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Gatta L, Bellini M, Scarpignato C, Marrocco W, Chiriatti A, Grosso A, Lambiase C, Usai-Satta P, Vassallo R, Bartoletti P, Monica F, Manta R, Scotti S, Soncini M. Rifaximin in diverticulosis and diverticular disease: a national survey among Italian gastroenterologists and general practitioners. Intern Emerg Med 2024:10.1007/s11739-024-03669-6. [PMID: 38850356 DOI: 10.1007/s11739-024-03669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/26/2024] [Indexed: 06/10/2024]
Abstract
The management of patients with diverticular disease remains challenging. The aim of this national survey was to assess how gastroenterologists and general practitioners use rifaximin to manage diverticulosis and diverticular disease. Members of the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Federation of General Practitioners (FIMMG) were invited to complete a 39-item online survey concerning the use of rifaximin in five clinical settings: (1) diverticulosis; (2) reducing symptoms in symptomatic uncomplicated diverticular disease; (3) reducing the occurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease (primary prevention); (4) reducing the recurrence of diverticulitis in patients with previous attacks of diverticulitis (secondary prevention); (5) treatment of uncomplicated acute diverticulitis. A total of 1094 physicians completed the survey. Overall, 25.1%, 83.5%, 68%, 74.2%, and 63% of physicians prescribed rifaximin for the clinical settings 1, 2, 3, 4, and 5, respectively. In each clinical setting, the dosage of rifaximin most frequently used was 800 mg/day, the most common duration of therapy was 7 days, and the cyclic administration of treatment (expressed in months) most frequently used was > 24 months. These results highlight that a reappraisal of the use of rifaximin in patients with diverticulosis and diverticular disease is required to reduce the gap between the evidence available and the daily clinical practice, optimizing also the use of healthcare resources.
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Affiliation(s)
- Luigi Gatta
- Gastroenterology Unit, ASL Toscana Nord-Ovest, Versilia Hospital, 55041, Lido di Camaiore, Italy.
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Walter Marrocco
- Primary Care Physician Azienda Sanitaria Locale (ASL), Roma 5, Tivoli, Rome, Italy
| | - Alberto Chiriatti
- Primary Care Physician Azienda Sanitaria Locale (ASL), Roma 3, Rome, Italy
| | - Antonio Grosso
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Christian Lambiase
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Roberto Vassallo
- Gastroenterology and Endoscopy Unit, Buccheri la Ferla Hospital, Palermo, Italy
| | | | - Fabio Monica
- Gastroenterology and Digestive Endoscopy Unit, Academic Hospital Cattinara, Trieste, Italy
| | - Raffaele Manta
- Digestive Endoscopy Unit, ASL Toscana Nord-Ovest, "Spedali Riuniti" Hospital, Livorno, Italy
| | - Silvestro Scotti
- Primary Care Physician Azienda Sanitaria Locale (ASL), Napoli 1, Naples, Italy
| | - Marco Soncini
- Department of Internal Medicine, "A. Manzoni" Hospital, Lecco, Italy
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2
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Carabotti M, Cuomo R, Marasco G, Barbara G, Radaelli F, Annibale B. Unmet needs in treatment of symptomatic uncomplicated diverticular disease and prevention of recurrent acute diverticulitis: a scoping review. Therap Adv Gastroenterol 2024; 17:17562848241255297. [PMID: 38812706 PMCID: PMC11135110 DOI: 10.1177/17562848241255297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
Background Diverticular disease (DD) represents a common gastrointestinal condition that poses a heavy burden on healthcare systems worldwide. A high degree of uncertainty surrounds the therapeutic approaches for the control of symptoms in patients with symptomatic uncomplicated diverticular disease (SUDD) and primary and secondary prevention of diverticulitis and its consequences. Objectives To review the current knowledge and discuss the unmet needs regarding the management of SUDD and the prevention of acute diverticulitis. Eligibility criteria Randomized trials, observational studies, and systematic reviews on lifestyle/dietary interventions and medical treatment (rifaximin, mesalazine, and probiotics) of SUDD or prevention of acute diverticulitis. Sources of evidence The literature search was performed from inception to April 2023, without language restriction, following the modified Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) reporting guidelines. References of the papers selected were checked to identify additional papers of potential interest. The final list of references was evaluated by a panel of experts, who were asked to check for any lack of relevant studies. Charting methods Information on patient population, study design, intervention, control group, duration of the observation, and outcomes assessed was collected by two authors independently. Results The review shows a high degree of uncertainty about therapeutic interventions, both dietary/lifestyle and pharmacological, in patients with SUDD, because of the scarcity and weakness of existing evidence. Available studies are generally of low quality, heterogeneous, and outdated, precluding the possibility to draw robust conclusions. Similarly, acute diverticulitis prevention has been seldom investigated, and there is a substantial lack of evidence supporting the role of dietary/lifestyle or pharmacological approaches to reduce the risk of diverticulitis. Conclusion The lack of robust evidence regarding therapeutic options for gastrointestinal symptoms in SUDD patients and for primary and secondary prevention of acute diverticulitis remains an important unmet need in the management of DD.
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Affiliation(s)
- Marilia Carabotti
- Department of Medical–Surgical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, via di Grottarossa 1035-1039, Rome 00185, Italy
| | - Rosario Cuomo
- UOC of Gastroenterology, AORN Sant’Anna e San Sebastiano, Caserta, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Bruno Annibale
- Department of Medical–Surgical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Lambiase C, Bellini M. SUDD, post-diverticulitis pain and IBS: are they really different? Intern Emerg Med 2024:10.1007/s11739-024-03649-w. [PMID: 38771424 DOI: 10.1007/s11739-024-03649-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Christian Lambiase
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Lungarno Pacinotti 43, 56126, Pisa, Italy.
- NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust and The University of Nottingham, Nottingham, UK.
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Lungarno Pacinotti 43, 56126, Pisa, Italy
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Bassotti G. Treating colonic diverticula with rifaximin: a call to action. Intern Emerg Med 2024:10.1007/s11739-024-03602-x. [PMID: 38642312 DOI: 10.1007/s11739-024-03602-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 04/22/2024]
Affiliation(s)
- Gabrio Bassotti
- Gastroenterology, Hepatology & Digestive Endoscopy Section, Department of Medicine & Surgery, University of Perugia, Perugia, Italy.
- Gastroenterology & Hepatology Unit, "Santa Maria Della Misericordia" Hospital, Piazzale Menghini, 1, 06156, Perugia, San Sisto, Italy.
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Marasco G, Buttitta F, Cremon C, Barbaro MR, Stanghellini V, Barbara G. The role of microbiota and its modulation in colonic diverticular disease. Neurogastroenterol Motil 2023; 35:e14615. [PMID: 37243442 DOI: 10.1111/nmo.14615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/06/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Diverticular disease (DD) is a common condition in Western countries. The role of microbiota in the pathogenesis of DD and its related symptoms has been frequently postulated since most complications of this disease are bacteria-driven and most therapies rely on microbiota modulation. Preliminary data showed fecal microbial imbalance in patients with DD, particularly when symptomatic, with an increase of pro-inflammatory and potentially pathogenetic bacteria. In addition, bacterial metabolic markers can mirror specific pathways of the disease and may be even used for monitoring treatment effects. All treatments currently suggested for DD can affect microbiota structure and metabolome compositions. PURPOSE Sparse evidence is available linking gut microbiota perturbations, diverticular disease pathophysiology, and symptom development. We aimed to summarize the available knowledge on gut microbiota evaluation in diverticular disease, with a focus on symptomatic uncomplicated DD, and the relative treatment strategies.
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Affiliation(s)
- Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Francesco Buttitta
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Cesare Cremon
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Vincenzo Stanghellini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
| | - Giovanni Barbara
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Science, University of Bologna, Bologna, Italy
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Airola C, Severino A, Porcari S, Fusco W, Mullish BH, Gasbarrini A, Cammarota G, Ponziani FR, Ianiro G. Future Modulation of Gut Microbiota: From Eubiotics to FMT, Engineered Bacteria, and Phage Therapy. Antibiotics (Basel) 2023; 12:antibiotics12050868. [PMID: 37237771 DOI: 10.3390/antibiotics12050868] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
The human gut is inhabited by a multitude of bacteria, yeasts, and viruses. A dynamic balance among these microorganisms is associated with the well-being of the human being, and a large body of evidence supports a role of dysbiosis in the pathogenesis of several diseases. Given the importance of the gut microbiota in the preservation of human health, probiotics, prebiotics, synbiotics, and postbiotics have been classically used as strategies to modulate the gut microbiota and achieve beneficial effects for the host. Nonetheless, several molecules not typically included in these categories have demonstrated a role in restoring the equilibrium among the components of the gut microbiota. Among these, rifaximin, as well as other antimicrobial drugs, such as triclosan, or natural compounds (including evodiamine and polyphenols) have common pleiotropic characteristics. On one hand, they suppress the growth of dangerous bacteria while promoting beneficial bacteria in the gut microbiota. On the other hand, they contribute to the regulation of the immune response in the case of dysbiosis by directly influencing the immune system and epithelial cells or by inducing the gut bacteria to produce immune-modulatory compounds, such as short-chain fatty acids. Fecal microbiota transplantation (FMT) has also been investigated as a procedure to restore the equilibrium of the gut microbiota and has shown benefits in many diseases, including inflammatory bowel disease, chronic liver disorders, and extraintestinal autoimmune conditions. One of the most significant limits of the current techniques used to modulate the gut microbiota is the lack of tools that can precisely modulate specific members of complex microbial communities. Novel approaches, including the use of engineered probiotic bacteria or bacteriophage-based therapy, have recently appeared as promising strategies to provide targeted and tailored therapeutic modulation of the gut microbiota, but their role in clinical practice has yet to be clarified. The aim of this review is to discuss the most recently introduced innovations in the field of therapeutic microbiome modulation.
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Affiliation(s)
- Carlo Airola
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Severino
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Serena Porcari
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - William Fusco
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Benjamin H Mullish
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, London W2 1NY, UK
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Antonio Gasbarrini
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giovanni Cammarota
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Romana Ponziani
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gianluca Ianiro
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Calini G, Abd El Aziz MA, Paolini L, Abdalla S, Rottoli M, Mari G, Larson DW. Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management. Clin Exp Gastroenterol 2023; 16:29-43. [PMID: 37013200 PMCID: PMC10066719 DOI: 10.2147/ceg.s340929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/18/2023] [Indexed: 04/05/2023] Open
Abstract
Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Medical Area, University of Udine, Udine, Italy
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Internal Medicine Department, MercyOne North Iowa, Mason City, IA, USA
| | - Lucia Paolini
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Oncologic and Digestive Surgery, Le Kremlin-Bicêtre University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Matteo Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giulio Mari
- Department of Laparoscopic and Oncological General Surgery, ASST Brianza, Desio Hospital, Desio, Italy
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Piccin A, Gulotta M, di Bella S, Martingano P, Crocè LS, Giuffrè M. Diverticular Disease and Rifaximin: An Evidence-Based Review. Antibiotics (Basel) 2023; 12:antibiotics12030443. [PMID: 36978310 PMCID: PMC10044695 DOI: 10.3390/antibiotics12030443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.
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Affiliation(s)
- Anna Piccin
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Marco Gulotta
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Stefano di Bella
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Infectious Disease Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Paola Martingano
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Lory Saveria Crocè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Liver Clinic, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), 34128 Trieste, Italy
| | - Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06510, USA
- Correspondence:
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Kruis W, Germer C, Böhm S, Dumoulin FL, Frieling T, Hampe J, Keller J, Kreis ME, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer AG, Leifeld L. German guideline diverticular disease/diverticulitis: Part II: Conservative, interventional and surgical management. United European Gastroenterol J 2022; 10:940-957. [PMID: 36459576 PMCID: PMC9731665 DOI: 10.1002/ueg2.12313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/11/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Wolfgang Kruis
- Apl Professor der MedizinischenFakultätUniversität KölnCologneGermany
| | - Christoph‐Thomas Germer
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | | | | | | | - Jochen Hampe
- Medizinische Klinik IUniversitätsklinikumTU DresdenDresdenGermany
| | - Jutta Keller
- Medizinische KlinikIsraelitisches KrankenhausHamburgGermany
| | - Martin E. Kreis
- Klinik für Allgemein‐, Viszeral‐ und GefäßchirurgieCharité ‐ Universitätsmedizin BerlinCampus Benjamin FranklinBerlinGermany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2Zentrum für Innere Medizin (ZIM)Universitätsklinikum WürzburgWürzburgGermany
| | - Joachim Labenz
- Abteilung für Innere MedizinEvang. Jung‐Stilling‐Krankenhaus, SiegenSiegenGermany
| | - Johann F. Lock
- Klinik und Poliklinik für Allgemein‐, Viszeral‐, Transplantations‐, Gefäß‐ und KinderchirurgieZentrum für Operative MedizinUniversitätsklinikum WürzburgWürzburgGermany
| | - Jörg Peter Ritz
- Klinik für Allgemein‐ und ViszeralchirurgieHelios Klinikum SchwerinSchwerinGermany
| | - Andreas G. Schreyer
- Institut für diagnostische und interventionelle RadiologieMedizinische Hochschule Brandenburg Theodor Fontane Klinikum BrandenburgBrandenburgGermany
| | - Ludger Leifeld
- Medizinische Klinik 3 – Gastroenterologie und Allgemeine Innere MedizinSt. Bernward KrankenhausHildesheimGermany
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Leifeld L, Germer CT, Böhm S, Dumoulin FL, Frieling T, Kreis M, Meining A, Labenz J, Lock JF, Ritz JP, Schreyer A, Kruis W. S3-Leitlinie Divertikelkrankheit/Divertikulitis – Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:613-688. [PMID: 35388437 DOI: 10.1055/a-1741-5724] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ludger Leifeld
- Medizinische Klinik 3 - Gastroenterologie und Allgemeine Innere Medizin, St. Bernward Krankenhaus, Hildesheim, apl. Professur an der Medizinischen Hochschule Hannover
| | - Christoph-Thomas Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Stephan Böhm
- Spital Bülach, Spitalstrasse 24, 8180 Bülach, Schweiz
| | | | - Thomas Frieling
- Medizinische Klinik II, Klinik für Gastroenterologie, Hepatologie, Infektiologie, Neurogastroenterologie, Hämatologie, Onkologie und Palliativmedizin HELIOS Klinikum Krefeld
| | - Martin Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Alexander Meining
- Medizinische Klinik und Poliklinik 2, Zentrum für Innere Medizin (ZIM), Universitätsklinikum Würzburg, Würzburg
| | - Joachim Labenz
- Abteilung für Innere Medizin, Evang. Jung-Stilling-Krankenhaus, Siegen
| | - Johan Friso Lock
- Klinik und Poliklinik für Allgemein-, Viszeral-, Transplantations-, Gefäß- und Kinderchirurgie, Zentrum für Operative Medizin, Universitätsklinikum Würzburg, Würzburg
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Klinikum Schwerin
| | - Andreas Schreyer
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Brandenburg Theodor Fontane Klinikum Brandenburg, Brandenburg, Deutschland
| | - Wolfgang Kruis
- Medizinische Fakultät, Universität Köln, Köln, Deutschland
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11
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Biondo S, Bordin D, Golda T. Treatment for Uncomplicated Acute Diverticulitis. COLONIC DIVERTICULAR DISEASE 2022:273-289. [DOI: https:/doi.org/10.1007/978-3-030-93761-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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12
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Jeganathan NA, Davenport ER, Yochum GS, Koltun WA. The microbiome of diverticulitis. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Arena R, Lisotti A, Mussetto A, Merighi A, Pezzoli A, Triossi O. Right-sided diverticulosis is an independent risk factor for bleeding in patients admitted for diverticular disease. Dig Liver Dis 2021; 53:835-840. [PMID: 33082088 DOI: 10.1016/j.dld.2020.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Diverticular bleeding is the main cause of lower gastrointestinal bleeding in both Eastern and Western countries. Several risk factors have been identified, such as comorbidities and concomitant medications. In Eastern population, the prevalence of right-side diverticulosis is higher than in Western one, and some Authors identified bilateral diverticulosis as a risk factor for bleeding. AIMS To identify risk factors for diverticular bleeding in patients admitted for diverticular disease (DD). METHODS All patients admitted for DD from January 2017 to December 2018 were retrieved from the hospital Information System. For each patient, age, gender, clinical presentation and concomitant medication were recorded. All patient underwent imaging assessment (computed tomography, ultrasound or MRI) and colonoscopy during hospitalization or within one month. RESULTS Among 1248 patients discharged with a diagnosis of DD during the study period, 293 (52.2% male, median age 75 years) were finally analyzed; of them, 105 (35.8%) for diverticular bleeding. On multivariate analysis, male gender (OR 4.27), age (OR 1.12), anti-thrombotic medications (OR 2.60) and right-sided DD (OR 5.70) were independently correlated to diverticular bleeding. CONCLUSION Our study provides evidence that, together with age, male gender and concomitant anti-thrombotic treatment, right-sided DD represents an independent risk factor for bleeding.
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Affiliation(s)
- Rosario Arena
- Gastroenterology Unit, University Hospital of Ferrara, Via Aldo Moro 8 - 44124 Cona, Ferrara, Italy.
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | | | - Alberto Merighi
- Gastroenterology Unit, University Hospital of Ferrara, Via Aldo Moro 8 - 44124 Cona, Ferrara, Italy
| | - Alessandro Pezzoli
- Gastroenterology Unit, University Hospital of Ferrara, Via Aldo Moro 8 - 44124 Cona, Ferrara, Italy
| | - Omero Triossi
- Gastroenterology Unit, S. Maria delle Croci Hospital, Ravenna, Italy
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14
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Saavedra-Perez D, Curbelo-Peña Y, Sampson-Davila J, Albertos S, Serrano A, Ibañez L, Errando X, Perez X. Management of symptomatic uncomplicated diverticular colon disease: A systematic review of diagnosis and treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 44:497-518. [PMID: 33647346 DOI: 10.1016/j.gastrohep.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/28/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.
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Affiliation(s)
- David Saavedra-Perez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España.
| | - Yuhamy Curbelo-Peña
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Jaime Sampson-Davila
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Sonia Albertos
- Servicio de Digestología, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Alejandro Serrano
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Luis Ibañez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Xavier Errando
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
| | - Xavier Perez
- Servicio de Cirugía General y Digestiva, Consorci Sanitari Alt Penedes-Garraf, Barcelona, España
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15
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Giacosa A, Riva A, Petrangolini G, Allegrini P, Fazia T, Bernardinelli L, Gasparri C, Faliva MA, Peroni G, Perna S, Rondanelli M. Symptomatic uncomplicated diverticular disease management: an innovative food-grade formulation of Curcuma longa and Boswellia serrata extracts. Drugs Context 2021; 9:dic-2020-9-2. [PMID: 33408751 PMCID: PMC7747791 DOI: 10.7573/dic.2020-9-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background The treatment of symptomatic uncomplicated colonic diverticular disease (SUDD) is still under debate, and new data show a pathogenic role of dysbiosis and low-grade inflammation in intestinal mucosa. Recent research has highlighted the anti-inflammatory effects of botanical extracts such as Curcuma longa L. and Boswellia serrata Roxb. ex Colebr. The aim of this work is to investigate the potential role of a new delivery formulation of the association of curcumin and boswellia phytosome extracts (CBP) in SUDD. Methods In a 30-day one-group longitudinal explanatory study, patients (men and women) were treated with an innovative association of CBP standardized extracts, 500 mg bid. Results Treatment of SUDD with the association of CBP was followed by a significant decrease in abdominal pain (p<0.0001). The study group showed that CBP supplementation was efficacious within 10 days and that efficacy was maintained almost constant until the 30th day of intervention. Conclusion A phytosome of curcumin and boswellia extracts may be useful for the relief of SUDD pain. However, controlled studies should be performed for final conclusions to be drawn.
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Affiliation(s)
- Attilio Giacosa
- Gastroenterology Unit, Policlinico di Monza, Monza, 20900 Italy.,CDI (Centro Diagnostico Italiano), Milan, 20147 Italy
| | - Antonella Riva
- Research and Development Unit, Indena SpA, Milan, 20139 Italy
| | | | | | - Teresa Fazia
- Department of Brain and Behavioral Science, University of Pavia, Pavia, 27100 Italy
| | - Luisa Bernardinelli
- Department of Brain and Behavioral Science, University of Pavia, Pavia, 27100 Italy
| | - Clara Gasparri
- Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona "Istituto Santa Margherita", University of Pavia, Pavia, 27100 Italy
| | - Milena Anna Faliva
- Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona "Istituto Santa Margherita", University of Pavia, Pavia, 27100 Italy
| | - Gabriella Peroni
- Endocrinology and Nutrition Unit, Azienda di Servizi alla Persona "Istituto Santa Margherita", University of Pavia, Pavia, 27100 Italy
| | - Simone Perna
- Department of Biology, University of Bahrain, College of Science, Sakhir Campus P. O. Box, 32038 Kingdom of Bahrain
| | - Mariangela Rondanelli
- IRCCS Mondino Foundation, Pavia, 27100 Italy.,Department of Public Health, Experimental and Forensic Medicine, Unit of Human and Clinical Nutrition, University of Pavia, Pavia, 27100 Italy
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16
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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Ubaldi E, Grattagliano I, Lapi F, Pecchioli S, Cricelli C. Overview on the management of diverticular disease by Italian General Practitioners. Dig Liver Dis 2019; 51:63-67. [PMID: 30143468 DOI: 10.1016/j.dld.2018.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although very common in Western countries, poor epidemiological data on diverticular disease (DD) is available from the family practice. AIMS To evaluate the behavior of Italian General Practitioners (GPs) on approaching DD. METHODS Health Search Database was analyzed retrospectively. RESULTS On a population of 975,523 individuals, 33,597 patients had a registered diagnosis of DD ("lifetime" prevalence = 3.4%, M = 3.2%, F = 3.7%; higher values are found in females over-65 years old; low rates of complications: diverticulitis = 0.3%, bleeding = 0.002%). As risk factors, NSAIDs and ASA were taken by 14.8% and 26.5% respectively, opioids by 7.5%, corticosteroids by 5.2%; as protective factors, 30.4% were under statins and 17.7% under calcium-antagonists. Approximately 13% of patients were referred to specialists. Colonoscopy and abdominal CT were prescribed to 48.5% and to 13% of already diagnosed patients. Among DD sufferers, 27% experienced hospitalization, but only 3.4% of cases were for a DD-linked problem. Treatment included rifaximin (61%), mesalazine (14.7%), probiotics (12.4%), ciprofloxacin (7.6%). CONCLUSION DD has a large impact in general practice with a higher prevalence in the elderly. GPs are required to pay particular attention to risk factors both for disease development and for its complications in order to reduce the costs deriving from diagnostic procedures, referral and hospitalization.
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Affiliation(s)
- Enzo Ubaldi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | - Francesco Lapi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Serena Pecchioli
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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Cuomo R, Cargiolli M, Cassarano S, Carabotti M, Annibale B. Treatment of diverticular disease, targeting symptoms or underlying mechanisms. Curr Opin Pharmacol 2018; 43:124-131. [PMID: 30291995 DOI: 10.1016/j.coph.2018.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/12/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
Abstract
Diverticular disease (DD) is a highly prevalent disease in western industrialized countries that encompasses a complex set of disorders. Because of its complexity and heterogeneity, both from a pathogenic and a clinical point of view, the management of this disease represent a challenge in clinical practice. This review aims to analyze and summarize the most recent evidence on the medical strategies for DD, considering separately the different stages of the disease, from prevention of diverticula formation to treatment of acute diverticulitis and prevention of recurrences. Based on some evidence, dietary fiber is useful to prevent diverticula formation and in diverticulosis, with no pharmacological treatment in these settings. Treatment of symptomatic uncomplicated diverticular disease as well as primary prevention of acute diverticulitis is based on probiotics, fibres, mesalazine and rifaximin, individually or as combination therapy, although a standard approach has not yet been defined. On the contrary, in acute diverticulitis (AD) recent acquisitions have clarified and standardized the role of systemic antibiotics, reserving its use only to complicated forms and in selected cases of uncomplicated disease. Secondary prevention of AD is essentially based on mesalazine and rifaximin but, despite promising results, no strong evidence have been produced. To date, grey areas remain in the medical management of DD.
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Affiliation(s)
- Rosario Cuomo
- Gastroenterology Department of Clinical Medicine and Surgery, School of Medicine "Federico II", Naples, Italy.
| | - Martina Cargiolli
- Gastroenterology Department of Clinical Medicine and Surgery, School of Medicine "Federico II", Naples, Italy
| | - Sara Cassarano
- Gastroenterology Department of Clinical Medicine and Surgery, School of Medicine "Federico II", Naples, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, University Sapienza, Rome, Italy
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Carabotti M, Cuomo R, Barbara G, Pace F, Andreozzi P, Cremon C, Annibale B. Demographic and clinical features distinguish subgroups of diverticular disease patients: Results from an Italian nationwide registry. United European Gastroenterol J 2018; 6:926-934. [PMID: 30023071 PMCID: PMC6047280 DOI: 10.1177/2050640618764953] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/22/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Clinical features and lifestyle factors associated with diverticulosis compared to diverticular disease (DD), either symptomatic uncomplicated diverticular disease (SUDD) or in patients who have had previous diverticulitis (PD), are unclear. OBJECTIVE The objective of this article is to compare cross-sectionally demographic and clinical features and quality of life (QoL) in diverticulosis, SUDD and PD patients. METHODS The REMAD Registry is a prospective, observational, multicentre, cohort study. Patients were categorised according to: diverticulosis; SUDD (recurrent abdominal symptoms attributed to diverticula in absence of overt inflammation) and PD (≥1 previous diverticulitis). RESULTS A total of 1217 patients (57.9% diverticulosis, 24.7% SUDD and 17.4% PD) were included. Compared to diverticulosis, female gender was associated to SUDD (OR 1.94; 95% CI: 1.43-2.62) and PD (OR 1.79; 95% CI: 1.24-2.56); age ≤ 60 years was associated to PD (OR 2.10; 95% CI: 1.42-3.08 vs diverticulosis, OR 1.57; 95% CI: 1.01-2.45 vs SUDD). PD patients showed an association with past bleeding (OR 29.29; 95% CI: 8.17-104.98 vs diverticulosis, OR 16.84; 95% CI: 3.77-75.25 vs SUDD). Compared to diverticulosis, family history for diverticula was associated to PD (OR 1.88; 95% CI: 1.27-2.78). Patients with diverticulosis showed higher QoL scores, both physical (p = 0.0001 and 0.0257) and mental (p < 0.0001 and 0.0038), in comparison to SUDD and PD. CONCLUSION Family history for diverticula and history of bleeding distinguish diverticulosis from DD. These clinical features should be kept in mind in the management of DD.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Roma, Italy
| | - Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Unit of Gastroenterology, “Bolognini” Hospital, Bergamo, Italy
| | - Paolo Andreozzi
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Cesare Cremon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Roma, Italy
- Bruno Annibale, Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035–1039, 00189 Rome, Italy.
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Scarpignato C, Barbara G, Lanas A, Strate LL. Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017. Therap Adv Gastroenterol 2018; 11:1756284818771305. [PMID: 29844795 PMCID: PMC5964860 DOI: 10.1177/1756284818771305] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/21/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticulosis is a common anatomical condition, which appears to be age-dependent. Individuals who develop chronic gastrointestinal symptoms or complications are referred to as having diverticular disease. Although the diagnosis of this condition can be relatively straightforward, randomized controlled trials are scarce and management often follows tradition rather than principles of evidence-based medicine. This report deals with the topics discussed during a symposium held during the United European Gastroenterology Week (Barcelona, October 2017). During the meeting, the role of dysbiosis in the pathogenesis of diverticular disease and its treatment were thoroughly discussed, by examining the efficacy and mechanisms of action of the currently used drugs. Recent studies have shown the presence of dysbiosis in patients with diverticular disease and suggest an imbalance in favor of bacteria with pro-inflammatory and pathogenetic potential. These microbiota changes correlate with mucosal immune activation, mirrored by a marked increase of macrophages in colonic mucosa, both in the diverticular region and at distant sites. The low-grade inflammation, driven by bacteria-induced immune activation, could be involved in the pathophysiology of symptoms. As a consequence, pharmacological approaches targeting enteric bacteria (with poorly absorbed antibiotics, like rifaximin, or probiotics) or intestinal inflammation (with 5-ASA derivatives or rifaximin) have shown capability of controlling symptoms and also preventing complications, albeit more research is needed to establish the optimal regimen (daily dose and duration) of therapy. Well-designed randomized-controlled trials (RCTs), including homogeneous populations of patients, are therefore needed. The future of management of many GI diseases, including symptomatic uncomplicated diverticular disease, will rely on the so-called 'microbiota-directed therapies'.
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Affiliation(s)
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Angel Lanas
- Clinic Hospital Lozano Blesa, University of Zaragoza, Zaragoza, Spain
| | - Lisa L. Strate
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
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21
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Carabotti M, Annibale B. Treatment of diverticular disease: an update on latest evidence and clinical implications. Drugs Context 2018; 7:212526. [PMID: 29623099 PMCID: PMC5866096 DOI: 10.7573/dic.212526] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Diverticular disease (DD) is a common condition, especially in Western countries. In about 80% of patients, colonic diverticula remain asymptomatic (diverticulosis), while approximately 20% of patients may develop abdominal symptoms (symptomatic uncomplicated diverticular disease, SUDD) and, eventually complications as acute diverticulitis (AD). The management of this condition has been improved, and in the last five years European countries and the USA have published guidelines and recommendations. SCOPE To summarize the latest evidence and clinical implication in treatment of DD focusing the attention either on the treatment of diverticulosis, SUDD and AD together with the primary and secondary prevention of diverticulitis. FINDINGS The present review was based on the latest evidence in the treatment of DD in the last 10 years. In the last 5 years, six countries issued guidelines on DD with differences regarding covered topics and recommendations regarding treatments. At present there is a lack of rationale for drug use in patients with asymptomatic diverticulosis, but there are limited indications to suggest an increase in dietary fibre to reduce risk of DD. To achieve symptomatic relief in SUDD patients, several therapeutic strategies with fibre, probiotics, rifaximin and mesalazine have been proposed even if a standard therapeutic approach remained to be defined. Agreement has been reached for the management of AD, since recent guidelines showed that antibiotics can be used selectively, rather than routinely in uncomplicated AD, although use of antibiotics remained crucial in the management of complicated cases. With regard to treatment for the primary and secondary prevention of AD, the efficacy of rifaximin and mesalazine has been proposed although with discordant recommendations among guidelines. CONCLUSION Treatment of DD represented an important challenge in clinical practice, especially concerning management of SUDD and the primary and secondary prevention of AD.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, Sapienza, Rome
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, Sapienza, Rome
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Severi C, Carabotti M, Cicenia A, Pallotta L, Annibale B. Recent advances in understanding and managing diverticulitis. F1000Res 2018; 7:F1000 Faculty Rev-971. [PMID: 30026920 PMCID: PMC6039950 DOI: 10.12688/f1000research.14299.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2018] [Indexed: 02/05/2023] Open
Abstract
In the past few decades, the increasing socioeconomic burden of acute diverticulitis (AD) has become evident, and with the growth of the population age, this significant economic impact will likely continue to rise. Furthermore, recent evidence showed an increased rate of hospital admissions especially evident among women and younger individuals. The natural history and pathophysiology of this clinical condition is still to be fully defined, and efforts continue to be made in the identification of risk factors and the establishment of relative preventive strategies. The actual therapeutic strategies aimed to modulate gut microbiota, such as rifaximin or probiotics, or to reduce mucosal inflammation, such as mesalazine, present a relatively poor efficacy for both the prevention of the first AD episode (primary prevention) and its recurrence (secondary prevention). In the last few years, the main goal achieved has been in the management of AD in that uncomplicated AD can, to a larger extent, be managed in an outpatient setting with no or little supportive therapy, a strategy that will certainly impact on the health costs of this disease. The problem of AD recurrence remains a topic of debate. The aim of this review is to present updated evidence on AD epidemiology and relative open clinical questions and to analyze in detail predisposing and protective factors with an attempt to integrate their possible modes of action into the several pathogenic mechanisms that have been suggested to contribute to this multifactorial disease. A unifying hypothesis dealing with the colonic luminal and extra-luminal microenvironments separately is provided. Finally, evidence-based changes in therapeutic management will be summarized. Because of an ascertained multifactorial pathogenesis of uncomplicated and complicated AD, it is probable that a single 'causa prima' will not be identifiable, and a better stratification of patients could allow one to pursue tailored therapeutic algorithm strategies.
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Affiliation(s)
- Carola Severi
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
| | - Alessia Cicenia
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Lucia Pallotta
- Department of Internal Medicine and Medical Specialties, University Sapienza of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital S. Andrea, University Sapienza of Rome, Via di Grottarossa 1035-1039, 00189 Roma, Italy
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The effect of cyclic rifaximin therapy on symptoms of diverticular disease from the perspective of the gastroenterology outpatient clinic: a "real-life" study. GASTROENTEROLOGY REVIEW 2017; 12:145-151. [PMID: 28702105 PMCID: PMC5497137 DOI: 10.5114/pg.2017.68167] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/24/2017] [Indexed: 01/15/2023]
Abstract
Introduction Symptomatic uncomplicated diverticular disease of the colon (SUDD) is one of the most common diseases with which patients present to a gastroenterologist. Mild forms of diverticulitis can also be treated using rifaximin. Although numerous randomised controlled trials have already demonstrated the efficacy of rifaximin therapy, there is still a lack of data from daily medical practice. Aim To assess the effect of rifaximin on the symptoms of diverticular disease (SUDD and mild diverticulitis) in patients undergoing routine treatment in gastroenterology outpatient clinics in Poland. Material and methods The retrospective study included 142 patients with a diagnosis of SUDD and mild diverticulitis, with a mean age of 60–69 years (41%), of whom 65% were women. Patients underwent three cycles of rifaximin therapy at a dose of 2 × 400 mg daily for 7 days over 3 consecutive months. Survey data were collected during monthly clinic appointments using a questionnaire completed by 48 gastroenterologists, and in selected cases standard inflammatory parameters were also determined. Results After just one cycle of therapy a significant reduction in disease symptoms was observed (abdominal pain, abdominal tenderness, bloating, disturbances in bowel habit), defined over a scale of 0–3 points. The mean intensity of symptoms decreased from 1.7 ±0.7 to 0.8 ±0.3 points (with a maximum symptom intensity of 3.0 points). After three cycles, the severity of symptoms decreased markedly to an average of 0.3 ±0.1, and as many as 75% of patients reported no abdominal pain (previously the percentage was only 4%). These differences were statistically significant, p < 0.001. The decrease in inflammatory parameters (white blood cell count, C-reactive protein and erythrocyte sedimentation rate) was statistically significant. Conclusions Rifaximin is highly effective in the symptomatic relief of uncomplicated diverticular disease of the large bowel, and it is also effective in the treatment of mild forms of diverticulitis. Although the effects were already visible after the first cycle of therapy, the highest efficacy was obtained after three cycles of therapy. Rifaximin can be successfully used in routine medical practice.
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