Association between colonic diverticular disease and colorectal cancer: a nationwide population-based study

Follow-Up Colonoscopy for Detection of Missed Colorectal Cancer After Diverticulitis

BACKGROUND & AIMS

Colonoscopy often is recommended after an episode of diverticulitis to exclude missed colorectal cancer (CRC). This is a controversial recommendation based on limited evidence. We estimated the prevalence and odds of CRC and advanced colorectal neoplasia on colonoscopy in patients with diverticulitis compared with CRC screening.

METHODS

Using data from the Gastrointestinal Quality Improvement Consortium registry, we performed a cross-sectional study with patients ≥40 years old undergoing outpatient colonoscopy for an indication of diverticulitis follow-up evaluation or CRC screening. The primary outcome was CRC. The secondary outcome was advanced colorectal neoplasia. Odds ratios (ORs) and 95% CIs were calculated.

RESULTS

We identified 4,591,921 outpatient colonoscopies performed for screening and 91,993 colonoscopies for diverticulitis follow-up evaluation. CRC prevalence was 0.33% in colonoscopies for screening and 0.31% in colonoscopies for diverticulitis. Compared with screening, patients with diverticulitis were less likely to have CRC (adjusted OR, 0.84; 95% CI, 0.74-0.94). CRC prevalence decreased to 0.17% in colonoscopies performed for diverticulitis only. Compared with screening, patients with diverticulitis as the only indication were less likely to have CRC (adjusted OR, 0.49; 95% CI, 0.36-0.68). CRC prevalence increased to 1.43% in patients with complicated diverticulitis. Compared with screening, patients with complicated diverticulitis were more likely to have CRC (adjusted OR, 3.57; 95% CI, 1.59-8.01).

CONCLUSIONS

The risk of CRC cancer is low in most patients with diverticulitis. Patients with complicated diverticulitis are the exception. Our results suggest that colonoscopy to detect missed CRC should include diverticulitis patients with a complication and those not current with CRC screening.

Risk of Cancer in Patients With Diverticular Disease: A Population-Based Cohort Study

BACKGROUND & AIMS

Several studies have investigated the association between diverticular disease (DD) and colorectal cancer. However, whether there is an association between DD and malignancies other than those in the colorectum remains uncertain.

METHODS

For the 1978-2019 period, we conducted a nationwide, population-based cohort study using national Danish health care data. We followed patients with DD for up to 20 years, beginning 1 year after the date of DD diagnosis until the first occurrence of incident cancer, emigration, death, 20 years of follow-up, or December 31, 2019. We calculated cumulative incidence proportions of cancer and standardized incidence ratios (SIRs) comparing cancer incidence among patients with DD with that in the general population.

RESULTS

We identified 200,639 patients with DD, of whom 20,498 were diagnosed with cancer during the 1-20 years after their DD diagnosis. The SIRs were increased for most cancer sites except for those in the colorectum (SIR, 0.75; 95% confidence interval, 0.72-0.78). The highest SIRs were observed for cancers of the lung, bronchi, and trachea (SIR, 1.20; 95% confidence interval, 1.15-1.24) and kidney (SIR, 1.27; 95% confidence interval, 1.16-1.39).

CONCLUSIONS

Our findings show an increased long-term relative risk of cancer following a diagnosis of DD. These findings are likely caused by prevalence of numerous risk factors in patients with DD that confer an increased risk of cancer. The decreased relative risk of colorectal cancer might be explained by an increased likelihood of patients with DD undergoing colonoscopy with polypectomy.

Risk for colorectal cancer after computed tomography verified acute diverticulitis: A retrospective cohort study with long-term follow-up

BACKGROUND AND OBJECTIVE

Colorectal cancer (CRC) can mimic acute diverticulitis and can thus be misdiagnosed. Therefore, colonic evaluation is recommended after an episode of acute diverticulitis. The aim of this study was to analyze the risk of CRC after computed tomography (CT) verified uncomplicated and complicated acute diverticulitis in short-term and, particularly, long-term follow-up to ensure the feasibility of the primary CT imaging in separating patients with uncomplicated and complicated acute diverticulitis.

METHODS

A retrospective cohort study was conducted in patients with CT-verified acute diverticulitis in 2003-2012. Data on CT findings and colonic evaluations were analyzed. The patients were divided into those with uncomplicated and complicated acute diverticulitis. Patient charts were reviewed 9-18 years after the initial acute diverticulitis episode.

RESULTS

The study population consisted of 270 patients. According to CT scans, 170 (63%) patients had uncomplicated acute diverticulitis and 100 (37%) had complicated acute diverticulitis. Further colonic evaluation was made in 146 (54%) patients. In the whole study population, CRC was found in 7 (2.6%) patients, but CRC was associated with acute diverticulitis in only 4 (1.5%) patients. The short-term risk for CRC was 0.6% (1/170) in uncomplicated acute diverticulitis and 3.0% (3/100) in complicated acute diverticulitis. No additional CRC was found in patients with complicated acute diverticulitis during the long-term follow-up and three cases of CRC found after uncomplicated acute diverticulitis had no observable association with previous diverticulitis.

CONCLUSIONS

In short-term follow-up, the risk of underlying CRC is very low in CT-verified uncomplicated acute diverticulitis but increased in complicated acute diverticulitis. Long-term follow-up revealed no additional CRCs associated with previous acute diverticulitis, indicating that the short-term results remain consistent also in the long run. These long-term results confirm that colonoscopy should be reserved for patients with complicated acute diverticulitis or with persisting or alarming symptoms.

Association between diverticular disease and colorectal cancer: a bidirectional mendelian randomization study

BACKGROUND

Diverticular disease has been inconsistently associated with colorectal cancer risk. We conducted a bidirectional Mendelian randomization study to assess this association.

METHODS

Forty-three and seventy single-nucleotide polymorphisms associated with diverticular disease and colorectal cancer at the genome-wide significance level (p < 5 × 10^- 8) were selected as instrumental variables from large-scale genome-wide association studies of European descent, respectively. Summary-level data for colon cancer, rectum cancer, and colorectal cancer were obtained from genome-wide association analyses of the FinnGen consortium and the UK Biobank study. Summary-level data for diverticular disease was derived from a genome-wide association study conducted in the UK Biobank population. The random effect inverse-variance weighted Mendelian randomization approach was used as the primary method and MR-Egger, weighted-median, and MR-PRESSO approaches were conducted as sensitivity analyses.

RESULTS

Genetically determined diverticular disease was associated with a higher risk of colorectal cancer (beta = 0.441, 95%CI: 0.081-0.801, P = 0.016) in the FinnGen population, but the association was not found in the UK Biobank (beta = 0.208, 95%CI: -0.291,0.532, P = 0.207). The positive association remained consistent direction in the three sensitivity analyses. In the stratified analysis in the FinnGen consortium, an association was found to exist between genetically predicted diverticular disease and colon cancer (beta = 0.489, 95%CI: 0.020-0.959, P = 0.041), rather than rectum cancer (beta = 0.328, 95%CI: -0.119-0.775, P = 0.151). Besides, we found a slight association between colorectal cancer and diverticular disease (beta = 0.007, 95%CI: 0.004-0.010, P < 0.001) when using colorectal cancer as exposome and diverticular disease as outcome. However, there is a large sample overlap in this step of analysis.

CONCLUSION

This Mendelian randomization study suggests that diverticular disease may be a possible risk factor for colorectal cancer and colon cancer rather than rectum cancer in the FinnGen population.

Cancer risk in patients with diverticular disease: A nationwide cohort study

BACKGROUND

There are little data on diverticular disease and cancer development other than colorectal cancer.

METHODS

We conducted a population-based, matched cohort study with linkage of nationwide registers to the Epidemiology Strengthened by histoPathology Reports in Sweden histopathology cohort. We included 75 704 patients with a diagnosis of diverticular disease and colorectal histopathology and 313 480 reference individuals from the general population matched on age, sex, calendar year, and county. Cox proportional hazards models estimated multivariable-adjusted hazard ratios (HRs) for associations between diverticular disease and overall cancer and specific cancers.

RESULTS

Over a median follow-up of 6 years, we documented 12 846 incident cancers among patients with diverticular disease and 43 354 incident cancers among reference individuals from the general population. Compared with reference individuals, patients with diverticular disease had statistically significantly increased overall cancer incidence (24.5 vs 18.1 per 1000 person-years), equivalent to 1 extra cancer case in 16 individuals with diverticular disease followed-up for 10 years. After adjusting for covariates, having a diagnosis of diverticular disease was associated with a 33% increased risk of overall cancer (95% confidence interval [CI] = 1.31 to 1.36). The risk increases also persisted compared with siblings as secondary comparators (HR = 1.26, 95% CI = 1.21 to 1.32). Patients with diverticular disease also had an increased risk of specific cancers, including colon cancer (HR = 1.71, 95% CI = 1.60 to 1.82), liver cancer (HR = 1.72, 95% CI = 1.41 to 2.10), pancreatic cancer (HR = 1.62, 95% CI = 1.42 to 1.84), and lung cancer (HR = 1.50, 95% CI = 1.39 to 1.61). The increase in colorectal cancer risk was primarily restricted to the first year of follow-up, and especially early cancer stages.

CONCLUSIONS

Patients with diverticular disease who have colorectal histopathology have an increased risk of overall incident cancer.

Association between diverticular disease and prevalence of colorectal adenomatous polyps or adenocarcinomas

Background/Aim: Although the link between diverticular disease (DD) of the colon and colon polyp is known, the relationship between colon adenocarcinoma is not clear. This study evaluated the association between DD and adenomatous polyp or colon adenocarcinoma. Methods: Patients who underwent colonoscopy for the first time in 2020-2021 were evaluated and included in this retrospective cohort study. Patients with a previous history of cancer diagnosis, colon surgery, DD, and inflammatory bowel disease were excluded from the study. Age, gender, colonoscopy indications, colonoscopy diagnoses, presence of DD, characteristics of polyps (pathology, diameter, number, localization), and presence of adenocarcinoma were recorded. Obtained data were analyzed between DD and non-DD groups. Results: A total of 2633 patients were included in the study. The prevalence of DD was 16.4%. Colon adenocarcinoma was detected in 4.7%. The adenomatous polyp rate was 14.1%. A significantly higher rate of adenomatous polyps was detected in the DD group compared to the non-DD group (19.7% vs. 12.9%; P = 0.001). Higher rates of high-grade dysplasia (3.0 vs. 1.1%; P = 0.002) and colon adenocarcinoma (7.2% vs. 4.2%; P = 0.008) were observed in the DD group also. In logistic regression analyses, it was observed that the presence of concomitant DD increases the risk of adenomatous polyps (OR: 1.469, 95% CI: 1.158–1.865), the risk of adenomatous polyps with positive villous component (OR: 2.378, 95% CI: 1.437–3.934), the risk of adenomatous polyps with high-grade dysplasia (OR: 2.822, 95% CI: 1.426–5.582), and the risk of colon adenocarcinoma (OR: 2.953, 95% CI: 1.445–6.533). Conclusion: DD is associated with precancerous lesions of the colon (adenomatous polyp, villous adenoma, high-grade dysplasia) and colon adenocarcinoma. Further studies are needed to investigate its association with colon carcinogenesis and its role and value in cancer screening.

German guideline diverticular disease/diverticulitis: Part I: Methods, pathogenesis, epidemiology, clinical characteristics (definitions), natural course, diagnosis and classification

Diverticulosis and diverticular disease are ranked among the most common gastroenterological diseases and conditions. While for many years diverticulitis was found to be mainly an event occurring in the elder population, more recent work in epidemiology demonstrates increasing frequency in younger subjects. In addition, there is a noticeable trend towards more complicated disease. This may explain the significant increase in hospitalisations observed in recent years. It is not a surprise that the number of scientific studies addressing the clinical and socioeconomic consequences in the field is increasing. As a result, diagnosis and conservative as well as surgical management have changed in recent years. Diverticulosis, diverticular disease and diverticulitis are a complex entity and apparently an interdisciplinary challenge. To meet theses considerations the German Societies for Gastroenterology and Visceral Surgery decided to create joint guidelines addressing all aspects in a truely interdisciplinary fashion. The aim of the guideline is to summarise and to evaluate the current state of knowledge on diverticulosis and diverticular disease and to develop statements as well as recommendations to all physicians involved in the management of patients with diverticular disease.

When to Perform a Colonoscopy in Diverticular Disease and Why: A Personalized Approach

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize “when” to safely perform a colonoscopy in the different DD settings and “why”.

Diverticulitis does not increase the long-term risk of developing colon cancer: a systematic review and meta-analysis

PURPOSE

The aim of this review was to examine if diverticulitis increases the long-term risk (> 6 months) of developing colon cancer.

METHODS

A systematic search was conducted in PubMed, Embase, and Cochrane CENTRAL. Google Scholar was also searched. We included studies with human adults of 18 years of age and above. Studies that included only patients with diverticulitis as well as studies comparing groups with and without diverticulitis were included. The primary outcome was the incidence of colon cancer 6 months or more after an episode of diverticulitis.

RESULTS

Twelve records were included with 38,621 patients with diverticulitis. The crude rate of colon cancer among the prospectively followed populations with diverticulitis was by meta-analysis found to be 0.6% (95% CI 0.5-0.6%). The limitations of this review include heterogeneous reporting of outcomes across studies, specifically regarding population and outcome as well as variations in the design and reporting of the studies.

CONCLUSION

We found that the long-term risk of colon cancer after diverticulitis is not increased. The results of our review support current practice on follow-up after an episode of diverticulitis with short-term follow-up being the primary focus.

Epidemiology of Diverticulitis and Prevalence of First-Ever Colorectal Cancer Postdiverticulitis in Adults in the United States: A Population-Based National Study

BACKGROUND

The incidence of acute diverticulitis is increasing, and previous studies showed a wide range of prevalence of colorectal cancer after diverticulitis. There is a lack of high-quality evidence to support performing colonoscopy after diverticulitis.

OBJECTIVE

We aimed to describe the incidence of first-ever diverticulitis and prevalence of first-ever colorectal cancer postdiverticulitis in the United States.

DESIGN

This is a retrospective cohort study.

SETTINGS

We queried a national database that contains data from 26 major integrated healthcare systems in the United States.

PATIENTS

We identified an aggregated patient cohort aged ≥18 years with a diagnosis of first-ever diverticulitis from February 2015 to February 2020, followed by first-ever colorectal cancer diagnosis, at least 1 day after and within 1 year of diverticulitis.

MAIN OUTCOME MEASURES

The incidence of first-ever diverticulitis was calculated. The prevalence and OR of first-ever colorectal cancer after diverticulitis were analyzed.

RESULTS

Among 31,778,290 individuals, we found the incidence of first-ever acute diverticulitis to be 2.9%. The prevalence of colorectal cancer within 1 year of first-ever acute diverticulitis was 0.57%, whereas the prevalence of colorectal cancer without a history of diverticulitis was 0.31% (OR = 1.8 (95% CI, 1.76-1.86)). The majority (92.3%) of the postdiverticulitis colorectal cancer were diagnosed within the first 6 months. The risk of colorectal cancer postdiverticulitis was higher in women (OR = 1.9), African Americans (OR = 2.0), and adults aged 18 to 65 years (OR = 2.3).

LIMITATIONS

We are unable to validate the diagnostic code because patient information in our database is deidentified.

CONCLUSIONS

Individuals are twice as likely to be diagnosed with colorectal cancer within 1 year of their first episode of acute diverticulitis compared with individuals without diverticulitis. We advocate for colonoscopy after the first occurrence of acute diverticulitis to screen for colorectal cancer, particularly for patients without a recent colonoscopy. See Video Abstract at http://links.lww.com/DCR/B412.

Association of Colonic Diverticula with Colorectal Adenomas and Cancer

Background and Objectives: Conflicting evidence is reported regarding any association between colonic diverticula with colorectal adenomas or cancer. The present study aimed to evaluate, in a cohort of Caucasian patients, the association between colonic diverticula and colorectal polyps and cancer. Materials and Methods: All consecutive patients undergoing colonoscopy at our institution were included in the study. The presence and location of diverticula, polyps, and cancers were recorded. Histologically, polyps were classified as adenoma (with low or high dysplasia), hyperplastic, or inflammatory. The relative risk of the association of polyps and cancer with diverticula was assessed. Multiple logistic regression analyses, including age, sex, family history for colorectal cancer (CRC), and family history for diverticula, were carried out. Results: During the study period, 1490 patients were enrolled; 37.2% (n = 555) showed colonic diverticula or polyps or CRC (308 males, mean age 66 years). Particularly, 12.3% (n = 183) patients presented only diverticula, 13.7% (n = 204) only polyps or cancer, 11.3% (n = 168) both diseases, and 62.7% (n = 935) neither diverticula nor polyps and cancer. A total of 38 patients presented colorectal cancer, 17 of which had also diverticula. A significant increase in relative risk (RR 2.81, 95% CI 2.27-3.47, p < 0.0001) of colorectal adenoma and cancer in patients with colonic diverticula was found. At multivariate analysis, only diverticula resulted to be significantly associated with colorectal adenomas and cancer (Odds Ratio, OR 3.86, 95% CI 2.90-5.14, p < 0.0001). Conclusions: A significant association of colonic diverticula with colorectal adenoma or cancer was found. This implies that patients with colonic diverticula require a vigilant follow-up procedure for the prevention of colorectal cancer from those applicable to the general population.

CT colonography evaluation of the relationship between colon anatomy and diverticula

OBJECTIVES

In this study, we aimed at investigating the relationship between diverticula and in vivo colonic features such as total colon length (TCL), using CTC. We also evaluated polyps, neoplastic lesions and the correlation among them.

METHODS

This retrospective study considered a series of patients who underwent CTC in our Hospital from 2010 to 2018. We evaluated TCL, the length of each colon segments and sigmoid colon diameter using dedicated software. We verified the presence of diverticula, polyps and neoplasm and measured the number of diverticula using a five-point class scale, evaluating the colonic segments involved by the disease and the number of diverticula for each segment. A logistic regression model was used to analyse the relationship between diverticula and the patients' age, sigmoid colonic diameter and the length of each colonic segments.

RESULTS

The population finally included 467 patients, 177 males and 290 females (average age of 67 ± 12; range 45-96). The mean TCL was 169 ± 25 cm (range 115-241 cm). Out of the 467, 323 patients (69%) had at least one analyse. The patients with diverticula had a mean TCL significantly shorter than patients without diverticula (164 ± 22 vs 181 ± 27 cm; p = 0.001). Among the different variables, sigmoid colon length, sigmoid colon diameter and patient's age were correlated with diverticula (p < 0.01). Otherwise there is no association among diverticula, polyps and neoplasm.

CONCLUSIONS

The presence of colonic diverticula was significantly inversely correlated with TCL.The TCL was not significantly correlated with polyps and cancers.

ADVANCES IN KNOWLEDGE

The presence of colonic diverticula was significantly inversely correlated with total colon length, and in particular they significantly decreased with increasing colon length; our observation could contribute to the comprehension of diverticula pathogenesis.

Prevalence of colorectal cancer and advanced adenoma in patients with acute diverticulitis: implications for follow-up colonoscopy

BACKGROUND AND AIMS

Guidelines recommend colonoscopy after an episode of diverticulitis to exclude neoplasia but the effectiveness of testing is uncertain. Patients with complicated diverticulitis may be at higher risk for neoplasia, but most patients have uncomplicated disease. We examined the incidence of colorectal cancer (CRC) and advanced adenoma (AA) in patients with diverticulitis compared with patients undergoing screening colonoscopy.

METHODS

CT scans from January 1, 2008, to May 1, 2013, at the University of Pittsburgh Medical Center (UPMC) were reviewed to identify those with confirmed acute diverticulitis. Subsequent surgical, colonoscopy, and pathology reports were abstracted to identify those with a diagnosis of AA and CRC. The incidence of neoplasia was compared with that reported for screening colonoscopy from a meta-analysis (n = 68,324), and from colonoscopy examinations at UPMC between 2013 and 2015 (n = 28,573).

RESULTS

A total of 5167 abdominal/pelvic CT scan reports identified 978 patients with acute diverticulitis, among which 474 (48.5%) patients had undergone at least 1 colonoscopy or gastrointestinal surgery to April 2015. The CRC rate in patients with diverticulitis (13/474, 2.7%) was significantly higher (P < .0001) compared with both the meta-analysis (0.8%) and UPMC (0.3%). The AA rate (19/474, 4.0%) was similar to the rate in the meta-analysis (5.0%, P = .39) but significantly lower than at UPMC (7.7%, P = .003). The incidence of AA or CRC in complicated diverticulitis (10/141, 7.1%) did not differ significantly (P = .85) from the incidence of AA or CRC in uncomplicated diverticulitis (22/332, 6.6%).

CONCLUSIONS

CRC after diverticulitis was significantly higher than that observed at screening colonoscopy and was not limited to complicated disease. Colonoscopy is advisable after the diagnosis of diverticulitis.

Colorectal Cancer and Polyps in Diverticulosis Patients: A 10-Year Retrospective Study in 13680 Patients

Introduction

Shared by certain epidemiological and etiological characteristics, diverticulosis and colorectal cancer (CRC) as well as colonic polyps has long been linked. This association was studied in several heterogeneous studies but has reported inconsistent results. Clarifying the association is clinically relevant for endoscopist awareness and potential modification of screening and surveillance intervals for diverticulosis patients.

Methods

In this retrospective single-center study, patients diagnosed with diverticulosis on colonoscopy over a 10-year period were included. Each diverticulosis patient was matched with 1 control by age, gender, setting (inpatient/outpatient), and procedure's indication. CRC and polyp detection rates were recorded and compared between the groups before and after adjustment for bowel preparation quality and exam completion. CRC location was recorded and compared between groups.

Results

A cohort of 13680 patients (6840 patients with diverticulosis and 6840 matched controls) was included. Diverticulosis was located mainly to the sigmoid and left colon (94.4%). The CRC diagnosis rate was lower in the diverticulosis group (2% vs. 4.5%, odds ratio = 0.472, P < 0.001, and 95%CI = 0.382‐0.584). Moreover, location of CRC was unrelated to diverticulosis location, as more CRCs in the diverticulosis group were located proximal to the splenic flexure as compared to the control group (42.5% vs 29.5%, respectively; P = 0.007). Diverticulosis, however, was associated with an increased polyp detection rate compared to controls (30.5% vs. 25.5%; odds ratio = 1.2, P < 0.001, and 95%CI = 1.11‐1.299).

Conclusion

We demonstrated that diverticulosis was not associated with an increased risk for CRC. A possible increased polyp detection rate, however, warrants further evaluation in large prospective studies.

The relationship between diverticulosis and colorectal neoplasia: A meta-analysis

Background/Aims

Diverticulosis and colorectal neoplasia share epidemiological trends and risk factors which are common in Western countries and incidences increase with age. However, the data on an association between diverticulosis and colorectal neoplasia are conflicting. Thus, we performed a meta-analysis to evaluate whether diverticulosis is associated with colorectal neoplasia.

Methods

A systematic literature search of PubMed, EMBASE, Cochrane Library, Web of Science, and SCOPUS was conducted to identify studies that investigated the association between diverticulosis and advanced colorectal neoplasia (advanced adenoma, colorectal cancer), adenomas, or polyps. The demographic characteristics of patients, including age, gender, indication for colonoscopy, confounding factors, and outcomes of colorectal neoplasia were assessed.

Results

We identified 29 cross-sectional studies (N = 450,953) that investigated the association between diverticulosis and colorectal neoplasia. The meta-analysis found that diverticulosis was not associated with advanced colorectal neoplasia (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.63–1.50). Although there was a positive correlation between diverticulosis and adenomas (OR 1.47, 95% CI 1.18–1.84) and diverticulosis and polyps (OR 1.95, 95% CI 1.15–3.31), diverticulosis did not increase the risk of adenomas (OR 1.34, 95% CI 0.87–2.06) in patients who underwent screening colonoscopy. Moreover, all the increased risk of colorectal neoplasia in patients with diverticulosis was observed in published studies only, and not in unpublished ones.

Conclusions

This meta-analysis demonstrated that diverticulosis is not associated with an increased risk of advanced colorectal neoplasia. Although diverticulosis was associated with a higher risk of polyps and adenomas, the risk was not increased in screening populations. Moreover, the increased risk of colorectal neoplasia in patients with diverticulosis was observed only in published studies and not in unpublished ones.

Risk of colorectal cancer in patients with diverticular disease

Colorectal cancer constitutes an important burden on the healthcare system. Screening at-risk populations to reduce colorectal cancer-related morbidity and mortality has become part of good clinical practice. However, recommendations regarding subgroups of patients with diverticular disease are subject to controversy.

Herein, we review the most recent literature regarding the prevalence of colorectal cancer in patients with diverticular disease, diverticulitis and uncomplicated diverticulitis.

The recent literature does not identify diverticular disease as a long-term risk factor for colorectal cancer. However, the risk of colorectal cancer is increased in the short-term period after hospitalization related to diverticular disease. According to a recent systematic review and meta-analysis, the prevalence of colorectal cancer is 1.6% in patients with acute diverticulitis who underwent colonoscopy. The risk of having colorectal cancer after an episode of acute diverticulitis is 44-fold higher than that of an age- and gender-adjusted reference population. Despite lower among patients with uncomplicated episode, the risk of colorectal cancer remains 40-fold higher in that subpopulation than that in the reference population.

To conclude, the recent literature describes an increased risk of colorectal cancer among patients with acute diverticulitis compared to the reference population. Colonoscopy is therefore recommended in patients with diverticulitis to exclude colorectal cancer.

Progress and challenges in the management of diverticular disease: which treatment?

Diverticular disease of the colon (DDC) includes a spectrum of conditions from asymptomatic diverticulosis to symptomatic uncomplicated diverticulosis, segmental colitis associated with diverticulosis, and acute diverticulitis without or with complications that may have serious consequences. Clinical and scientific interest in DDC is increasing because of the rising incidence of all conditions within the DDC spectrum, a better, although still limited understanding of the pathogenic mechanisms involved; the increasing socioeconomic burden; and the new therapeutic options being tested. The goals of treatment in DDC are symptom and inflammation relief and preventing disease progression or recurrence. The basis for preventing disease progression remains a high-fiber diet and physical exercise, although evidence is poor. Other current strategies do not meet expectations or lack a solid mechanistic foundation; these strategies include modulation of gut microbiota or dysbiosis with rifaximin or probiotics, or using mesalazine for low-grade inflammation in uncomplicated symptomatic diverticulosis. Most acute diverticulitis is uncomplicated, and the trend is to avoid hospitalization and unnecessary antibiotic therapy, but patients with comorbidities, sepsis, or immunodeficiency should receive broad spectrum and appropriate antibiotics. Complicated acute diverticulitis may require interventional radiology or surgery, although the best surgical approach (open versus laparoscopic) remains a matter of discussion. Prevention of acute diverticulitis recurrence remains undefined, as do therapeutic strategies. Mesalazine with or without probiotics has failed to prevent diverticulitis recurrence, whereas new studies are needed to validate preliminary positive results with rifaximin. Surgery is another option, but the number of acute events cannot guide this indication. We need to identify risk factors and disease progression or recurrence mechanisms to implement appropriate preventive strategies.

Management of Diverticular Disease in the Setting of Other Colorectal Pathology: Data on Simultaneous Issues in Segmental Colitis, Inflammatory Bowel Disease, Cancer, and Complications

Diverticulosis of the colon is a very common anatomical condition. In the Western world, it affects more than 70% of over 65 years old population and represents the fifth most important gastrointestinal disease in terms of health care costs in Western countries. The diagnosis of diverticular disease and diverticulitis can be challenging. Often, there is overlap with other colonic pathologies, such as segmental colitis, ischemia, inflammatory bowel disease, cancer, or infectious colitis. Management of diverticular disease in these settings might be different.

Risk of colorectal adenomas, advanced adenomas and cancer in patients with colonic diverticular disease: Systematic review and meta-analysis

BACKGROUND AND AIM

Diverticular disease and colorectal neoplasia are common digestive disorders worldwide. Both diseases share epidemiological trends and certain risk factors including advancing age, physical inactivity, and Western diet and lifestyle. Studies assessing the association between these diseases reported inconsistent results. Thus, we conducted a systematic review and meta-analysis to determine the association between diverticular disease and colorectal adenomas, advanced adenomas and cancer.

METHODS

A comprehensive search of the databases MEDLINE and EMBASE was done from inception through March 2016. Inclusion criterion was the observational studies' assessment of the association between diverticular disease and colorectal neoplasia in adult participants. Pooled OR and 95% confidence interval (CI) were calculated using a random effect.

RESULTS

Data were extracted from 14 observational studies (11 cross-sectional studies, one case-control study and two cohort studies). Diverticular disease was associated with increased odds of adenomas (OR = 1.67, 95% CI 1.27-2.21, 10 studies), but not associated with advanced adenomas (OR = 1.19, 95% CI 0.88-1.62, I²  = 52%, four studies) or colorectal cancer (OR = 1.36, 95% CI 0.47-3.92, I²  = 98%, seven studies).

CONCLUSIONS

Our meta-analysis demonstrated that diverticular disease was associated with colorectal adenomas. Colonoscopists should be aware of this association and carefully examine the entire large bowel in individuals with diverticulosis.

Diverticular Disease of the Colon: News From Imaging

Different scenarios embrace computed tomography imaging and diverticula, including asymptomatic (diverticulosis) and symptomatic patients (acute diverticulitis, follow-up of acute diverticulitis, chronic diverticulitis). If the role of computed tomography is validated and widely supported by evidence in case of acute diverticulitis, this is not the case of patients in their follow-up for acute diverticulitis or with symptoms related to diverticula, but without acute inflammation. In these settings, computed tomography colonography is gaining consensus as the preferred radiologic test.

Diverticular Disease and Colorectal Cancer: Incidental Diagnosis or Real Association? Final Answer

Associations between diverticular disease of the colon and the colorectal cancer has been studied for >60 years. Observational, cross-sectional, and case-control studies as well as large population-based studies gave conflicting results and association was not fully proven. Obtaining the proof was difficult because both diseases share similar clinical characteristics, both increase with age, and both involve similar dietary factors. Long-term observations are difficult as diagnostic methods changed over time from barium enema 50 to 60 years ago, through endoscopy, up to CT and MR in recent years. Cancer or adenomas may be missed within diverticular segment; diverticula may be underreported in patients with colon cancer diagnosis. Most recent 2 large cohort studies have solved the dilemma. These studies have clearly shown that diverticular disease does not increase the risk of colon cancer after the first year of diagnosis. Within the first year of diagnosis the association is strong, most probably due to difficulties with differential diagnosis and misclassifications and shared symptoms. Findings of these studies have led to the conclusion that colon cancer has to be excluded using modern techniques after the first episode of suspected diverticulitis.

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.

Increased Risk of Pyogenic Liver Abscess Among Patients With Colonic Diverticular Diseases: A Nationwide Cohort Study

Whether patients with diverticular diseases exhibit a higher risk of developing pyogenic liver abscess (PLA) remains inconclusive.From the inpatient claims in Taiwan's National Health Insurance Research Database, we identified 54,147 patients diagnosed with diverticulosis in the 1998 to 2010 period and 216,588 controls without the disorder. The 2 cohorts were matched by age, sex, and admission year, and were followed up until the end of 2010 to estimate the risk of PLA.Overall, the incidence of PLA was 2.44-fold higher in the diverticular-disease group than in the controls (11.5 vs 4.65 per 10,000 person-year). The adjusted hazard ratio (aHR) of PLA was 2.11 (95% confidence interval [CI], 1.81-2.44) for the diverticular-disease group, according to a multivariate Cox proportional hazards regression model. The age-specific data showed that the aHR for the diverticular-disease group, compared with the controls, was the highest inpatients younger than 50 years old (aHR, 4.03; 95% CI, 2.77-5.85). Further analysis showed that the diverticular-disease group exhibited an elevated risk of PLA regardless of whether patients had diverticulitis.The patients with diverticular diseases exhibited a higher risk of PLA.

Hand-Assisted Laparoscopic (HAL) Multiple Segmental Colorectal Resections: Are They Feasible and Safe?

The objective of this study was to evaluate the short-term outcomes of synchronous hand-assisted laparoscopic (HAL) segmental colorectal resections. The surgical options for synchronous colonic pathology include extensive colonic resection with single anastomosis, multiple synchronous segmental resections with multiple anastomoses, or staged resections. Traditionally, multiple open, synchronous, segmental resections have been performed. There is a lack of data on HAL multiple segmental colorectal resections. A retrospective chart review was compiled on all patients who underwent HAL synchronous segmental colorectal resections by all the colorectal surgeons from our Group during the period of 1999 to 2014. Demographics, operative details, and short-term outcomes are reported. During the period, 9 patients underwent HAL synchronous multiple segmental colorectal resections. There were 5 women and 4 men, with median age of 54 (24-83) years and median BMI of 24 (19.8-38.7) kg/m(2). Two patients were on long-term corticosteroid therapy. The median operative time was 210 (120-330) minutes and median operative blood loss was 200 (75-300) mLs. The median duration for return of bowel function was 2 days and the median length of stay was 3.5 days. We had 2 minor wound infections. There were no deaths. Synchronous segmental colorectal resections with anastomoses using the hand-assisted laparoscopic technique are safe. Early conversion to open and use of stomas are advisable in challenging cases.