Diverticular disease of the colon in a far-eastern community

Dietary pattern and its association with right-colonic diverticulosis

BACKGROUND AND AIM

In East Asia, colonic diverticulosis develops most commonly in the right colon and is known to have different characteristics compared with left-sided one. This study was designed to investigate whether right-colonic diverticulosis is associated with posteriori dietary patterns.

METHODS

We retrospectively reviewed medical records of prospectively collected cohort that received health check-up in Korea between May 2011 and January 2012. Their anthropometric data, biochemical results, medication history, underlying diseases, colonoscopic findings, and dietary data obtained from semi-quantitative food-frequency questionnaire were analyzed. Three dietary patterns were identified using factor analysis: healthy dietary pattern (vegetables, fish, seaweed, fruits, and beans), meat dietary pattern (red meat, processed meat/fish, fried noodle, poultry, and cephalopods), and snack dietary pattern (bread, sweets, dairy products, nuts, and rice cake).

RESULTS

Out of the total 1911 patients, 203 (10.6%) had right-colonic diverticulosis, 21 (1.1%) had pan-colonic diverticulosis, and 12 (0.6%) had left-colonic diverticulosis. Among the total, none of the three patterns were associated with right-colonic diverticulosis, under adjustment with age, gender, body mass index, metabolic syndrome, and total energy intake. However, among women, meat dietary pattern was positively associated with right-colonic diverticulosis (odds ratio 1.866, 95% confidence interval: 1.0983-3.173, P = 0.021).

CONCLUSION

This study demonstrated that meat dietary pattern is positively associated with right-colonic diverticulosis among women.

A seven-year retrospective review of colonoscopy records from a single centre in Zambia

Introduction

Colorectal disease is common throughout the world, but the spectrum of diagnoses across Africa remains largely unexplored. There is anecdotal evidence of changing colorectal disease but this has not been systematically investigated. The aim of this study was to enhance our insight into the spectrum of colonoscopic diagnoses in Zambia.

Methods

We retrieved written colonoscopy reports from January 2008 to December 2015. Collected data were coded by experienced endoscopists and analysed by age, sex, referral source, indication and diagnosis.

Results

Included in this analysis were 573 colonoscopy reports. The most common diagnosis was haemorrhoids (n=151, 26%), followed by tumours (n=96,17%). Over this time period, the proportion of normal colonoscopies decreased by 32% (P<0.001), presumably due to introduction of screening of all requests, while the rate of polyp detection increased from 5% to 10% (P=0.006). The detection of polyps was highest in patients less than 16 years (OR 8.4; 95% CI 2.4–26.2, P<0.001). Of those with colorectal tumours, 33/96 (35%) were less than 45 years although the occurrence was higher with advancing age (P=0.02). Diverticular disease was more common in older age groups (median (IQR) age 70 (60–75) years, versus 47 (34–62) years for those without the disease; P=0.0001).

Conclusion

This audit has shown that more than a third of colorectal tumours seen during colonoscopy are in patients below the age of 45 years, with the occurrence of polyps being highest in those below 16 years. Diverticular disease is most common in older age groups.

Risk factors for recurrence of right colonic uncomplicated diverticulitis after first attack

PURPOSE

Most patients with acute right colonic uncomplicated diverticulitis can be managed conservatively. The aim of this study was to assess the clinical and radiologic risk factors for recurrence in patients with right colonic uncomplicated diverticulitis.

METHODS

The present survey included 469 patients who were successfully managed conservatively for the first episode of right colonic uncomplicated diverticulitis between 2002 and 2012 in a referral center, and records were reviewed from collected data. Patients were divided into two groups: a nonrecurrent and a recurrent group. The clinical and radiologic features of all patients were analyzed to identify possible risk factors for recurrence. The Kaplan-Meier method and Cox regression were used.

RESULTS

Seventy-four (15.8 %) patients had recurrence, and 15 (3.2 %) received surgery at recurrence within a median follow-up of 59 months. The mean recurrence interval after the first attack was 29 months. In univariate and multivariate analyses, risk factors for recurrence were confirmed multiple diverticula (relative risk [RR], 2.62; 95 % confidence interval [CI], 1.56-4.40) and intraperitoneally located diverticulitis (RR, 3.73; 95 % CI, 2.13-6.52). Of 66 patients with two risk factors, 36 (54.5 %) had recurrence and 10 (15.2 %) received surgery at recurrence.

CONCLUSIONS

In patients with right colonic uncomplicated diverticulitis who have multiple diverticula and intraperitoneally located diverticulitis, the possibility of recurrence and surgical rate are high. Poor outcome may be cautioned in these patients.

Pattern and distribution of colonic diverticulosis: Analysis of 2877 barium enemas in Thailand

AIM: To determine the pattern and distribution of colonic diverticulosis in Thai adults.

METHODS: A review of the computerized radiology database for double contrast barium enema (DCBE) in Thai adults was performed at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. Incomplete studies and DCBE examinations performed in non-Thai individuals were excluded. The pattern and distribution of colonic diverticulosis detected during DCBE studies from June 2009 to October 2011 were determined. The occurrence of solitary cecal diverticulum, rectal diverticulum and giant diverticulum were reported. Factors influencing the presence of colonic diverticulosis were evaluated.

RESULTS: A total of 2877 suitable DCBE examinations were retrospectively reviewed. The mean age of patients was 59.8 ± 14.7 years. Of these patients, 1778 (61.8%) were female and 700 (24.3%) were asymptomatic. Colonic diverticulosis was identified in 820 patients (28.5%). Right-sided diverticulosis (641 cases; 22.3%) was more frequently reported than left-sided diverticulosis (383 cases; 13.3%). Pancolonic diverticulosis was found in 98 cases (3.4%). The occurrence of solitary cecal diverticulum, rectal diverticulum and giant diverticulum were 1.5% (42 cases), 0.4% (12 cases), and 0.03% (1 case), respectively. There was no significant difference in the overall occurrence of colonic diverticulosis between male and female patients (28.3% vs 28.6%, P = 0.85). DCBE examinations performed in patients with some gastrointestinal symptoms revealed the frequent occurrence of colonic diverticulosis compared with those performed in asymptomatic individuals (29.5% vs 25.3%, P = 0.03). Change in bowel habit was strongly associated with the presence of diverticulosis (a relative risk of 1.39; P = 0.005). The presence of diverticulosis was not correlated with age in symptomatic patients or asymptomatic individuals (P > 0.05).

CONCLUSION: Colonic diverticulosis was identified in 28.5% of DCBE examinations in Thai adults. There was no association between the presence of diverticulosis and gender or age.

Acute inflammation of the true cecal diverticulum--case report

In this case report, we describe a rare event: acute inflammation of the true cecal diverticulum. Emergency surgery enabled proper diagnosis and management of this condition. Diagnostic approaches and the management of this disease are described in detail and based on literature review. In conclusion, pathologies of cecal diverticula should be considered in differential diagnosis of pain in the right iliac fossa.

Association between colonic polyps and diverticular disease

AIM: To evaluate the association between colonic polyps and diverticular disease in Japan.

METHODS: We retrospectively reviewed the medical records of 672 consecutive patients who underwent total colonoscopy between August 2006 and April 2007 at Nishinjo Hospital, Okinawa, Japan. Patients with a history of any of the following were excluded from the study: previous polypectomy, colonic resection, and inflammatory bowel diseases. The association between colonic polyps and diverticular disease was analyzed by logistic regression analysis, adjusted for age and sex.

RESULTS: Prevalence of colonic polyps in all patients with diverticular disease was significantly higher than that in those without diverticular disease (adjusted odds ratio 1.7).

CONCLUSION: Our data showed that patients with diverticular disease have a higher risk of colonic polyps compared to those without.

Epidemiology and management of diverticular disease of the colon

The aim of this review is mainly to show the high prevalence of diverticulosis and the clinical relevance of uncomplicated and complicated diverticular disease worldwide. The prevalence of diverticular disease is directly related to the aging of the population and in western countries is diagnosed in approximately 50–65% of adult subjects. The often more frequent adoption of an incorrect dietary style, such as a low-fiber diet, and the progressive increase in the average age of western populations will increase the prevalence of this pathology and the economic burden for health systems even more so. Furthermore, the management of uncomplicated diverticular disease, segmental colitis associated to diverticula and diverticulitis, which represent the different manifestations of the symptomatic spectrum of colonic diverticulosis, are reported.

Review article: uncomplicated diverticular disease of the colon

Diverticular disease of the colon is the fifth most important gastrointestinal disease in terms of direct and indirect health care costs in western countries. Uncomplicated diverticular disease is defined as the presence of diverticula in the absence of complications such as perforation, fistula, obstruction and/or bleeding. The distribution of diverticula along the colon varies worldwide being almost always left-sided and directly related to age in western countries and right-sided where diet is rich in fibre. The pathophysiology of diverticular disease is complex and relates to abnormal colonic motility, changes in the colonic wall, chronic mucosal low-grade inflammation, imbalance in colonic microflora and visceral hypersensitivity. Moreover, there can be genetic factors involved in the development of colonic diverticula. The use of non-absorbable antibiotics is the mainstay of therapy in patients with mild to moderate symptoms, and the effect of fibre-supplementation alone does not appear to be significantly different from placebo, although no definite data are available. More recently, alternative treatments have been reported. Mesalazine acts as a local mucosal immunomodulator and has been shown to improve symptoms and prevent recurrence of diverticulitis. In addition, probiotics have also been shown to be beneficial by re-establishing a normal gut microflora. In this study, the current literature on uncomplicated diverticular disease of the colon is reviewed.

An analysis of the development of colonic diverticulosis in the Japanese

PURPOSE

There are quite different characteristics between colonic diverticulosis in the West and that in Asia, including Japan. These differences include the predominance of a few diverticula over others, right-sidedness, young generation, male, and few complications. In Japan, colonic diverticulosis started increasing in the 1970s. This study was performed to obtain exact evidence of diverticular development in contemporary Japanese by observing changes in diverticula in the same individuals examined over a period of ten or more years.

METHODS

This study included 82 subjects (56 (68 percent) males and 26 (32 percent) females) who underwent barium enema examinations repeatedly for more than ten years from 1982 to 2000. The diverticula were categorized according to their location in the colon: right, left, or bilateral. They were also categorized by whether they appeared individually, were scattered with two to nine diverticula, or were numerous with ten or more diverticula.

RESULTS

At the beginning of observation, the most frequent location was the right side (55; 67 percent), followed by bilateral (20; 24 percent) and the left side (7; 9 percent). Ten or more years later, the number on the right side had decreased to 39 (48 percent). The number of bilateral diverticula had increased to 38 (46 percent), and the number on the left had barely changed, to 5 (6 percent). The number of diverticula increased from 253 to 604 (239 percent) in the right and from 380 to 929 (244 percent) in the bilateral. The initially very small number in the left increased from 9 to 48 (533 percent). The data show marked increases in the right and bilateral diverticula, and also the spread from the right side to the left side.

CONCLUSION

In contemporary Japanese, although the right predominated initially, diverticulosis showed a strong tendency to increase and spread from the right to the bilateral. The number of bilateral diverticula also tended to increase. The left did not change much.

Colonic diverticular disease in a multiracial Asian patient population has an ethnic predilection

BACKGROUND

Traditionally, diverticular disease of the colon has been attributed to ageing, low dietary fibre and a high intraluminal pressure. Recently, genetic and racial factors have also been implicated.

METHODS

Four-hundred and ten consecutive multiracial Asian patients undergoing colonoscopy for a variety of bowel symptoms in a private endoscopy unit were studied for differing frequencies (if any) in colonic diverticular disease and concomitant abnormalities.

RESULTS

Forty-one patients (10%) had diverticular disease. Diverticula were present in 22/147 Chinese (15%), 14/153 Indians (9%) and 5/110 Malays (4.5%). The mean age of patients with diverticular disease was 55 years as compared with 51.3 years in those without (P = 0.12) and there was no gender difference. Thirty-six patients (88%) had diverticula in the right colon only, four patients (10%) exclusively in the left hemicolon, and one patient (2%) had bilateral involvement. Using regression analysis, Chinese ethnicity [odds ratio (OR)=2.11; 95% confidence interval (CI), 1.09-4.09; P = 0.027), constipation (OR = 2.65; 95% CI, 1.23-5.42; P = 0.007) and colorectal adenomas (OR = 2.65; 95% CI, 1.08-6.46; P = 0.033) were independently associated with diverticular disease.

CONCLUSIONS

Colonic diverticular disease in a multiracial Asian patient population has an ethnic predilection and is predominantly right-sided.

Diverticular disease of the colon: New perspectives in symptom development and treatment

Diverticular disease of the colon is a common disease worldwide. Although the disease is asymptomatic in about 70%-80% of patients, it represents, at least in Western countries, one of the most important gastrointestinal diseases in terms of direct and indirect health costs. Pathogenesis of the disease is still unknown. However, it is the result of complex interactions between colonic structure, intestinal motility, diet and genetic factors. Whilst efficacious preventive strategies remain to be identified, fibre supplementation in the diet is recommended. Why symptoms develop is still unclear. Results of recent experimental studies on irritable bowel syndrome speculated that low grade inflammation of colonic mucosa, induced by changes in bacterial microflora, could affect the enteric nervous system, which is crucial for normal gut function, thus favouring symptom development. This hypothesis could be extrapolated also for diverticular disease, since bacterial overgrowth is present, at least in a subgroup of patients. These perspectives on symptom development are reviewed and new therapeutic approaches are hypothesized.

Decision making in right-sided diverticulitis

AIM: To evaluate systematically our nine-year experience in treating right-sided diverticulitis of the colon, and to explore its clinical and radiological relationship.

METHODS: The clinical and radiological data of 40 patients with colonic diverticulitis treated in Mackay Memorial Hospital, Taipei, from 1993 through 2002 were reviewed retrospectively.

RESULTS: The average age of the patients with right-sided diverticulitis was 53.1 years, which was 11.6 years younger than that of the patients with left-sided diverticulitis. The preoperative diagnosis of appendicitis was made in 8 of 13 right-sided diverticulitis patients. Nine (69%) had right lower quadrant abdominal pain for more than 48 hours, and ten patients (77%) presented with fever. CT findings suggesting acute right-sided diverticulitis including thickening of the intestinal wall and pericolonic inflammation were present in five patients.

CONCLUSION: Right-sided diverticulitis is easily confused with acute appendicitis because it occurs at a somewhat younger age than that in left-sided diverticulitis. Barium enema and CT are helpful for the early diagnosis of right-sided diverticulitis. While clearly not required in the majority of patients with right lower quadrant abdominal pain, barium enema and CT may be helpful in making the decision with a clinical history or physical examinations atypical of acute appendicitis.

Diverticular disease in adolescence

Diverticular disease is rare in the adolescent. Acute diverticulitis is almost never considered as a diagnosis for a young patient presenting with abdominal pain. Unfortunately, unrecognized it may be associated with significant morbidity and mortality. Also, when present, diverticulitis in the young adult is considered to be more aggressive compared to diverticulitis in older adults. Therefore, it is important to recognize, diagnose and manage diverticular disease appropriately in this age group. In tis chapter we will review the available literature on diverticula disease in the adolescent and young adult, discuss epidemiology, aetiology and pathogenesis and suggest guidelines for diagnosis and management.

Clinical features and differential diagnosis of diverticular disease

Colonic diverticulosis occurs in the majority of Western populations with age, but only a small proportion of people experience symptoms. Diverticular disease usually presents with either haemorrhage or diverticulitis. A quarter of patients with diverticulitis will develop complications including perforation, fistulation, obstruction or stricture. This chapter deals with the natural history, risk factors, clinical features and differential diagnoses of symptomatic diverticular disease.

Epidemiology of diverticular disease

Diverticulosis, which is an acquired condition marked by mucosal herniation through defects in the colonic wall, has been termed both a "disease of the 20th century" and a "disease of Western civilization" due to its increasing prevalence in modern times and its striking geographical variability. Both of these epidemiological observations may provide interesting insights into the pathophysiology of diverticulosis. This chapter will review the known epidemiology of diverticulosis coli and its main complications: diverticulitis and diverticular haemorrhage. Where possible, attempts will be made to place these observational reports in the context of both the cause and clinical behaviour of this disorder.

Physiological small bowel malabsorption of carbohydrates protects against large bowel diseases in Africans

In African black people there is a paucity of 'developed society' large bowel diseases such as diverticular disease, colorectal adenomas and carcinomas, ulcerative colitis and Crohn's disease. Appendicitis has an incidence of about 5-10% of the number likely to be observed in a white population. The conundrum is that the disparity exists despite many Africans having adopted an urbanized lifestyle with major changes in their dietary pattern. Dietary fiber intake, which was previously 30-35 g, has decreased to 12-14 g daily. Studies on small bowel function in black people have shown that physiological malabsorption of lactose, fructose, sucrose and maize (the staple food) occurs. It is hypothesized that the increased concentration of substrate available for fermentation in the colon compensates for the low dietary fiber intake, is protective to the large bowel and is a factor in the prevention of 'developed society' large bowel diseases in the African population.

Diverticular disease in the elderly

Diverticular disease is common among the elderly. Because of the advanced age and muted symptoms and signs of many of those affected, diagnosis can be difficult. Consequently, great demands are placed on the physician to diagnose and treat clinically evident diverticular disease. Endoscopic, radiologic, and surgical advances have increased the availability of more definitive therapies for patients with complicated diverticular disease and diverticular hemorrhage.

Sonography of acute right side colonic diverticulitis

BACKGROUND

To describe the prevalence and sonographic findings and ultrasound diagnostic accuracy of the right side colonic diverticulitis in patients having right lower abdominal pain with indeterminate nature.

METHODS

A total of 934 patients with acute right lower abdominal pain of clinically indeterminate nature were referred for ultrasound examination (US). US studies were performed with 3.5 to 7.0 (or occasionally 10) MHz transducers using graded compression method. Twenty-three patients were finally diagnosed to have an uncomplicated acute diverticulitis of the right colon. The gray-scale sonographic images were reviewed. A retrospective study was undertaken to evaluate diagnostic contribution of US.

RESULTS

The prevalence of acute right side colonic diverticulitis was 2.5% in patients with clinically indeterminate acute right lower abdominal pain. Locations of the inflamed diverticula include cecum in 6 patients, proximal ascending colon in 15 patients, and distal ascending colon in only 2 patients. Sonography detected 21 inflamed diverticula with 1 false positive and 2 false negative results. The most typical sonographic feature of an inflamed diverticulum of right side colon was a rounded or oval-shaped hypoechoic or nearly anechoic structure (52%) protruding out from the segmentally thickened colonic wall. Some of them might contain strong echoes representing gas or feces (43%), or stone in the lumen (5%). Regional pericolic or peridiverticular fat thickening was noted in 57% of patients, and segmental colon wall thickening in 38%. US examination yielded a sensitivity of 91.3%, a specificity of 99.8%, an overall accuracy of 99.5%, a positive predictive value of 95.5%, and a negative predictive value of 99.7%. A positive sonogram made the likelihood of acute right side diverticulitis 456.5 times greater compared with the pretest clinical impression. US differentiated acute right side colonic diverticulitis from acute appendicitis with a 100% accuracy.

CONCLUSIONS

Ultrasound can be extremely useful in diagnosing acute right side colonic diverticulitis. Careful ultrasound evaluation of the right colon and the cecum may facilitate a correct diagnosis and help differentiate from acute appendicitis, and steer the surgeon to a more effective management.

Dietary habits and right-sided colonic diverticulosis

PURPOSE

In Asian populations, there is a high prevalence of right-sided colonic diverticulosis, the cause of which is uncertain. It is suspected that dietary habits may interact with a congenital predilection to cause this condition. To evaluate the relationship between long-term dietary habits and the prevalence of right-sided diverticulosis in the general population, we performed a retrospective case-control study.

METHODS

We reviewed the records of 3,105 screening colonoscopies performed on healthy, asymptomatic adults. All cases of right-sided diverticulosis were selected, and a similar number of gender-matched and age-matched controls with negative colonoscopies were randomly sampled from the same cohort. All case and control subjects were interviewed by a single-blinded nurse to establish their dietary habits during the past decade, in addition to other demographic characteristics. Based on consumption frequency, they were assigned to one of three diet classes for each of three food categories of interest: meat, vegetable, and fruit products. Staple foods such as rice were not included. Odds ratios were then calculated using multivariate conditional logistic regression and tests for trend were performed.

RESULTS

A total of 86 cases of right-sided diverticulosis were included, whereas 106 controls were randomly selected. There was a marked association between meat consumption frequency and right-sided diverticulosis, with a trend P value of <0.01 and an odds ratio of 24.81 between the most and least frequent consumers of meat products.

CONCLUSIONS

The prevalence of right-sided diverticulosis is strongly positively associated with past meat consumption frequency. There is no association with vegetable or fruit consumption frequency, laxative use, supplemental fiber intake, smoking, or family history.

A prospective study of dietary fiber types and symptomatic diverticular disease in men

To examine prospectively dietary fiber calculated from food composition values based on analytic techniques and specific dietary fiber types in relation to risk of diverticular disease, we analyzed data from a prospective cohort of 43,881 U.S. male health professionals 40-75 y of age at base line; subjects were free of diagnosed diverticular disease, colon or rectal polyps, ulcerative colitis and cancer. The insoluble component of fiber was inversely associated with risk of diverticular disease relative risk (RR) = 0. 63, 95% confidence interval (CI), 0.44-0.91, P for trend = 0.02, and this association was particularly strong for cellulose (RR = 0.52, 95% CI, 0.36-0.75, P for trend = 0.002). The association between diverticular disease and total dietary fiber intake calculated from the AOACstandards method was not appreciably different from results using the Southgate or Englyst method [for AOAC method, RR = 0.60, 95% CI, 0.41-0.87; for Southgate method, RR = 0.61, 95% CI, 0.42-0. 88; for Englyst method, RR = 0.60, 95% CI, 0.42-0.87, for the highest quintiles]. Our findings provide evidence for the hypothesis that a diet high in dietary fiber decreases the risk of diverticular disease, and this result was not sensitive to the use of different analytic techniques to define dietary fiber. Our findings suggest that the insoluble component of fiber was significantly associated with a decreased risk of diverticular disease, and this inverse association was particularly strong for cellulose.

Clinical behavior of complicated right-sided and left-sided diverticulosis

PURPOSE

The aim of the study was to characterize the clinical entity of multiple right-sided (RS) diverticular disease, which is uniquely common in Asians.

METHODS

Patients hospitalized with proven diverticular disease from June 1989 to January 1996 were reviewed. Data were retrieved from a prospectively collected computerized database.

RESULTS

One hundred eighty consecutive patients were admitted to the Department of Colorectal Surgery, Singapore General Hospital, with multiple diverticular disease. Average age was 65.1 (standard error of the mean, 13.9) years. There were 96 men and 84 women. Women presented, on average, 8.4 years later than men (P < 0.005). Eighty-five patients (47 percent) had massive rectal bleeding, 65 (36 percent) had diverticulitis, 21 (12 percent) had obstructive symptoms, and 9 (15 percent) had enteric fistulas. The diverticula were RS in 76 patients(42 percent), left-sided (LS) in 62 patients (34 percent), and on both sides in 42 patients (24 percent). RS diverticulosis tended to present with massive rectal bleeding (42/76; 55 percent) more often than LS disease (14/62; 23 percent; P < 0.005). Surgery for bleeding was also required more often for RS (17/42; 41 percent) than for LS disease (1/14; 7 percent; P < 0.05); however, diverticulitis was more common on the left (RS, 25/76, 33 percent; LS, 32/62, 52 percent; P < 0.05). Seventy-eight patients (43 percent) required surgery for these complications of diverticular disease. At a mean follow-up of 15.2 (standard error of the mean, 2) months, mortality was 2 in 78 patients who underwent surgery (3 percent), and morbidity was 15 percent.

CONCLUSIONS

In comparison with LS, RS diverticular disease tended to present more often with massive bleeding than with diverticulitis and fistulation. This bleeding was often more severe and required surgical intervention.

Case report: calcified stones in right-sided colonic diverticula stimulating gallstones

Right-sided colonic diverticulosis, though unusual in the Western population, is common in the Orient. Calcified stones are rarely found within colonic diverticula. Standard textbooks of diagnostic radiology do not list calcified stones within caecal or ascending colonic diverticula as possible causes of calcification in the right hypochondrium or right iliac fossa. We present a patient with multiple laminated right-sided diverticular concretions mimicking gallstones. This possibility should be included in the differential diagnosis of gallstones or calcifications on the right side of the abdomen.

A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men

The relationship between smoking, caffeine, and alcohol intake and the risk of symptomatic diverticular disease has not been investigated directly. We examined these associations in a prospective cohort of 47,678 US men, 40 to 75 years old. During 4 years of follow-up (1988 to 1992), we documented 382 newly diagnosed cases of symptomatic diverticular disease. After adjustments for age, physical activity, and energy-adjusted intake of dietary fiber and total fat, alcohol intake (comparing those who drink > 30 g of alcohol/d to nondrinkers) was only weakly and nonsignificantly associated with risk of symptomatic diverticular disease (relative risk (RR) = 1.36; 95 percent confidence interval (CI), 0.94 to 1.97; P for trend = 0.37). We observed no association between caffeine, specific caffeinated beverages, and decaffeinated coffee and the risk of symptomatic diverticular disease. Current smoking was not appreciably associated with risk of symptomatic diverticular disease compared to nonsmokers (RR = 1.25; 95 percent CI, 0.75 to 2.09) after adjustment for age, physical activity, and energy-adjusted intake of dietary fiber and total fat. In a subset analysis restricted to men who had undergone sigmoidoscopy or colonoscopy, a modest positive association was seen between smoking and risk of symptomatic diverticular disease. These results suggest that smoking, caffeine, and alcohol intake are not associated with any substantially increased risk of symptomatic diverticular disease.

Prospective study of physical activity and the risk of symptomatic diverticular disease in men

The relationship between physical activity and risk of symptomatic diverticular disease has not been investigated directly. This association was examined in a prospective cohort of 47,678 American men, 40 to 75 years of age, and free of diagnosed diverticular disease, colon or rectal polyp, ulcerative colitis, and cancer before 1988. During four years of follow up, 382 newly diagnosed cases of symptomatic diverticular disease were documented. After adjustment for age, energy adjusted dietary fibre, and energy adjusted total fat, overall physical activity was inversely associated with the risk of symptomatic diverticular disease (for highest versus lowest extremes, relative risk (RR) = 0.63 (95% confidence interval (CI) 0.45, 0.88). Most of the inverse association was attributable to vigorous activity, for extreme categories RR = 0.60 (95% CI 0.41, 0.87). For activity that was not vigorous the RR was 0.93 (95% CI 0.67, 1.69). Several specific activities were inversely associated with the risk of diverticular disease, but jogging and running combined was the only individual activity that was statistically significant (p for trend = 0.03). For men in the lowest quintile for dietary fibre intake and total physical activity (compared with those in the opposite extreme), the RR was 2.56 (95% CI 1.36, 4.82). Physical activity, along with a high fibre diet, may be an important factor in the prevention of symptomatic diverticular disease.

Diverticular disease. Epidemiology and pharmacological treatment

Diverticular disease is worldwide in distribution, but the incidence is highest in industrialised countries. It is associated with aging and low intake of dietary fibre. There is a broad range of clinical manifestations--from asymptomatic diverticula to life-threatening complications. Elderly patients often present with complicated diverticular disease, and may lack typical symptoms and signs. Treatment includes fibre supplementation, drugs or antibiotics for complications, and surgery for refractory disease. Proper diagnosis and treatment requires knowledge of the full range of presentations and careful selection and timing of medical versus surgical intervention.

Surgical management of cecal diverticulitis

Ninety surgical cases of cecal diverticulitis at the University of Hawaii hospitals were reviewed from 1980 to 1991. Seventy-eight percent of the study group were of Asian descent, with a mean age of 41.7 years. Right lower quadrant pain and tenderness were the only constant findings, occurring in 86 and 87 of the 90 patients, respectively. The most common preoperative diagnosis was acute appendicitis, occurring in 73% of patients. A right colectomy or cecectomy was performed in 49 patients, an appendectomy in 29, and a diverticulectomy in 10. Seventeen complications occurred, only 1 of which was in the appendectomy group. Follow-up of up to 10 years was successful in 27 of 29 appendectomy patients, only 4 of whom had recurrent pain. There were no instances of a missed cecal carcinoma. We concluded that in those patients in whom carcinoma can be ruled out and in whom there is no evidence of abscess formation, appendectomy combined with postoperative antibiotics is a safe and effective method for the treatment of cecal diverticulitis.

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.

Surgical management of right colon diverticulitis

The infrequent occurrence of right colon diverticulitis in the developed West has led to a controversy in the management of this disease. In Singapore, we continued to avoid colectomy whenever possible because this disease is usually nonprogressive. We reviewed 68 patients treated by conservative surgery to evaluate the effectiveness of this treatment policy. Almost 70 percent of our patients were below 40 years of age, and the clinical presentation was indistinguishable from acute appendicitis. Diverticulectomy was done only for inflamed and perforated diverticula (25 cases), while the nonperforated diverticulum was left alone (40 cases). The inflammation invariably responded to antibiotic therapy. Only three patients had colonic resection since a malignant neoplasm could not be excluded. There were no adverse sequelae over a mean follow-up period of three and one-half years, except for one patient who had recurrent attacks of right colon diverticulitis necessitating colectomy. With this policy of management we encountered no mortality, and morbidity was acceptable.

Trends of diverticular disease of the large bowel in a newly developed country

Five hundred twenty four consecutive barium enemas done over an 18-month period were reviewed in Singapore to ascertain the prevalence and distribution of diverticular disease in the large bowel. In this study, the prevalence rate was 20 percent, which is comparable to European and American studies but higher than similar studies in Asian countries. However, the distribution of the disease showed a predominance of right-sided disease (70 percent). This is a pattern that is markedly different from that seen in Europe and North America, where the disease involves largely the left side of the large bowel. The high prevalence rate in this series is at variance with the widely held belief that diverticulosis occurs less frequently in oriental communities.

The distributional pattern of diverticular disease

In Western communities diverticular disease occurs mainly in the sigmoid colon. This contrasts with Oriental populations, in which diverticula occur mainly in the right colon. Diverticular disease has recently emerged in black South Africans. This study shows that diverticula in this population occurs predominantly in the descending colon. The variable anatomic distribution of diverticula in different ethnic groups implies that fiber deficiency is not the only factor responsible for this condition. It is suggested that diverticular disease may comprise several entities with different causes.

Diverticular disease of the large bowel in Singapore. An autopsy survey

One thousand fourteen consecutive large intestines were removed at autopsy from persons over the age of 14 years and examined for diverticular disease. Diverticulosis was encountered in 194 patients (19 percent). The lesion appeared early in life, after the second decade. Men were affected more frequently than women before the age of 60 years. Chinese men had significantly more diverticular disease than Malayan men (P less than 0.01) and Indian men (P less than 0.02). Chinese men also had significantly more diverticular disease than Chinese women. There was a predominance of right colon involvement, with the disease affecting especially the ascending colon and cecum. This pattern was observed in all three major ethnic groups, and in both the Singapore-born and foreign-born Singaporeans. The cause of right-sided diverticulosis is unknown. It appears that, while adoption of the western diet may influence the prevalence of diverticular disease, the site of predilection is determined more by racial or genetic predisposition. All diverticula examined histologically were false, including 39 (20 percent) solitary diverticula. The distribution of solitary diverticula was similar to that of multiple diverticulosis. It is suggested that solitary and multiple diverticulosis are part of the spectrum of the same disease.

Polyps and diverticula of the large intestine: a necropsy survey in Hong Kong

The study is based on a prospective survey of 200 necropsies, to determine the prevalence of colonic polyps and diverticula in Hong Kong. Adenomatous polyps were found in 34% of men and 19% of women. The corresponding figures for hyperplastic polyps were 22% and 15%. When compared with European countries having similar rates for colorectal cancer, the polyp pattern by type, prevalence, and distribution is very similar. For diverticula the prevalence rate in this study was only 5%; most of these were situated in the caecum. This is at marked variance to the European pattern.

Diverticular disease of the colon in Japan. A review of 615 cases

Of 615 patients with diverticular disease of the colon, 429 had diverticula in the cecum and ascending colon, 98 in the sigmoid and descending colon and 88 in both the right- and left-side colon. The right-sided type was more common in younger people and more predominant in men, whereas the left-sided type was more common in the elderly and showed no difference in numbers between men and women. More than 50 per cent of patients were asymptomatic and 25 per cent complained of disturbed bowel function. The frequency of diverticulitis was not related to location, but to the number of diverticula. Seventy-seven were complicated by acute inflammation (right-sided diverticulitis, 61, and left-sided diverticulitis, 16). Many patients with right-sided diverticulitis improved with medical treatment and the operative procedure of choice was drainage of the inflamed area with supplemental appendectomy.