age from 0.45% in the second decade to 2.5% in the seventh decade. 3) Patient age ranged from 19 to 77 years with more than 70% of the patients in the 5th, 6th and 7th decades. 4) The greater majority (81%) of the diverticular disease the right colon. 5) Fifty percent of the cases were classified as multiple diverticula. 6) The mean age of patients with right sided diverticula was 47.5 years and that of patients with left sided diverticula was 57.7 years. The mean age of single diverticular patients was 50.4 years and that of multiple diverticular patients was 48.4 year. 7) Associated diseases were hemorrhoids (18%), gall stones (12%) and previous appendectomy (11%). Among the 29 patients who had hemorrhoids and or a previous appendectomy, 28 of those had right sided diverticula.