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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; 19:1675-1685. [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] [MESH Headings] [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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Montgomery G, Patel A, Pfeil S. Treatment and Management of Gastrointestinal Disorders. Med Clin North Am 2024; 108:777-794. [PMID: 39084834 DOI: 10.1016/j.mcna.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
This article reviews the evaluation and management of several gastrointestinal disorders that are commonly encountered by gastroenterologists and primary care physicians. With a focus on newer therapies, we discuss the management of chronic constipation, irritable bowel syndrome, Clostridioides difficile infection, gastroparesis, steatotic liver disease, and diverticulitis.
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Affiliation(s)
- Garren Montgomery
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Arsheya Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sheryl Pfeil
- Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University Medical Center, Columbus, OH, USA
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Garfinkle R, Boutros M. Current Management of Diverticulitis. Adv Surg 2024; 58:87-106. [PMID: 39089789 DOI: 10.1016/j.yasu.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Over the last few decades, our understanding of the pathophysiology and natural history of sigmoid diverticulitis has greatly improved. This knowledge has challenged many of the traditional principles in the management for diverticulitis, such as routine antibiotic administration in all cases, number-based recommendations for elective surgery, and the necessity for an end colostomy in emergency surgery. This review will cover the breadth of management for sigmoid diverticulitis, covering both uncomplicated and complicated disease as well as elective and emergent disease presentations. New and emerging concepts in management will be highlighted with a particular focus on level-1 data, when available.
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Affiliation(s)
- Richard Garfinkle
- Division of Mayo Clinic Colon and Rectal Surgery, 200 First Street, SW, Rochester, MN 55905, USA; Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marylise Boutros
- Department of Surgery, McGill University, Montreal, Quebec, Canada; Department of Colorectal Surgery, Cleveland Clinic Florida, Ellen Leifer Shulman and Steven Shulman Digestive Disease Institute, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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Völkerer A, Wernly S, Semmler G, Flamm M, Radzikowski K, Datz L, Götz N, Hofer H, Aigner E, Datz C, Wernly B. Association between Cardiovascular Risk Assessment by SCORE2 and Diverticulosis: A Cross-Sectional Analysis. J Pers Med 2024; 14:862. [PMID: 39202053 PMCID: PMC11355319 DOI: 10.3390/jpm14080862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND The aim of this retrospective observational study was to examine the relationship between SCORE2 and the occurrence of colonic diverticula in a screening population without cardiovascular or gastrointestinal symptoms. SCORE2, recognized and supported by the European Society of Cardiology for cardiovascular risk assessment, served as the primary metric for the analysis in this investigation. METHODS We studied 3935 asymptomatic individuals undergoing screening colonoscopy. SCORE2 was calculated for each participant and categorized into three groups based on the following projected 10-year cardiovascular disease risk: SCORE2 0-4.9%, SCORE2 5-9.9%, and SCORE2 ≥ 10%. Logistic regression was used to assess the relationship between SCORE2 and diverticulosis. RESULTS SCORE2 was associated with the presence of diverticulosis (OR 1.09, 95%CI 1.07-1.10; p < 0.001) in univariable logistic regression, translating into an RR of 1.07 per unit increase. The association persisted after multivariable adjusting for metabolic syndrome (aOR 1.08; 95%CI 1.06-1.10; p < 0.001). Patients with high cardiovascular risk had higher rates of diverticulosis compared to those with lower risk: high risk (OR 2.00, 95%CI 1.71-2.33; p < 0.001); very high risk (OR 2.53, 95%CI 2.10-3.05; p < 0.001). This association remained after adjusting for metabolic syndrome: high risk (aOR 1.86, 95%CI 1.59-2.18; p < 0.001); very high risk (aOR 2.27, 95%CI 1.88-2.75; p < 0.001). CONCLUSIONS A higher SCORE2 was found to be a suitable screening parameter for diverticular disease. This suggests a potential link between cardiovascular risk factors and colon diverticula development, warranting further research on whether optimizing cardiovascular risk factors could positively influence diverticular disease.
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Affiliation(s)
- Andreas Völkerer
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Sarah Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Center for Public Health and Healthcare Research Paracelsus Medical University, 5020 Salzburg, Austria
| | - Konrad Radzikowski
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Leonora Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Nikolaus Götz
- Department of Internal Medicine, General Hospital St. Vinzenz Zams, 6511 Zams, Austria
| | - Hannah Hofer
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Elmar Aigner
- Clinic I for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
- Institute of General Practice, Family Medicine and Preventive Medicine, Center for Public Health and Healthcare Research Paracelsus Medical University, 5020 Salzburg, Austria
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Marasco G, Bruni A, Nardone OM, Lopetuso LR. Insights into Probiotic Prescription among Gastroenterologists and Other Healthcare Professionals: Evidence from an Italian Survey. J Clin Med 2024; 13:4749. [PMID: 39200891 PMCID: PMC11355817 DOI: 10.3390/jcm13164749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/04/2024] [Accepted: 08/09/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Probiotics, which are live microorganisms that provide health benefits, have been extensively studied for their various clinical applications. However, despite their potential, high-quality data supporting their use in several gastrointestinal diseases are often lacking, and prescription behaviors can widely differ. This study aimed to assess different behaviors in probiotics knowledge and prescriptions among Italian gastroenterologists and healthcare professionals (HPs). Methods: A web-based electronic survey was distributed to all participants at the National Meeting of the Italian Young Gastroenterologist and Endoscopist Association (AGGEI) held in 2023. The survey investigated probiotic prescription practices for several gastrointestinal conditions, such as acute diarrhea, irritable bowel syndrome, inflammatory bowel disease, and diverticular disease. Results: Among 200 participants, 142 completed the survey, of whom 59 were gastroenterologists and 83 were HPs (surgeons, nutrition biologists, and other physicians). Significant differences were observed in the prescription of probiotics for the treatment of acute diarrhea and H. pylori. Both groups prescribed probiotics in monthly cycles for patients with IBS, although the majority prescribed multistrain formulations. Gastroenterologists were more likely to prescribe cyclic courses for IBS, while HPs tended to continue therapy by changing the probiotic strain in case of inefficacy. For ulcerative colitis, gastroenterologists prescribed probiotics more but for shorter durations. In Crohn's disease, gastroenterologists prescribed probiotics less and were less likely to prescribe multistrain formulations. Regarding SUDD, gastroenterologists tended to prescribe probiotics less frequently, although without a significant difference, with similar rates of preference for multistrain formulations. Conclusions: This survey highlights heterogeneous behaviors in probiotic prescription between gastroenterologists and HPs, with gastroenterologists more aligned with guidelines and available scientific evidence. Hence, enhancing probiotic education among healthcare professionals and gastroenterologists is crucial. Further studies are needed to better understand probiotics' role in gastrointestinal disorders through large-scale randomized controlled trials.
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Affiliation(s)
- Giovanni Marasco
- Division of Internal Medicine and Digestive Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Angelo Bruni
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Olga Maria Nardone
- Gastroenterology, Department of Public Health, University Federico II of Naples, 80131 Naples, Italy;
| | - Loris Riccardo Lopetuso
- CEMAD—IBD UNIT—Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy;
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Barzi KV, Galli R, Denhaerynck K, Rosenberg R, von Strauss Und Torney M. Quality of life with diverticular disease: translation and validation of the German version of the diverticulitis quality of life questionnaire (DV-QOL). Tech Coloproctol 2024; 28:98. [PMID: 39138701 DOI: 10.1007/s10151-024-02982-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/12/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND The DV-QoL is a 17-item questionnaire measuring health-related quality of life in patients affected by symptomatic diverticular disease, covering four domains: physical symptoms, concerns, feelings, and behavioral changes. Given the lack of a diverticulitis-specific questionnaire to be used for German-speaking patients, we prospectively validated the German version of the DV-QoL. METHODS German-speaking patients with CT-confirmed history of recurrent diverticular disease admitted to a Swiss surgical department completed the German version of the DV-QoL, along with short form-36 (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI). Reliability was examined using exploratory and confirmatory factor analysis, a Martin-Loef test, and Cronbach's alpha. For convergent validity testing, correlations were calculated with the GIQLI and SF-36. Discriminant validity tests included age and gender. RESULTS We included 121 patients, of whom 77 were admissions for elective surgery and 44 presented with acute diverticulitis treated conservatively. The DV-QoL's total score showed good correlations with the GIQLI (r = - 0.77) and its subscales (r = - 0.76 to - 0.45), as well as with the SF-36's subscales (r = - 0.30 to - 0.57). No relationships were found with age or gender (p < 0.05). The Cronbach's alpha coefficient was 0.89 over all items and 0.69, 0.90, 0.78, and 0.77 for the four separated domains (physical symptoms, cognitions/concerns, feelings, and behavioral changes, respectively). A nonsignificant Martin-Loef test indicated unidimensionality (p = 1), further supported by the exploratory factor analysis, which showed an item information sharing of 65%. CONCLUSION The German DV-QoL questionnaire can be used as a valid and reliable disease-specific measure for quality of life in patients with recurrent diverticular disease.
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Affiliation(s)
- K V Barzi
- Department of Surgery, Cantonal Hospital Baselland, 4410, Liestal, Switzerland
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - R Galli
- Department of Surgery, Cantonal Hospital Baselland, 4410, Liestal, Switzerland.
| | - K Denhaerynck
- Department of Public Health, University of Basel, Basel, Switzerland
| | - R Rosenberg
- Department of Surgery, Cantonal Hospital Baselland, 4410, Liestal, Switzerland
| | - M von Strauss Und Torney
- Department of Visceral Surgery Clarunis, University Center for Gastrointestinal and Liver Disease, Basel, Switzerland
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Dalby HR, Orrú A, Sundh F, Buchwald P, Brännström F, Hansske B, Haapaniemi S, Nikberg M, Chabok A. Management of acute uncomplicated diverticulitis and adherence to current guidelines-a multicentre SNAPSHOT study. Int J Colorectal Dis 2024; 39:128. [PMID: 39115694 PMCID: PMC11310278 DOI: 10.1007/s00384-024-04701-z] [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] [Accepted: 07/31/2024] [Indexed: 08/11/2024]
Abstract
PURPOSE To explore whether previous participation in clinical studies increases adherence to management guidelines in acute uncomplicated diverticulitis (AUD). METHODS This retrospective cohort study was designed to give a SNAPSHOT of the management of AUD at six hospitals, three of which had participated in the AVOD trial comparing antibiotic versus non-antibiotic treatment of AUD. Patients with AUD were included from March 2019 through June 2020 and followed for 90 days. The primary outcome was treatment of AUD categorised by antibiotic treatment and inpatient or outpatient management compared between AVOD and non-AVOD hospitals. Descriptive statistics were compiled, and differences between hospitals were assessed with Pearson's chi-squared test. RESULTS The cohort included 449 patients with AUD of which 63% were women and the median age was 63 (IQR: 52-73) years. Patient characteristics were comparable across the hospitals. Antibiotics were administered to 84 (19%) patients and 113 (25%) patients were managed as inpatients. Management varied significantly between AVOD and non-AVOD hospitals. The mean proportion of patients treated with antibiotics was 7% at AVOD hospitals compared to 38% at non-AVOD hospitals (p < 0.001). The mean proportion of in-hospital management was 18% at AVOD hospitals versus 38% at non-AVOD hospitals (p < 0.001). CONCLUSION Most patients with AUD were managed according to current guidelines. However, the management varies between hospitals and previous participation in clinical studies may increase knowledge of and adherence to guidelines.
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Affiliation(s)
- Helene R Dalby
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research, Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden.
- Department of Surgery, Randers Regional Hospital, Randers, Denmark.
| | - Alessandro Orrú
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research, Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
| | - Frida Sundh
- Division of Surgery, Danderyd University Hospital, Stockholm, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Lund University, Malmö, Lund, Sweden
| | | | - Bengt Hansske
- Department of Surgery, Torsby Hospital, Torsby, Region Värmland, Sweden
| | | | - Maziar Nikberg
- Colorectal Unit, Department of Surgery, and Centre for Clinical Research, Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
- Center for Clinical Research, Uppsala University, Västerås, Region Västmanland, Sweden
| | - Abbas Chabok
- Division of Surgery, Danderyd University Hospital, Stockholm, Sweden
- Center for Clinical Research, Uppsala University, Västerås, Region Västmanland, Sweden
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Milhem FS, Awashra A, Hamshary H, Sawaftah Z, Khaled A, Nabresi N, Salman I. Cohen Syndrome With Complex Medical Complications: A Case Report. Cureus 2024; 16:e66033. [PMID: 39221324 PMCID: PMC11366416 DOI: 10.7759/cureus.66033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
Cohen syndrome (CS) is a rare autosomal recessive disorder marked by developmental delays, distinct facial features, and a variety of systemic manifestations. We present a case of a 28-year-old male previously misdiagnosed with Prader-Willi syndrome who exhibited recurrent generalized weakness, fever, fatigue, and significant hemoglobin drops requiring multiple blood transfusions due to thalassemia major. The patient displayed characteristic CS features, including developmental delays, distinct facial characteristics, morbid obesity, and heterochromia iridis. Severe gastrointestinal bleeding led to a diagnosis of ulcerative colitis (UC) via colonoscopy. Management included blood transfusions, hydrocortisone, mesalamine, and azathioprine, resulting in stabilized UC and improved overall health. CS presents with a spectrum of clinical features that overlap with other syndromic conditions, necessitating careful differential diagnosis. Early diagnosis and supportive care significantly improve quality of life and help manage complications effectively.
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Affiliation(s)
- Fathi S Milhem
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Ameer Awashra
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, PSE
| | - Husam Hamshary
- Department of Medicine, An-Najah National University, Nablus, PSE
| | - Zaid Sawaftah
- Department of Medicine, An-Najah National University, Nablus, PSE
| | - Amr Khaled
- Department of Medicine, An-Najah National University, Nablus, PSE
| | - Noor Nabresi
- Pediatrics and Neonatology, Tulkarim Governmental Hospital, Tulkarm, PSE
| | - Israa Salman
- Pediatrics and Neonatology, Tulkarim Governmental Hospital, Tulkarim, PSE
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Carabotti M, Sgamato C, Amato A, Beltrame B, Binda GA, Germanà B, Leandro G, Pasquale L, Peralta S, Viggiani MT, Severi C, Annibale B, Cuomo R. Italian guidelines for the diagnosis and management of colonic diverticulosis and diverticular disease. Dig Liver Dis 2024:S1590-8658(24)00841-7. [PMID: 39004551 DOI: 10.1016/j.dld.2024.06.031] [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: 03/03/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Abstract
Colonic diverticulosis and diverticular disease are among the most common gastrointestinal disorders encountered in clinical practice. These Italian guidelines focus on the diagnosis and management of diverticulosis and diverticular disease in the adult population, providing practical and evidence-based recommendations for clinicians. Experts from five Italian scientific societies, constituting a multidisciplinary panel, conducted a comprehensive review of meta-analyses, systematic reviews, randomised controlled trials, and observational studies to formulate 14 PICO questions. The assessment of the quality of the evidence and the formulation of the recommendations were carried out using an adaptation of the GRADE methodology. The guidelines covered the following topics: i) Management of diverticulosis; ii) Symptomatic uncomplicated diverticular disease: diagnosis and treatment; iii) Acute diverticulitis: diagnosis and treatment; iv) Management of diverticular disease complications; v) Prevention of recurrent acute diverticulitis; vi) Interventional management of diverticular disease.
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Affiliation(s)
- Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Costantino Sgamato
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
| | | | - Benedetta Beltrame
- Department of Technical-Health Care Professions Dietetics Unit- AUSL Toscana Centro Santa Maria Nuova Hospital, Italy
| | | | - Bastianello Germanà
- Gastroenterology and Digestive Endoscopy San Martino Hospital, Belluno, Italy
| | | | - Luigi Pasquale
- Gastroenterology and Digestive Endoscopy, Avellino, Italy
| | - Sergio Peralta
- UOS Diagnostic and Interventional Digestive Endoscopy AOU Policlinico P.Giaccone, Palermo, Italy
| | | | - Carola Severi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Rosario Cuomo
- Gastroenterology and Endoscopy Unit, "Sant'Anna e San Sebastiano" Hospital Caserta, 81100 Caserta, Italy
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Kodadek LM, Davis KA. Current diagnosis and management of acute colonic diverticulitis: What you need to know. J Trauma Acute Care Surg 2024; 97:1-10. [PMID: 38509056 DOI: 10.1097/ta.0000000000004304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
ABSTRACT Acute colonic diverticulitis is a common disease treated by acute care surgeons. Acute uncomplicated colonic diverticulitis involves thickening of the colon wall with inflammatory changes and less commonly requires the expertise of a surgeon; many cases may be treated as an outpatient with or without antibiotics. Complicated diverticulitis involves phlegmon, abscess, peritonitis, obstruction, stricture, and/or fistula and usually requires inpatient hospital admission, treatment with antibiotics, and consideration for intervention including operative management. This review will discuss what the acute care surgeon needs to know about diagnosis and management of acute colonic diverticulitis.
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Affiliation(s)
- Lisa M Kodadek
- From the Division of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Urquhart SA, Ewy MW, Flicek KT, Fidler JL, Sheedy SP, Harmsen WS, Chedid VG, Coelho-Prabhu N. Clinical and Radiographic Characteristics in Segmental Colitis Associated With Diverticulosis, Diverticulitis, and Crohn's Disease. GASTRO HEP ADVANCES 2024; 3:901-909. [PMID: 39286621 PMCID: PMC11402292 DOI: 10.1016/j.gastha.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/03/2024] [Indexed: 09/19/2024]
Abstract
Background and Aims Segmental colitis associated with diverticulosis (SCAD) is an underrecognized disease characterized by chronic segmental inflammation surrounding colonic diverticula. SCAD is recognized as an autonomous entity, although shares similar pathogenic and therapeutic aspects to inflammatory bowel disease and may be considered a complication of diverticulitis. We aimed to characterize the clinical, endoscopic, and radiographic findings of SCAD and its potential overlap with diverticulitis and inflammatory bowel disease. Methods All patients with suspected diagnosis of SCAD were identified using a bioinformatics search tool from January 1996 to October 2021 at our institution. Relevant demographic, clinical, endoscopic, and radiographic data were abstracted. Disease-related outcomes and radiographic characteristics were determined. Results Seventy-five patients with SCAD were included (48.0% female) with average age at diagnosis 62.5 years. Thirty-seven (49.3%) had a prior episode of diverticulitis. The most common presenting symptoms were abdominal pain (33.3%) and hematochezia (22.7%). Antibiotics (42.7%) and mesalamine (36.0%) were most used as first-line treatment options. Twenty (26.7%) required surgical intervention. The most common initial endoscopic finding was isolated sigmoid inflammation (86.7%). Fifty-one patients with confirmed SCAD, 72 with diverticulitis, and 12 with Crohn's disease (CD) had imaging available for review. Penetrating disease was seen in 7 (13.7%) with SCAD compared to 7 (9.7%) and 2 (16.6%) with diverticulitis and CD, respectively (P = .14). Blinded radiologists diagnosed SCAD, CD, or diverticulitis correctly in 43.8%, 8.3%, and 27.1%, respectively. Conclusion SCAD should be considered when isolated sigmoid colon inflammation is seen on cross-sectional imaging. Penetrating disease is not a specific radiologic feature for either SCAD or diverticulitis. Further prospective studies are needed to correlate imaging characteristics with endoscopic findings to better describe radiographic features in SCAD.
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Affiliation(s)
- Siri A Urquhart
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Matthew W Ewy
- Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kristina T Flicek
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Shannon P Sheedy
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - William S Harmsen
- Division of Clinical Trials and Biostatistics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Victor G Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Nayantara Coelho-Prabhu
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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12
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Portolese AC, Jeganathan NA. Contemporary management of diverticulitis. Surg Open Sci 2024; 19:24-27. [PMID: 38585040 PMCID: PMC10995854 DOI: 10.1016/j.sopen.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 04/09/2024] Open
Abstract
The treatment of diverticulitis is experiencing a shift in management due to a number of large scale clinical trials. For instance, clinicians are beginning to recognize that avoidance of antibiotics in uncomplicated diverticulitis is not associated with worse outcomes. Additionally, while the decision to proceed with elective surgical resection for recurrent uncomplicated disease is less conclusive and favors a patient-centric approach, complicated disease with a large abscess denotes more aggressive disease and would likely benefit from elective surgical resection. Lastly, in patient with acutely perforated diverticulitis who require urgent surgical intervention, laparoscopic lavage is generally not recommended due to high re-intervention rates and the preferred surgical procedure is primary anastomosis with or without diversion due to high morbidity and low rates of Hartmann reversal.
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Affiliation(s)
- Austin C. Portolese
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Nimalan A. Jeganathan
- Department of Surgery, Division of Colon & Rectal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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13
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Domas E, Starks K, Kanneganti S. Current Management of Diverticulitis. Surg Clin North Am 2024; 104:529-543. [PMID: 38677818 DOI: 10.1016/j.suc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Diverticulosis and diverticulitis remain common diagnoses in western countries, and the incidence continues to rise. Diverticulitis accounts for roughly one-third of admissions to acute care hospitals annually, with even more patients being treated as outpatients due to improved understanding of risk stratification and the natural history of disease progression. Thus, having a thorough understanding of the etiology of the disease in conjunction with computed tomography findings and patient presentation can help dictate the appropriate treatment.
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Affiliation(s)
- Erik Domas
- Virginia Mason Franciscan Health, St. Joseph Medical Center General Surgery Residency, 1708 South Yakima Avenue, Suite 115, Tacoma, WA 98405, USA
| | - Kiefer Starks
- Virginia Mason Franciscan Health, St. Joseph Medical Center General Surgery Residency, 1708 South Yakima Avenue, Suite 115, Tacoma, WA 98405, USA
| | - Shalini Kanneganti
- Department of Colon and Rectal Surgery, Virginia Mason Franciscan Health, Franciscan Surgical Associates at St. Joseph, 1708 South Yakima Avenue, Suite 105 & 112, Tacoma, WA 98405, USA.
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14
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Layunta E, Mesonero JE, Latorre E. Guardians at the Gate: Immune System in Gastrointestinal Diseases. Int J Mol Sci 2024; 25:5933. [PMID: 38892119 PMCID: PMC11172644 DOI: 10.3390/ijms25115933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
The immune system plays a key role in gastrointestinal (GI) pathologies, being responsible for protecting the body against infection, maintaining homeostasis, and regulating the inflammatory response in the GI tract [...].
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Affiliation(s)
- Elena Layunta
- Departamento de Anatomía, Embriología y Genética Animal, Facultad de Veterinaria, Universidad de Zaragoza, 50013 Zaragoza, Spain
- Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón-IA2, Universidad de Zaragoza-CITA, 50013 Zaragoza, Spain
| | - Jose Emilio Mesonero
- Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón-IA2, Universidad de Zaragoza-CITA, 50013 Zaragoza, Spain
- Departamento de Farmacología, Fisiología y Medicina Legal y Forense, Facultad de Veterinaria, Universidad de Zaragoza, 50013 Zaragoza, Spain
| | - Eva Latorre
- Instituto de Investigación Sanitaria de Aragón (IIS Aragón), 50009 Zaragoza, Spain
- Instituto Agroalimentario de Aragón-IA2, Universidad de Zaragoza-CITA, 50013 Zaragoza, Spain
- Departamento de Bioquímica y Biología Molecular y Celular, Facultad de Ciencias, Universidad de Zaragoza, 50009 Zaragoza, Spain
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15
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Gunby SA, Ma W, Levy MJ, Giovannucci EL, Chan AT, Strate LL. Smoking and Alcohol Consumption and Risk of Incident Diverticulitis in Women. Clin Gastroenterol Hepatol 2024; 22:1108-1116. [PMID: 38122959 PMCID: PMC11045313 DOI: 10.1016/j.cgh.2023.11.036] [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: 04/09/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Much of what is known about the effects of alcohol and tobacco use on diverticular disease derives from studies of asymptomatic diverticulosis or complicated diverticulitis. We examined smoking and alcohol consumption and risk of incident diverticulitis in a large cohort of women. METHODS We conducted a prospective study of 84,232 women in the Nurses' Health Study II (NHS II) who were 39-52 years old and without known diverticulitis at baseline in 2003. Smoking was ascertained every 2 years and alcohol use every 4 years. We used Cox proportional hazards regression to estimate multivariable-adjusted hazards ratios (HRs) and 95% confidence intervals (CIs). RESULTS During 1,139,660 person-years of follow up, we identified 3018 incident cases of diverticulitis. After adjustment for other risk factors, current (HR, 1.20; 95% CI, 1.04-1.39) and past smoking (HR, 1.20; 95% CI, 1.11-1.30) were associated with increased risk of diverticulitis when compared with never smokers. Women who consumed ≥30 g/d of alcohol had a multivariate HR of 1.26 (95% CI, 1.05-1.50) when compared with women who did not drink. A joint analysis of smoking and alcohol found that individuals who ever smoked and consumed ≥15 g/d of alcohol were at highest risk of diverticulitis (multivariate HR, 1.60; 95% CI, 1.16-2.21), compared with participants who never smoked and reported no alcohol use. CONCLUSIONS In this large prospective study of women, smoking and alcohol consumption were associated with an increased risk of incident diverticulitis. These data highlight additional modifiable risk factors for diverticulitis that may aid in prevention.
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Affiliation(s)
- Sarah A Gunby
- University of Washington Department of Medicine, Seattle, Washington
| | - Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School Department of Medicine, Boston, Massachusetts
| | - Miriam J Levy
- University of Washington Department of Medicine, Seattle, Washington
| | | | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School Department of Medicine, Boston, Massachusetts; Harvard University T H Chan School of Public Health, Boston, Massachusetts; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa L Strate
- University of Washington Department of Medicine, Seattle, Washington.
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16
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Ma W, Wang Y, Nguyen LH, Mehta RS, Ha J, Bhosle A, Mclver LJ, Song M, Clish CB, Strate LL, Huttenhower C, Chan AT. Gut microbiome composition and metabolic activity in women with diverticulitis. Nat Commun 2024; 15:3612. [PMID: 38684664 PMCID: PMC11059386 DOI: 10.1038/s41467-024-47859-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/11/2024] [Indexed: 05/02/2024] Open
Abstract
The etiopathogenesis of diverticulitis, among the most common gastrointestinal diagnoses, remains largely unknown. By leveraging stool collected within a large prospective cohort, we performed shotgun metagenomic sequencing and untargeted metabolomics profiling among 121 women diagnosed with diverticulitis requiring antibiotics or hospitalizations (cases), matched to 121 women without diverticulitis (controls) according to age and race. Overall microbial community structure and metabolomic profiles differed in diverticulitis cases compared to controls, including enrichment of pro-inflammatory Ruminococcus gnavus, 1,7-dimethyluric acid, and histidine-related metabolites, and depletion of butyrate-producing bacteria and anti-inflammatory ceramides. Through integrated multi-omic analysis, we detected covarying microbial and metabolic features, such as Bilophila wadsworthia and bile acids, specific to diverticulitis. Additionally, we observed that microbial composition modulated the protective association between a prudent fiber-rich diet and diverticulitis. Our findings offer insights into the perturbations in inflammation-related microbial and metabolic signatures associated with diverticulitis, supporting the potential of microbial-based diagnostics and therapeutic targets.
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Affiliation(s)
- Wenjie Ma
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yiqing Wang
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Long H Nguyen
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Raaj S Mehta
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jane Ha
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Amrisha Bhosle
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lauren J Mclver
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mingyang Song
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Clary B Clish
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lisa L Strate
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA
| | - Curtis Huttenhower
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Cancer Center, Massachusetts General Hospital, Boston, MA, USA.
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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17
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Redd WD, Holub JL, Nichols HB, Sandler RS, Peery AF. Follow-Up Colonoscopy for Detection of Missed Colorectal Cancer After Diverticulitis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00393-8. [PMID: 38670477 DOI: 10.1016/j.cgh.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024]
Abstract
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.
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Affiliation(s)
- Walker D Redd
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer L Holub
- Gastrointestinal Quality Improvement Consortium, Bethesda, Maryland
| | - Hazel B Nichols
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Robert S Sandler
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina
| | - Anne F Peery
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina.
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18
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Mortensen LQ, Andresen K, Thygesen L, Pommergaard HC, Rosenberg J. Diverticulitis Is Associated with Increased Risk of Colon Cancer-A Nationwide Register-Based Cohort Study. J Clin Med 2024; 13:2503. [PMID: 38731032 PMCID: PMC11084441 DOI: 10.3390/jcm13092503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
Background: An association between diverticulitis and colon cancer has been proposed. The evidence is conflicting, and the guidelines differ regarding recommended follow-up with colonoscopy after an episode of diverticulitis. To guide regimes for follow-up, this study aimed to investigate if patients with diverticulitis have an increased risk of colon cancer. Methods: This study is reported according to the RECORD statement. We performed a cohort study with linked data from nationwide Danish registers. The inclusion period was 1997-2009, and the complete study period was 1995-2013. The primary outcome was the risk of developing colon cancer estimated using a Cox regression analysis with time-varying covariates. We performed a sensitivity analysis on a cohort of people with prior colonoscopies, comparing the risk of colon cancer between the diverticulitis group and the control group. Results: We included 29,173 adult males and females with diverticulitis and 145,865 controls matched for sex and age. The incidence proportion of colon cancer was 2.1% (95% confidence interval (CI) 1.9-2.3) in the diverticulitis group and 1.5% (95% CI 1.4-1.5) in the matched control group (hazard ratio 1.6; 95% CI 1.5-1.8). The risk of having a colon cancer diagnosis was significantly increased in the first six months after inclusion (hazard ratio 1.7; 95% CI 1.5-1.8), and hereafter there was a lower risk in the diverticulitis group compared with controls (hazard ratio 0.8; 95% CI 0.7-0.9). This protective effect lasted eight years. The increased risk of colon cancer during the first six months after diverticulitis was also found in the cohort with prior colonoscopies. Conclusions: The risk of a colon cancer diagnosis was significantly increased for patients with diverticulitis 0-6 months after the diagnosis of diverticulitis. Hereafter, we found a protective effect of diverticulitis until eight years later, possibly due to a screening effect. We recommend a follow-up colonoscopy after the first diagnosis of diverticulitis.
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Affiliation(s)
- Laura Quitzau Mortensen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, 2730 Herlev, Denmark; (L.Q.M.)
- Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Amager and Hvidovre Hospital, 2650 Hvidovre, Denmark
| | - Kristoffer Andresen
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, 2730 Herlev, Denmark; (L.Q.M.)
| | - Lau Thygesen
- National Institute of Public Health, University of Southern Denmark, 1455 Copenhagen, Denmark
| | - Hans-Christian Pommergaard
- Hepatic Malignancy Surgical Research Unit (HEPSURU), Department of Surgery and Transplantation, Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Jacob Rosenberg
- Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, 2730 Herlev, Denmark; (L.Q.M.)
- Department of Clinical Medicine, University of Copenhagen, 2200 Copenhagen, Denmark
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Santacroce G, Lenti MV, Abruzzese GM, Alunno G, Di Terlizzi F, Frenna C, Gentile A, Latorre MA, Petrucci C, Ruggeri D, Soriano S, Aronico N, De Silvestri A, Corazza GR, Iacucci M, Di Sabatino A. Clinical outcomes of diverticular disease in young adults: results from a tertiary referral center. Front Med (Lausanne) 2024; 11:1363548. [PMID: 38646562 PMCID: PMC11027500 DOI: 10.3389/fmed.2024.1363548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction Diverticular disease (DD), commonly associated with the elderly, is becoming more prevalent among younger individuals. This retrospective study aimed to evaluate the differences in the natural history and outcomes between young and old patients with DD. Methods Adult patients with DD diagnosed between 2010 and 2022 at an Italian tertiary referral center were enrolled, and their demographic and clinical data were retrieved. The patients were categorized as young or old based on the 25th percentile of the population's age at diagnosis. Univariate and multivariate analyses were performed to assess the association between the collected variables and the age of disease presentation. Additionally, survival analyses were conducted to evaluate the association between the age of diagnosis and clinical outcomes at follow-up, including disease recurrence, hospital access, surgery, and death. Results A total of 220 DD patients (with a median age of 66 years, IQR 55-74, and a female-to-male ratio of 1.4:1) were included in the study, comprising 54 patients receiving a diagnosis before the age of 49 years (young DD patients) and 166 patients diagnosed after the age of 49 years (old DD patients). Male sex (57 vs. 36%, p < 0.01), smoking (38 vs. 14%, p < 0.01), and alcohol consumption (54 vs. 38%) were highly prevalent in young patients. The complications at the time of diagnosis, particularly abscesses and free perforations, occurred more frequently in younger patients (p = 0.04). Moreover, young DD patients experienced a higher rate of hospitalization and surgical intervention (p = 0.01 and p = 0.04, respectively) over a median follow-up period of 5 years. Conclusion Preventive strategies and prompt diagnosis are crucial in young patients with DD for achieving better disease outcomes and preventing complications.
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Affiliation(s)
- Giovanni Santacroce
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Marco Vincenzo Lenti
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Giulia Maria Abruzzese
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Giacomo Alunno
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Francesco Di Terlizzi
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Carmine Frenna
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Antonella Gentile
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Mario Andrea Latorre
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Clarissa Petrucci
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Damiano Ruggeri
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Simone Soriano
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Nicola Aronico
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Annalisa De Silvestri
- Scientific Direction, Clinical Epidemiology and Biometric Unit, San Matteo Hospital Foundation, Pavia, Italy
| | - Gino Roberto Corazza
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
| | - Marietta Iacucci
- APC Microbiome Ireland, College of Medicine and Health, University College of Cork, Cork, Ireland
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, San Matteo Hospital Foundation, Pavia, Italy
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20
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Völkerer A, Wernly S, Semmler G, Flamm M, Radzikowski K, Datz L, Aigner E, Datz C, Wernly B. The Impact of Educational Status on the Occurrence of Colonic Diverticula: Insights from an Austrian Cohort Study. Med Princ Pract 2024; 33:242-250. [PMID: 38471466 PMCID: PMC11175605 DOI: 10.1159/000538308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/11/2024] [Indexed: 03/14/2024] Open
Abstract
OBJECTIVE Education often reflects socioeconomic status. Research indicates that lower socioeconomic status may increase the risk of diverticulosis, and according to data from the USA, diverticular disease is a significant and costly health problem. Our study explores the link between educational level and colonic diverticula occurrence. SUBJECT AND METHODS We conducted a cohort study on 5,532 asymptomatic Austrian patients who underwent colonoscopy, categorizing them by education level using the updated Generalized International Standard Classification of Education (GISCED). Logistic regression models, adjusting for age, gender, metabolic syndrome, diet, and activity, were used to determine the association between education and diverticulosis. RESULTS Overall, 39% of the patients had low educational status, while 53% had medium, and 8% had high educational status. Colon diverticula were less frequent in patients with medium (OR 0.73) and high (aOR 0.62) educational status. Medium educational level remained associated with lower rates of diverticulosis after adjustment for age and sex (aOR 0.85) and further metabolic syndrome, dietary habits, and physical activity (aOR 0.84). In higher education status, this phenomenon was only seen by trend. CONCLUSION Low education correlated with higher colon diverticula risk, while medium education showed lower rates even after adjustments. This trend persisted at higher education levels, highlighting the potential for strategies for cost reduction tailored to socioeconomic conditions.
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Affiliation(s)
- Andreas Völkerer
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Sarah Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Konrad Radzikowski
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Leonora Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Elmar Aigner
- Clinic I for Internal Medicine, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
| | - Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
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21
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Long B, Werner J, Gottlieb M. Emergency medicine updates: Acute diverticulitis. Am J Emerg Med 2024; 76:1-6. [PMID: 37956503 DOI: 10.1016/j.ajem.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS An understanding of literature updates can improve the ED care of patients with acute diverticulitis.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Jessie Werner
- Department of Emergency Medicine, UCSF Fresno, Fresno, CA, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Hoshino Y, Ito R, Kikuchi M, Takahashi K, Ishimoto M. Efficacy of cefmetazole in immunocompetent patients with uncomplicated colonic diverticulitis: A propensity score matching analysis. J Infect Chemother 2024; 30:118-122. [PMID: 37739180 DOI: 10.1016/j.jiac.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/13/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION The incidence of colonic diverticulitis is increasing in Japan. Although antimicrobial chemotherapy is a treatment option, Japanese guidelines for diverticulosis do not recommend any antibiotic in particular and antibiotic selection is left to the discretion of the prescribing physician, who often selects antibiotics with anti-pseudomonal activity. Therefore, this study compared the efficacy of cefmetazole (CMZ) with that of tazobactam/piperacillin (TAZ/PIPC) in hospitalized Japanese immunocompetent patients with uncomplicated colonic diverticulitis. PATIENTS AND METHODS This retrospective study included Japanese immunocompetent patients hospitalized for colonic diverticulitis between April 2019 and March 2022. Participants were divided into the CMZ and TAZ/PIPC groups. After propensity score matching, the intergroup differences in clinical outcomes, including adverse events, mortality, and re-admission rate, were ascertained. RESULTS During the study period, 142 Japanese patients were hospitalized with community-onset colonic diverticulitis; 124 of these patients were immunocompetent. Of the 124 patients, 42 were excluded, and the CMZ and TAZ/PIPC groups comprised 62 and 20 patients, respectively. After propensity score matching, there were 16 patients in each group. There was no significant intergroup difference in the mortality and re-admission rates; however, the incidence of liver dysfunction was significantly higher (p = 0.018) in the TAZ/PIPC group. CONCLUSION In patients with colonic diverticulitis, CMZ therapy should be selected because of the adequate clinical outcomes and lower incidence of adverse events, as this would reduce broad-spectrum antibiotic use and minimize antibiotic-resistant bacteria.
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Affiliation(s)
- Yuta Hoshino
- Department of Pharmacy, Tohoku Rosai Hospital, Miyagi, 981-8563, Japan.
| | - Ryota Ito
- Department of Pharmacy, Tohoku Rosai Hospital, Miyagi, 981-8563, Japan
| | - Miyu Kikuchi
- Department of Pharmacy, Tohoku Rosai Hospital, Miyagi, 981-8563, Japan
| | - Kenichi Takahashi
- Department of Colorectal Surgery, Tohoku Rosai Hospital, Miyagi, 981-8563, Japan
| | - Masahiro Ishimoto
- Department of Pharmacy, Tohoku Rosai Hospital, Miyagi, 981-8563, Japan
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Konyukova AK, Mikhaleva LM, Kozlova MA, Areshidze DA, Pechnikova VV, Shapovaliants SG, Mikhalev AI, Bolikhov KV, Shulaev AV. [Pathological changes in the muscular tissue of the colon in diverticular disease]. Arkh Patol 2024; 86:13-22. [PMID: 39073537 DOI: 10.17116/patol20248604113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
The high incidence of colonic diverticular disease (DD) in the general population is a serious public health problem. According to statistics, DD is among the top five most common colorectal diseases. Complicated course of DD is observed in 12-15% of patients, and in 10.7% of cases can lead to death. Algorithms and recommendations for predicting the complicated course of DD for further prevention have not been developed. OBJECTIVE Comparative analysis of clinical data and structural characteristics of the colonic muscular tissue in patients with different course of DD and without colonic diverticula to identify morphological predictors of a complicated DD. MATERIAL AND METHODS A comparative analysis of clinical data, pathomorphological and ultrastructural changes of the colonic musculature in the surgical material from 68 patients undergoing left-sided hemicolectomy was carried out. RESULTS The operative material of 37 patients with complicated course of DD, 19 with uncomplicated course of DD and 12 without diverticula was analyzed. In men, this disease occurs at a younger age than in women (Median age of men 49 (39.5; 61) years, women 66.5 (58; 81) years; U=178, p<0.001). It was shown that the area occupied by connective tissue fibres in the colonic musculature in patients with a complicated DD was 5 times greater (15%) than in observations with an uncomplicated DD (3%) and 50 times greater than in cases without colonic diverticula (0.3%; p<0.001). CONCLUSION The present study demonstrates age- and sex-specific features of DD, as well as significant differences in the prevalence of fibrosis of the colonic musculature, which can be considered as a potential predictor of a complicated course of DD.
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Affiliation(s)
- A K Konyukova
- Avtsyn Research Institute of Human Morphology of Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - L M Mikhaleva
- Avtsyn Research Institute of Human Morphology of Petrovsky National Research Centre of Surgery, Moscow, Russia
- Savelyeva Moscow City Clinical Hospital No. 31, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - M A Kozlova
- Avtsyn Research Institute of Human Morphology of Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - D A Areshidze
- Avtsyn Research Institute of Human Morphology of Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - V V Pechnikova
- Avtsyn Research Institute of Human Morphology of Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - S G Shapovaliants
- Pirogov Russian National Research Medical University, Moscow, Russia
- Savelyeva Moscow City Clinical Hospital No. 31, Moscow, Russia
| | - A I Mikhalev
- Pirogov Russian National Research Medical University, Moscow, Russia
- Savelyeva Moscow City Clinical Hospital No. 31, Moscow, Russia
| | - K V Bolikhov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Shulaev
- Savelyeva Moscow City Clinical Hospital No. 31, Moscow, Russia
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24
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Mahmood MW, Schmidt PT, Olén O, Hellsing C, Hjern F, Abraham-Nordling M. Identification of diverticular disease in Swedish healthcare registers: a validation study. Scand J Gastroenterol 2024; 59:176-182. [PMID: 37936435 DOI: 10.1080/00365521.2023.2278422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The Swedish National Patient Register (SNPR) is frequently used in studies of colonic diverticular disease (DD). Despite this, the validity of the coding for this specific disease in the register has not been studied. METHODS From SNPR, 650 admissions were randomly identified encoded with ICD 10, K572-K579. From the years 2002 and 2010, 323 and 327 patients respectively were included in the validation study. Patients were excluded prior to, or up to 2 years after a diagnosis with IBD, Celiac disease, IBS, all forms of colorectal cancer (primary and secondary), and anal cancer. Medical records were collected and data on clinical findings with assessments, X-ray examinations, endoscopies and laboratory results were reviewed. The basis of coding was compared with internationally accepted definitions for colonic diverticular disease. Positive predictive values (PPV) were calculated. RESULTS The overall PPV for all diagnoses and both years was 95% (95% CI: 93-96). The PPV for the year 2010 was slightly higher 98% (95% CI: 95-99) than in the year 2002, 91% (95% CI: (87-94) which may be due to the increasing use of computed tomography (CT). CONCLUSION The validity of DD in SNPR is high, making the SNPR a good source for population-based studies on DD.
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Affiliation(s)
- Mahmood Wael Mahmood
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter T Schmidt
- Department of Medical Sciences, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Christine Hellsing
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Hjern
- Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mirna Abraham-Nordling
- Department of Pelvic Cancer, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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25
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Williams S, Bjarnason I, Hayee B, Haji A. Diverticular disease: update on pathophysiology, classification and management. Frontline Gastroenterol 2024; 15:50-58. [PMID: 38487561 PMCID: PMC10935533 DOI: 10.1136/flgastro-2022-102361] [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: 04/19/2023] [Accepted: 07/19/2023] [Indexed: 03/17/2024] Open
Abstract
Colonic diverticulosis is prevalent, affecting approximately 70% of the western population by 80 years of age. Incidence is rapidly increasing in younger age groups. Between 10% and 25% of those with diverticular disease (DD) will experience acute diverticulitis. A further 15% will develop complications including abscess, bleeding and perforation. Such complications are associated with significant morbidity and mortality and constitute a worldwide health burden. Furthermore, chronic symptoms associated with DD are difficult to manage and present a further significant healthcare burden. The pathophysiology of DD is complex due to multifactorial contributing factors. These include diet, colonic wall structure, intestinal motility and genetic predispositions. Thus, targeted preventative measures have proved difficult to establish. Recently, commonly held conceptions on DD have been challenged. This review explores the latest understanding on pathophysiology, risk factors, classification and treatment options.
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Affiliation(s)
- Sophie Williams
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | - Ingvar Bjarnason
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Amyn Haji
- Department of Colorectal Surgery, King's College Hospital, London, UK
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Brière R, Benhamed A, Émond M, Blanchard PG, Drolet S. Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey. CAN J EMERG MED 2023; 25:968-975. [PMID: 37861926 DOI: 10.1007/s43678-023-00606-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change. METHODS A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change. RESULTS The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%). CONCLUSION Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.
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Affiliation(s)
- Raphaëlle Brière
- Département de Chirurgie, CHU de Québec, Université Laval, Quebec, QC, Canada.
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marcel Émond
- Département de Médecine Familiale et de Médecine d'urgence, Centre de Recherche du CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Pierre-Gilles Blanchard
- Département de Médecine Familiale et de Médecine d'urgence, Centre de Recherche du CHU de Québec-Université Laval, Quebec, QC, Canada
| | - Sébastien Drolet
- Département de Chirurgie, CHU de Québec, Université Laval, Quebec, QC, Canada
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27
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Cohan JN, Horns JJ, Ramsay JM, Huang LC, Allen-Brady K. Diverticulitis Familiality: A Statewide Case-Control Study. J Am Coll Surg 2023; 237:689-696. [PMID: 37403933 DOI: 10.1097/xcs.0000000000000799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
BACKGROUND The etiology of diverticulitis is multifactorial and poorly understood. We estimated the familiality of diverticulitis using the Utah Population Database, a statewide database linking medical records with genealogy data. STUDY DESIGN We identified patients with diverticulitis diagnosed between 1998 and 2018 and age- and sex-matched controls in the Utah Population Database. Risk of diverticulitis in family members of patients and controls was calculated using multivariable Poisson models. We performed exploratory analyses to determine the association of familial diverticulitis with severity of disease and age of onset. RESULTS The study population included 9,563 diverticulitis patients (with 229,647 relatives) and 10,588 controls (with 265,693 relatives). Relatives of patients were more likely to develop diverticulitis (incidence rate ratio [IRR] 1.5, 95% CI 1.4 to 1.6) compared with relatives of controls. There was an elevated risk of diverticulitis among first-degree (IRR 2.6, 95% CI 2.3 to 3.0), second-degree (IRR 1.5, 95% CI 1.3 to 1.6), and third-degree relatives of patients (IRR 1.3, 95% CI 1.2 to 1.4). Complicated diverticulitis was more common among relatives of patients compared with relatives of controls (IRR 1.6, 95% CI 1.4 to 1.8). Age at diverticulitis diagnosis was similar between groups (relatives of patients 0.2 years older than relatives of controls, 95% CI -0.5 to 0.9). CONCLUSIONS Our results indicate that the first-, second-, and third-degree relatives of diverticulitis patients are at elevated risk of developing diverticulitis. This information may aid surgeons in counseling patients and family members about diverticulitis risk and can inform the development of future risk-stratification tools. Further work is needed to clarify the causal role and relative contribution of various genetic, lifestyle, and environmental factors in the development of diverticulitis.
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Affiliation(s)
- Jessica N Cohan
- From the Departments of Surgery (Cohan, Horns, Ramsay, Huang), University of Utah, Salt Lake City, UT
| | - Joshua J Horns
- From the Departments of Surgery (Cohan, Horns, Ramsay, Huang), University of Utah, Salt Lake City, UT
| | - Joemy M Ramsay
- From the Departments of Surgery (Cohan, Horns, Ramsay, Huang), University of Utah, Salt Lake City, UT
| | - Lyen C Huang
- From the Departments of Surgery (Cohan, Horns, Ramsay, Huang), University of Utah, Salt Lake City, UT
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28
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Lee JG, Park YE, Chang JY, Song HJ, Kim DH, Yang YJ, Kim BC, Lee SH, You MW, Kim SE. Comparative outcomes of acute colonic diverticulitis in immunocompromised versus immunocompetent patients: a systematic review and meta-analysis. Intest Res 2023; 21:481-492. [PMID: 37248174 PMCID: PMC10626017 DOI: 10.5217/ir.2023.00005] [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: 01/09/2023] [Revised: 02/22/2023] [Accepted: 03/31/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND/AIMS Immunocompromised patients with acute colonic diverticulitis are at high risk for complications and failure of non-surgical treatment. However, evidence on the comparative outcomes of immunocompromised and immunocompetent patients with diverticulitis is lacking. This systematic review and meta-analysis investigated the outcomes of medical treatment in immunocompromised and immunocompetent patients with diverticulitis. METHODS A comprehensive literature search was conducted in PubMed, Embase, and the Cochrane Library. Studies comparing the clinical outcomes of immunocompromised and immunocompetent patients with diverticulitis were included. RESULTS A total of 10 studies with 1,946,461 subjects were included in the quantitative synthesis. The risk of emergency surgery and postoperative mortality after emergency surgery was significantly higher in immunocompromised patients than in immunocompetent patients with diverticulitis (risk ratio [RR], 1.76; 95% confidence interval [CI], 1.31-2.38 and RR, 3.05; 95% CI, 1.70-5.45, respectively). Overall risk of complications associated with diverticulitis was non-significantly higher in immunocompromised than in immunocompetent patients (RR, 1.24; 95% CI, 0.95-1.63). Overall mortality irrespective of surgery was significantly higher in immunocompromised than in immunocompetent patients with diverticulitis (RR, 3.65; 95% CI, 1.73-7.69). By contrast, postoperative mortality after elective surgery was not significantly different between immunocompromised and immunocompetent patients with diverticulitis. In subgroup analysis, the risk of emergency surgery and recurrence was significantly higher in immunocompromised patients with complicated diverticulitis, whereas no significant difference was shown in mild disease. CONCLUSIONS Immunocompromised patients with diverticulitis should be given the best medical treatment with multidisciplinary approach because they had increased risks of surgery, postoperative morbidity, and mortality than immunocompetent patients.
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Affiliation(s)
- Jae Gon Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Yong Eun Park
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ji Young Chang
- Department of Health Promotion Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hyun Joo Song
- Division of Gastroenterology, Department of Internal Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medica Center, CHA University, Seongnam, Korea
| | - Young Joo Yang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Shin Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Myung-Won You
- Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Seong-Eun Kim
- Division of Gastroenterology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
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29
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Park Y. Not all acute colonic diverticulitis follows the same course: a potential risk for immunocompromised individuals. Intest Res 2023; 21:415-417. [PMID: 37915178 PMCID: PMC10626014 DOI: 10.5217/ir.2023.00142] [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: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Yehyun Park
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
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30
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Seta T, Iwagami H, Agatsuma N, Noma A, Ikenouchi M, Kubo K, Akamatsu T, Uenoyama Y, Ito D, Yamashita Y, Nakayama T. Efficacy of antimicrobial therapy in patients with uncomplicated acute colonic diverticulitis: an updated systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2023; 35:1097-1106. [PMID: 37577799 DOI: 10.1097/meg.0000000000002622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
The need for antimicrobial therapy for uncomplicated acute diverticulitis of the colon remains controversial. We conducted a systematic review of the efficacy of antimicrobial agents against this disease, including new randomized controlled trials (RCTs) reported in recent years, and evaluated their efficacy using a meta-analytic approach. RCTs were searched using PubMed, EMBASE, Google Scholar, Cochrane Library, Ichushi-Web, and eight registries. Keywords were 'colonic diverticulitis', 'diverticulitis', 'antimicrobial agents', ''antibiotics, 'complication', 'abscess', 'gastrointestinal perforation', 'gastrointestinal obstruction', 'diverticular hemorrhage', and 'fistula'. Studies with antimicrobial treatment in the intervention group and placebo or no treatment in the control group were selected by multiple reviewers using uniform inclusion criteria, and data were extracted. Prevention of any complication was assessed as the primary outcome, and efficacy was expressed as risk ratio (RR) and risk difference (RD). A meta-analysis was performed using 5 RCTs of the 21 studies that were eligible for scrutiny in the initial search and which qualified for final inclusion. Three of these studies were not included in the previous meta-analysis. Subjects included 1039 in the intervention group and 1040 in the control group. Pooled RR = 0.86 (95% confidence interval, 0.58-1.28) and pooled RD = -0.01 (-0.03 to 0.01) for the effect of antimicrobial agents in reducing any complications. Recurrences, readmissions, and surgical interventions did not significantly show the efficacies of using antimicrobial agents. A meta-analysis of recently reported RCTs did not provide evidence that antimicrobial therapy improves clinical outcomes in uncomplicated acute diverticulitis of the colon.
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Affiliation(s)
- Takeshi Seta
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
- Department of Health Informatics, Graduate School of Medicine & School of Public Health, Kyoto University
| | - Hiroyoshi Iwagami
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Nobukazu Agatsuma
- Departments of Gastroenterology
- Hepatology, Kyoto University Graduate School of Medicine Faculty of Medicine, Kyoto
| | - Atsushi Noma
- Department of Gastroenterological Surgery and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Maiko Ikenouchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Hyogo
| | - Kenji Kubo
- Department of Infectious Diseases and Emergency Medicine, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Takuji Akamatsu
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Yoshito Uenoyama
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Daisuke Ito
- Department of Gastroenterological Surgery and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Yukitaka Yamashita
- Departments of Gastroenterology
- Hepatology and Digestive Cancer Center, Japanese Red Cross Wakayama Medical Center, Wakayama
| | - Takeo Nakayama
- Department of Health Informatics, Graduate School of Medicine & School of Public Health, Kyoto University
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Lee JG, Park YE, Chang JY, Song HJ, Kim DH, Yang YJ, Kim BC, Lee SH, You MW, Kim SE. Diagnosis and management of acute colonic diverticulitis: results of a survey among Korean gastroenterologists. Korean J Intern Med 2023; 38:672-682. [PMID: 37586812 PMCID: PMC10493441 DOI: 10.3904/kjim.2023.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/09/2023] [Accepted: 05/30/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS Some management strategies for acute colonic diverticulitis remain controversial in Korean real-world practice because their clinical features differ from those in the West. This study aimed to investigate the opinions of Korean physicians regarding the diagnosis and treatment of acute diverticulitis. METHODS A web-based survey was conducted among gastroenterologists specializing on treating lower gastrointestinal disorders. The questionnaires concerned overall management strategies for colonic diverticulitis, including diagnosis, treatment, and follow-up. RESULTS In total, 209 gastroenterologists responded to the survey. Less than one-fourth of the respondents (23.6%) answered that left-sided colonic diverticulitis is more likely to be complicated than right-sided colonic diverticulitis. Most respondents agreed that immunocompromised patients with diverticulitis have worse clinical outcomes than immunocompetent patients (71.3%). Computed tomography was the most preferred tool for diagnosing diverticulitis (93.9%). Approximately 89% of the respondents answered that they believed antibiotic treatment is necessary to treat acute uncomplicated diverticulitis. Most respondents (92.6%) agreed that emergency surgery is not required for diverticulitis with an abscess or microperforation without panperitonitis. Further, 94.7% of the respondents agreed that colon cancer screening is necessary in patients aged ≥ 50 years with diverticulitis after they have recovered from acute illness. Many respondents (71.4%) agreed that surgery for recurrent diverticulitis should be individualized. CONCLUSION Opinions regarding management strategies for colonic diverticulitis among Korean gastroenterologists were well agreed upon in some areas but did not agree well in other areas. Evidence-based guidelines that meet the practical needs of the Korean population should be developed.
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Affiliation(s)
- Jae Gon Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong,
Korea
| | - Yong Eun Park
- Division of Gastroenterology, Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan,
Korea
| | - Ji Young Chang
- Department of Health Promotion Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Hyun Joo Song
- Division of Gastroenterology, Department of Internal Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju,
Korea
| | - Duk Hwan Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam,
Korea
| | - Young Joo Yang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon,
Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang,
Korea
| | - Shin Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon,
Korea
| | - Myung-Won You
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul,
Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Ewha Womans University College of Medicine, Seoul,
Korea
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32
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Aguilar-Alvarado MY, Baker B, Chiu LS, Shah MK. Benign Colorectal Disorders. Prim Care 2023; 50:461-480. [PMID: 37516514 DOI: 10.1016/j.pop.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Benign conditions of the colon and rectum are a heterogeneous group of conditions that range from inflammatory to infectious to pelvic floor health conditions that affect large segments of the US population. These conditions include diverticular disease, hemorrhoids, and anorectal lesions. The initial presentation of these very common conditions often occurs in the outpatient primary care setting, and most can be managed by the primary care clinician. This article will provide an overview on the prevalence, diagnosis, and management of some of the most common benign colorectal disorders; these are broadly divided into diverticular disease, hemorrhoids, and anorectal conditions.
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Affiliation(s)
| | - Bernadette Baker
- Department of Family and Preventive Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Laura S Chiu
- Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, MA, USA
| | - Megha K Shah
- Department of Family and Preventive Medicine, Emory School of Medicine, Atlanta, GA, USA.
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Cirocchi R, Duro F, Avenia S, Capitoli M, Tebala GD, Allegritti M, Cirillo B, Brachini G, Sapienza P, Binda GA, Mingoli A, Fedeli P, Nascimbeni R. Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review. J Clin Med 2023; 12:5522. [PMID: 37685590 PMCID: PMC10488020 DOI: 10.3390/jcm12175522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses. MATERIAL AND METHODS A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. CONCLUSIONS Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Francesca Duro
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Stefano Avenia
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | - Matteo Capitoli
- Department of Medicine and Surgery, S. Maria Hospital, University of Perugia, 05100 Terni, Italy; (R.C.); (F.D.); (M.C.)
| | | | | | - Bruno Cirillo
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | - Gioia Brachini
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | - Paolo Sapienza
- Department of Surgery, Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy;
| | | | - Andrea Mingoli
- Emergency Department, Policlinico Umberto I, Sapienza University, 00185 Rome, Italy; (G.B.); (A.M.)
| | | | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy;
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Bhatia M, Mattoo A. Diverticulosis and Diverticulitis: Epidemiology, Pathophysiology, and Current Treatment Trends. Cureus 2023; 15:e43158. [PMID: 37565180 PMCID: PMC10410187 DOI: 10.7759/cureus.43158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 08/12/2023] Open
Abstract
Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.
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Affiliation(s)
- Mohit Bhatia
- Surgery Department, Princess Royal University Hospital, King's College, Orpington, GBR
| | - Aastha Mattoo
- Emergency Department, Princess Royal University Hospital, King's College, Orpington, GBR
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Altman-Merino A, Bonnet K, Schlundt D, Wrenn J, Self WH, Gordon EJ, Hawkins AT. Complex Patient Perspectives on Evolving Diverticulitis Treatment Patient Perspectives on Diverticulitis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.26.23291565. [PMID: 37425810 PMCID: PMC10327256 DOI: 10.1101/2023.06.26.23291565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Despite evidence that antibiotics may not be necessary to treat acute uncomplicated diverticulitis, they remain the mainstay of treatment in the United States. A randomized controlled trial evaluating antibiotic effectiveness could accelerate implementation of an antibiotic-free treatment strategy, but patients may be unwilling to participate. Objective This study aims to assess patients' attitudes regarding participation in a randomized trial of antibiotics versus placebo for acute diverticulitis, including willingness to participate. Design This is a mixed-methods study with qualitative and descriptive methods. Settings Interviews were conducted in a quaternary care emergency department and surveys were administered virtually through a web-based portal. Patients Patients with either current or previous acute uncomplicated diverticulitis participated. Interventions Patients underwent semi-structured interviews or completed a web-based survey. Main Outcome measures: Rates of willingness to participate in a randomized controlled trial was measured. Salient factors related to healthcare decision-making were also identified and analyzed. Results Thirteen patients completed an interview. Reasons to participate included a desire to help others or contribute to scientific knowledge. Doubts about the efficacy of observation as a treatment method were the main barrier to participation. In a survey of 218 subjects, 62% of respondents reported willingness to participate in a randomized clinical trial. "What my doctor thinks," followed by "What I've experienced in the past" were the most important decision-making factors. Limitations There is possible selection bias inherent to using a study to evaluate willingness to participate in a study. Also, the population sampled was disproportionately White compared to the population affected by diverticulitis. Conclusions Patients with acute uncomplicated diverticulitis maintain complex and varying perceptions of the use of antibiotics. Most surveyed patients would be willing to participate in a trial of antibiotics versus placebo. Our findings support a trial's feasibility and facilitate an informed approach to recruitment and consent.
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Affiliation(s)
| | | | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN
| | - Jessie Wrenn
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN
- Vanderbilt University Medical Center Department of Biomedical Informatics, Nashville, TN
| | - Wesley H Self
- Vanderbilt University Medical Center, Vanderbilt Institute for Clinical and Translational Research and Department of Emergency Medicine, Nashville, TN
| | - Elisa J Gordon
- Vanderbilt University Medical Center, Department of Surgery, and Center for Biomedical Ethics and Society, Nashville, TN
| | - Alexander T Hawkins
- Vanderbilt University Medical Center, Division of General Surgery, Section of Colon & Rectal Surgery, Nashville, TN
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Libman H, Nee JW, Lembo AJ, Burns RB. How Would You Manage This Patient With Recurrent Diverticulitis? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:836-843. [PMID: 37307586 DOI: 10.7326/m23-0669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Acute diverticulitis, which refers to inflammation or infection, or both, of a colonic diverticulum, is a common medical condition that may occur repeatedly in some persons. It most often manifests with left-sided abdominal pain, which may be associated with low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction. The American College of Physicians recently published practice guidelines on the diagnosis and management of acute diverticulitis, the role of colonoscopy after resolution, and interventions to prevent recurrence of this condition. Among the recommendations were the use of abdominal computed tomography (CT) scanning in cases where there was diagnostic uncertainty, initial management of uncomplicated cases in the outpatient setting without antibiotics, referral for colonoscopy after an initial episode if not performed recently, and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. Here, 2 gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease.
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Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
| | - Judy W Nee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
| | - Anthony J Lembo
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH (A.J.L.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (H.L., J.W.N., R.B.B.)
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Strate LL, Peery AF. Tips for the Medical Management of Diverticulitis. Am J Gastroenterol 2023; 118:585-589. [PMID: 36434810 PMCID: PMC10065882 DOI: 10.14309/ajg.0000000000002073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/12/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Anne F Peery
- University of North Carolina, Chapel Hill, North Carolina, USA
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Singh K, Liptrot S, Tou S, Mehigan B, McCormick P, Ravi N, Reynolds J, Al Chalabi H. A multicentre study assessing the role of routine colonoscopy after acute uncomplicated diverticulitis and the incidence of colorectal cancer diagnosis. Int J Colorectal Dis 2023; 38:84. [PMID: 36976397 DOI: 10.1007/s00384-023-04374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE The low rates of colonic malignancy detected on interval colonoscopy for patients diagnosed with diverticulitis have led recent studies to question the utility of the practice. The aim of this study was to assess the detection rate of colorectal cancer on colonoscopy for patients with a first episode of acute uncomplicated diverticulitis across three separate centres in Ireland and the UK. METHODS A retrospective review was performed of patients with a first episode of acute, uncomplicated diverticulitis who underwent interval colonoscopy at three separate centres in the UK and Ireland between 2007 and 2019. The follow-up period was one year. RESULTS A total of 5485 patients were admitted with acute diverticulitis between the three centres. All patients had CT verified diverticulitis. A 90.8% (n = 4982) underwent subsequent colonic evaluation with colonoscopy. Of these, a histologically proven diagnosis of colorectal carcinoma was made in 1.28% (n = 64). CONCLUSION Routine colonoscopy following an episode of acute, uncomplicated diverticulitis may not be necessary in every patient. It may be appropriate to reserve this more invasive investigation for those with higher risk factors for malignancy.
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Affiliation(s)
- Kaushiki Singh
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, UK.
| | - Sarah Liptrot
- University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | - Sam Tou
- University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | | | | | | | | | - Hasan Al Chalabi
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, UK
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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40
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Albshesh A, Ukashi O, Lahat A, Kopylov U, Horesh N, Pflantzer B, Laish I. Risk of colorectal advanced neoplasia in patients with acute diverticulitis with and without previous colonoscopy. Colorectal Dis 2023; 25:897-904. [PMID: 36636896 DOI: 10.1111/codi.16481] [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: 09/29/2022] [Revised: 11/30/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Guidelines recommend a colonoscopy after an episode of complicated diverticulitis and after a first episode of uncomplicated diverticulitis. The influence of a previous colonoscopy on postdiverticulitis colonoscopic findings has not been studied. The aim of this work was to examine the incidence of adenoma detection rate (ADR), advanced adenoma (AA) and colorectal cancer (CRC) in patients with diverticulitis with and without previous colonoscopy. METHOD This was a retrospective case-control study of subjects with acute diverticulitis. Subsequent and previous colonoscopies were abstracted for ADR, AA and CRC diagnoses. The incidence of neoplasia was compared between patients with and without previous colonoscopy and also with that of a screening population. RESULTS Compared with a healthy control group (n = 975), diverticulitis patients without prior colonoscopy (n = 325) had a significantly higher ADR (26.8% vs. 20.5%, p = 0.019) and invasive CRC rate (0.9% vs. 0%, p = 0.016). Risk factors for advanced neoplasia included age ≥ 70 years and complicated diverticulitis. Among subjects with diverticulitis and previous colonoscopy (n = 124), only one patient developed AA and there were no cancer cases. CONCLUSIONS A previous normal colonoscopy within 5 years before diverticulitis probably overshadows other risk factors for findings of advanced neoplasia and should be considered in the decision to repeat a colonoscopy.
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Affiliation(s)
- Ahmad Albshesh
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Offir Ukashi
- Department of Internal Medicine A, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Lahat
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Kopylov
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Horesh
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery and Transplantations B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Barak Pflantzer
- Department of Internal Medicine A, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ido Laish
- Gastroenterology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Management of Common Postoperative Infections in the Surgical Intensive Care Unit. Infect Dis Clin North Am 2022; 36:839-859. [DOI: 10.1016/j.idc.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hammami MB, Jinadasa SP, Kesar V. A Trapped Colon. Gastroenterology 2022; 163:e14-e16. [PMID: 35667409 DOI: 10.1053/j.gastro.2022.06.004] [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: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Muhammad B Hammami
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Sayuri P Jinadasa
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Varun Kesar
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
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Peery AF. New German guidelines for the management of diverticulitis. United European Gastroenterol J 2022; 10:913-914. [PMID: 36302089 PMCID: PMC9731652 DOI: 10.1002/ueg2.12331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Anne F Peery
- University of North Carolina, Chapel Hill, North Carolina, USA
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Diverticular Disease—An Updated Management Review. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13040033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Diverticular disease is highly prevalent in the Western world, placing an increased burden on healthcare systems. This review clarifies the consensus in the literature on the disease’s classification, etiology, and management. Diverticular disease, caused by sac-like protrusions of colonic mucosa through the muscular colonic wall, has a varied disease course. Multiple theories contribute to our understanding of the etiology of the disease, with pathogenesis affected by age, diet, environmental conditions, lifestyle, the microbiome, genetics, and motility. The subtypes of diverticular disease in this review include symptomatic uncomplicated diverticular disease, segmental colitis associated with diverticulosis, and uncomplicated and complicated diverticulitis. We discuss emerging treatments and outline management options, such as supportive care, conservative management with or without antibiotics, and surgical intervention.
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Walter FA, Rimkus G. Complicated Diverticulitis With Associated Small Bowel Obstruction: A Case Report. Cureus 2022; 14:e28942. [PMID: 36159356 PMCID: PMC9495291 DOI: 10.7759/cureus.28942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
Diverticulitis is a common disease of the colon with a broad spectrum of presentations. This case outlines a less commonly seen presentation of delayed complicated diverticulitis with abscess formation and associated small bowel obstruction. This report outlines the case of a 58-year-old obese male who initially presented to the emergency department with uncomplicated diverticulitis, was discharged home, and returned two days later with worsening symptoms. A repeat computed tomography (CT) scan demonstrated abscess formation with an associated small bowel obstruction. He underwent midline exploratory laparotomy with adhesiolysis of the portion of obstructed small bowel and resection of the diseased segment with primary anastomosis and diverting loop ileostomy. He had an ileostomy reversal at a later date. Small bowel obstruction is a less observed complication of diverticulitis. This report serves to educate on the presentation of these patients as well as to discuss the potential surgical management of these patients. If this patient had presented without the small bowel obstruction, he may have just needed percutaneous drainage.
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Wingo MT, Huber JM, Bornstein SL, Sundsted KK, Mauck KF, Szostek JH, Post JA, Wieland ML. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2021. Am J Med 2022; 135:1069-1074. [PMID: 35367181 DOI: 10.1016/j.amjmed.2022.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Abstract
It can be challenging to identify new evidence that may shift clinical practice within internal medicine. Synthesis of relevant articles and guideline updates can facilitate staying informed of these changes. The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded. The New England Journal of Medicine (NEJM), The Lancet, Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 8 practice-changing articles were included.
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Affiliation(s)
- Majken T Wingo
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn.
| | - Jill M Huber
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Shari L Bornstein
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Jason A Post
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
| | - Mark L Wieland
- Division of Community Internal Medicine, Geriatrics and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, Minn
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O'Toole D. Rapid recommendations: Updates from 2021 guidelines: part 1. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:664-666. [PMID: 36100372 PMCID: PMC9470190 DOI: 10.46747/cfp.6809664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Danielle O'Toole
- Practising family physician in Academic Family Medicine and Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont
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48
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Choksey R, Stead TS, Mangal R, Amatea J, Ganti L. Diverticulitis With Microperforation. Cureus 2022; 14:e27159. [PMID: 36017297 PMCID: PMC9393316 DOI: 10.7759/cureus.27159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 12/20/2022] Open
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49
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Cadet MJ. An Update on Managing Diverticulitis. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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50
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Pathophysiology of Diverticular Disease: From Diverticula Formation to Symptom Generation. Int J Mol Sci 2022; 23:ijms23126698. [PMID: 35743141 PMCID: PMC9223421 DOI: 10.3390/ijms23126698] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 01/04/2023] Open
Abstract
Diverticular disease is a common clinical problem, particularly in industrialized countries. In most cases, colonic diverticula remain asymptomatic throughout life and sometimes are found incidentally during colonic imaging in colorectal cancer screening programs in otherwise healthy subjects. Nonetheless, roughly 25% of patients bearing colonic diverticula develop clinical manifestations. Abdominal symptoms associated with diverticula in the absence of inflammation or complications are termed symptomatic uncomplicated diverticular disease (SUDD). The pathophysiology of diverticular disease as well as the mechanisms involved in the shift from an asymptomatic condition to a symptomatic one is still poorly understood. It is accepted that both genetic factors and environment, as well as intestinal microenvironment alterations, have a role in diverticula development and in the different phenotypic expressions of diverticular disease. In the present review, we will summarize the up-to-date knowledge on the pathophysiology of diverticula and their different clinical setting, including diverticulosis and SUDD.
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