Diverticular complications of renal failure

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.

Symptomatic Diverticular Disease in Patients With Severely Reduced Kidney Function: Higher Rates of Complications and Transfusion Requirement

Background

The prevalence of diverticulosis is increasing with 5-10% of patients developing diverticulitis and 5-15% developing symptomatic bleeding. Diverticulitis can result in abscess, perforation, fistula, or obstruction. Bleeding has combined morbidity and mortality rates of 10-20%. The purpose of this study was to compare diverticulitis-related complications and transfusion requirements for diverticular bleeding in patients with normal to moderately reduced kidney function (glomerular filtration rate (GFR) ≥ 30 mL/min/1.73 m²) and patients with severe renal impairment (GFR < 30 mL/min/1.73 m²), and identify factors associated with these outcomes.

Methods

We retrospectively reviewed records of all patients with diverticulitis and diverticular bleeding treated at our hospital from January 1, 2011 to July 31, 2016. Patients were evaluated for baseline characteristics, GFR, baseline hemoglobin, medications, comorbidities, length of stay (LOS), presence of perforations or abscesses and the need for transfusion.

Results

Of the 291 patients included, males were 167 (58%). Perforations and abscesses complicating diverticulitis developed in 31/136 (23%) of patients with GFR ≥ 30 mL/min/1.73 m², and in 13/26 (50%) of patients with GFR < 30 mL/min/1.73 m² (odds ratio (OR): 3.4; 95% confidence interval (CI): 1.423 - 8.06; P = 0.0073). Mean LOS (days) was 6.3 ± 4 in the GFR ≥ 30 mL/min/1.73 m² group and 8.5 ± 4.4 in GFR < 30 mL/min/1.73 m² group (P = 0.0001). Blood transfusion for diverticular bleeding occurred in 11/78 (14%) of patients with GFR ≥ 30 mL/min/1.73 m² and in 22/51 (43%) of patients with GFR < 30 mL/min/1.73 m² (OR: 4.6; 95% CI: 1.99 - 10.76; P = 0.0004). Among patients who needed transfusion, mean LOS was 8.5 ± 2.5 in GFR ≥ 30 mL/min/1.73 m² group and 9 ± 5 in those with GFR < 30 mL/min/1.73 m² (P = 0.04). There were no differences in age, gender or race between the study groups.

Conclusion

There was a significant increase in complicated diverticulitis cases, transfusion requirements for diverticular bleeding and LOS in patients with severely reduced kidney function compared to patients with normal-moderately reduced renal function.

Colorectal surgery after kidney transplantation: characteristics of early vs. late posttransplant interventions

BACKGROUND

The majority of colorectal complications after kidney transplantation reportedly occur <1 year of transplant. We aimed to identify differences in complications in the early and late posttransplant period.

METHODS

We retrospectively reviewed kidney transplant recipients undergoing colorectal resection from 1 June 2000 to 1 June 2012 at a single institution, comparing patients by posttransplant year (<1 vs. >1 year). Measured outcomes included major complications, postoperative length of stay, perioperative mortality, reoperations, and readmissions.

RESULTS

We identified 45 patients aged 31-77 (median 55). Gastrointestinal malignancy (31 %), diverticular disease (24 %), and ischemic colitis (16 %) were the most common indications for surgery. The early group (n = 9) had more cases of ischemic colitis (44 vs. 6 %, p = 0.01), emergent operations (100 vs. 33 %, p = 0.0003), blood transfusion (78 vs. 31 %, p = 0.02), longer length of stay (23.2 ± 12 vs. 11.7 ± 10 days, p = 0.02), and higher mortality rate (33 vs. 6 %, p = 0.05 compared to the late group (n = 36)). There were no significant differences in major complications, reoperations, or readmissions.

CONCLUSIONS

Kidney transplant recipients undergoing colorectal resection <1 year of transplant have a higher incidence of emergency surgery and ischemic colitis compared with those with >1 year posttransplant. Despite these findings, patients with grafts <1 year had a similar postoperative complication rate to patients with grafts >1 year.

Lanthanum, constipation, bafflying X-rays and a perforated colonic diverticulum

Lanthanum carbonate (LC) is used as a phosphate binder in dialysed patients. Abdominal pain and constipation are known side effects of its use. Furthermore, in radiological studies, LC tablets are seen as intense radio-opaque deposits within the entire gastrointestinal tract—findings which can lead to diagnostic misinterpretations. An elderly patient on peritoneal dialysis and taking LC presented with peritonitis, secondary to a perforated colonic diverticulum. The possible association between the use of LC, worsening constipation and complications arising from colonic diverticular disease, are discussed.

Hypertension and concomitant arteriosclerotic diseases are risk factors for colonic diverticular bleeding: a case-control study

PURPOSE

Colonic diverticular bleeding is a major cause of lower gastrointestinal bleeding. However, a limited number of studies have been reported on the risk factors for diverticular bleeding. Our aim was to identify risk factors for diverticular bleeding.

METHODS

Our study design is a case (diverticular bleeding)-control (diverticulosis) study. We prospectively collected information of habits, comorbidities, history of medications and symptoms by a questionnaire, and diagnosed diverticular bleeding and diverticulosis by colonoscopy. Logistic regression models were used to estimate odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 254 patients (diverticular bleeding, 45; diverculosis, 209) were selected for analysis. Cluster (≥10 diverticula) type (OR, 4.0; 95% CI, 1.8-8.9), hypertension (OR, 2.2; 95% CI, 1.0-4.6), ischemic heart disease (OR, 2.4; 95% CI, 1.1-5.4), and chronic renal failure (OR, 6.4; 95% CI, 1.3-32) were independent risk factors for diverticular bleeding.

CONCLUSIONS

Large number of diverticula, hypertension, and concomitant arteriosclerotic diseases including ischemic heart disease and chronic renal failure are risk factors for diverticular bleeding. This study identifies new information on the risk factors for diverticular bleeding.

Diverticulitis

Diverticulitis is an important complication of diverticulosis that affects only 10% to 20% of patients with this condition. Medical and surgical aspects of management of diverticulitis are discussed in this article. Some unusual and less well-known complications and manifestations of this common clinical problem are also described. This disease remains a challenging problem that demands sound clinical judgement by the internist and the surgeon.

Colonic diverticulitis in young patients with chronic renal failure and transplantation

The association of colonic diverticulitis with chronic renal failure is well known. In those patients with "adult" autosomal dominant polycystic kidney disease, colonic diverticulitis is an especially common complication. We present two young patients (one teenager and one mid-twenties) who developed intra-abdominal abscess several years after renal transplantation. Neither patient had autosomal dominant polycystic disease nor a known history of gastrointestinal problems but both proved to have underlying, previously unsuspected colonic diverticular disease with abscess formation.