Pathophysiology and Epidemiology of Diverticular Disease

Exploring the gut-exercise link: A systematic review of gastrointestinal disorders in physical activity

BACKGROUND

The relationship between exercise and gastrointestinal (GI) health is complex and bidirectional. While moderate exercise generally promotes gut health by enhancing motility, reducing inflammation, and supporting microbial balance, intense or prolonged physical activity may exacerbate GI symptoms, particularly in individuals with pre-existing digestive disorders. A deeper understanding of this interplay is essential for optimizing both exercise performance and GI well-being.

AIM

To synthesize current evidence on exercise-related GI disorders, exploring the prevalence, mechanisms, risk factors, and management strategies associated with exercise-induced GI symptoms.

METHODS

Following PRISMA guidelines, comprehensive searches of databases, including PubMed, Scopus, Web of Science, and EMBASE were conducted. Studies were included if they focused on exercise-induced GI disorders, encompassed randomized controlled trials, cohort studies, case-control studies, and cross-sectional designs, and addressed symptoms across various exercise modalities. Data were extracted and analyzed to identify patterns and implications for clinical and athletic practice.

RESULTS

A total of 231 studies met the inclusion criteria, highlighting both the benefits and risks of exercise on GI health. Regular moderate-intensity exercise, including activities such as walking, cycling, and yoga has been associated with improved GI function in conditions like gastroesophageal reflux disease, irritable bowel syndrome, inflammatory bowel disease, and constipation. These benefits are attributed to enhanced intestinal motility, reduced systemic inflammation, and improved gut barrier integrity. Additionally, exercise plays a role in regulating the gut-brain axis, with practices like yoga and Tai Chi demonstrating particular effectiveness in alleviating functional GI disorders. Conversely, high-intensity or prolonged exercise may contribute to symptoms such as nausea, diarrhea, and abdominal pain due to mechanisms like splanchnic hypoperfusion and increased intestinal permeability. Individual factors, including fitness level, dietary habits, hydration status, and underlying GI conditions, significantly influence the body’s response to exercise.

CONCLUSION

Moderate-intensity exercise is a beneficial and well-tolerated intervention for promoting GI health, whereas high-intensity activities require careful monitoring, particularly in individuals with pre-existing GI disorders. Personalized exercise and dietary strategies are essential for balancing the benefits of physical activity with the risk of GI distress. Further research is needed to explore the long-term effects of exercise on gut microbiota composition and overall digestive health.

Unmet social needs and diverticulitis: a phenotyping algorithm and cross-sectional analysis

OBJECTIVE

To validate a phenotyping algorithm for gradations of diverticular disease severity and investigate relationships between unmet social needs and disease severity.

MATERIALS AND METHODS

An algorithm was designed in the All of Us Research Program to identify diverticulosis, mild diverticulitis, and operative or recurrent diverticulitis requiring multiple inpatient admissions. This was validated in an independent institution and applied to a cohort in the All of Us Research Program. Distributions of individual-level social barriers were compared across quintiles of an area-level index through fold enrichment of the barrier in the fifth (most deprived) quintile relative to the first (least deprived) quintile. Social needs of food insecurity, housing instability, and care access were included in logistic regression to assess association with disease severity.

RESULTS

Across disease severity groups, the phenotyping algorithm had positive predictive values ranging from 0.87 to 0.97 and negative predictive values ranging from 0.97 to 0.99. Unmet social needs were variably distributed when comparing the most to the least deprived quintile of the area-level deprivation index (fold enrichment ranging from 0.53 to 15). Relative to a reference of diverticulosis, an unmet social need was associated with greater odds of operative or recurrent inpatient diverticulitis (OR [95% CI] 1.61 [1.19-2.17]).

DISCUSSION

Understanding the landscape of social barriers in disease-specific cohorts may facilitate a targeted approach when addressing these needs in clinical settings.

CONCLUSION

Using a validated phenotyping algorithm for diverticular disease severity, unmet social needs were found to be associated with greater severity of diverticulitis presentation.

Colouterine Fistula: A Rare Presentation of Severe Diverticular Disease

Colouterine fistula as a sequela of diverticulitis is an extremely rare complication due to the extraordinarily thick layer of myometrium of the uterus. Because of this, an aggressive clinical evaluation is required to rule out other potential causes of fistula formation such as malignancy. However, imaging and laboratory techniques may be inconclusive, and surgery with pathologic analysis may be required for a definitive diagnosis. The case presented here illustrates the atypical presentation of a 63-year-old woman with acutely symptomatic, severely extensive diverticular disease with resultant colouterine fistula. The patient underwent exploratory laparotomy, sigmoidectomy with end colostomy, appendectomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy. Eventually, she was discharged with an excellent prognosis and had an uneventful recovery. This case is being presented because of the rarity of the disease course as well as the complexity of the decision-making and surgical approach that resulted in patient recovery.

Diagnosis and management of diverticular disease in primary care

ABSTRACT

Each year, more than 1 million ambulatory patient visits occur for diverticular disease, with nearly 75% of these patients seen in outpatient clinics. Although diverticulitis historically had been considered a disease of the older adult, it has become increasingly prevalent among the younger population. Likewise, in the past, antibiotics were considered first-line treatment for uncomplicated diverticulitis (Hinchey classification 0 and Ia); however, two large clinical trials compared treatment with antibiotics versus without antibiotics in uncomplicated cases of the disease and found no significant difference in patient outcomes. Based on these findings, first-line management now constitutes clear-liquid diet along with bowel rest for resolution of symptoms in these patients. Proper management with lifestyle modifications can help prevent complications and improve outcomes for patients with this condition; patient education is therefore critical.

Multiancestry transferability of a polygenic risk score for diverticulitis

OBJECTIVE

Polygenic risk scores (PRS) for diverticular disease must be evaluated in diverse cohorts. We sought to explore shared genetic predisposition across the phenome and to assess risk stratification in individuals genetically similar to European, African and Admixed-American reference samples.

METHODS

A 44-variant PRS was applied to the All of Us Research Program. Phenome-wide association studies (PheWAS) identified conditions linked with heightened genetic susceptibility to diverticular disease. To evaluate the PRS in risk stratification, logistic regression models for symptomatic and for severe diverticulitis were compared with base models with covariates of age, sex, body mass index, smoking and principal components. Performance was assessed using area under the receiver operating characteristic curves (AUROC) and Nagelkerke's R2.

RESULTS

The cohort comprised 181 719 individuals for PheWAS and 50 037 for risk modelling. PheWAS identified associations with diverticular disease, connective tissue disease and hernias. Across ancestry groups, one SD PRS increase was consistently associated with greater odds of severe (range of ORs (95% CI) 1.60 (1.27 to 2.02) to 1.86 (1.42 to 2.42)) and of symptomatic diverticulitis ((95% CI) 1.27 (1.10 to 1.46) to 1.66 (1.55 to 1.79)) relative to controls. European models achieved the highest AUROC and Nagelkerke's R2 (AUROC (95% CI) 0.78 (0.75 to 0.81); R2 0.25). The PRS provided a maximum R2 increase of 0.034 and modest AUROC improvement.

CONCLUSION

Associations between a diverticular disease PRS and severe presentations persisted in diverse cohorts when controlling for known risk factors. Relative improvements in model performance were observed, but absolute change magnitudes were modest.

Smoking and Alcohol Consumption and Risk of Incident Diverticulitis in Women

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.

Colouterine fistula relating to diverticulitis: a rare clinical entity

Colouterine fistula is a rare but recognizable complication of diverticulitis. This case illustrates the presence of a colouterine fistula in an elderly patient who had an atypical presentation for diverticulitis. She was initially treated with intravenous antibiotics for diverticulitis with a contained abscess. This gave her an opportunity to avoid surgery. However, her sepsis failed to respond to the initial treatment. Progress computerized tomography imaging demonstrated the presence of a colouterine fistula for which she required source control. Thus she underwent laparotomy, Hartmann's procedure, and total abdominal hysterectomy with bilateral salpingo-oophorectomy. The diagnosis of colouterine fistula was confirmed intraoperatively and on histopathology. Subsequently, the patient had an uneventful recovery following the operation. This case highlights the rarity but also the veracity of this clinical entity.

[Pathological changes in the muscular tissue of the colon in diverticular disease]

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.

Genetic Variants in Matrix Metalloproteinases MMP3 (rs3025058) and MMP9 (rs3918242) Associated with Colonic Diverticulosis

Background and Objectives: Diverticulosis affects a significant portion of the elderly population, with age and lifestyle being established risk factors. Additionally, genetic predisposition is gaining recognition as a contributing factor. This pilot study sought to explore the frequency of genetic variants in matrix metalloproteinases (MMPs) 3, 9, and 12 in a population of colonic diverticulosis patients. Materials and Methods: The study encompassed 134 participants: 59 diagnosed with colon diverticulosis during colonoscopy and 75 healthy controls. The cases and controls were meticulously matched in terms of age and gender. We assessed the distribution of genetic variants MMP3 rs3025058, MMP9 rs3918242, and MMP12 rs2276109 using the polymerase chain reaction-restriction fragments length polymorphism technique. Results: The MMP9 rs3918242 allele T was notably more frequent in individuals with diverticulosis when compared with the control group (p < 0.03). Furthermore, it was associated with dominant (OR = 2.62; 95% CI: 1.24-5.56; p < 0.01) and co-dominant (OR = 2.10; 95% CI: 1.06-4.13; p < 0.03) genetic models. The MMP3 rs3025058 5A/5A genotype was nearly twice as frequent in patients with diverticulosis, while the 6A/6A genotype was only half as common in this group. Conversely, no significant correlation was established between MMP12 rs2276109 and colonic diverticulosis. Conclusions: Our study offers the first insight into a potential connection between genetic variants in MMPs and colon diverticulosis. Specifically, allele T of MMP9 rs3918242 and allele 5A of MMP3 rs3025058 appear to be linked to this condition. These findings indirectly suggest a role for extracellular matrix proteins in the pathogenesis of diverticulosis.

Antibiotics vs observational therapy in acute uncomplicated diverticulitis, a systemic review and meta-analysis

PURPOSE

Antibiotics have long been recommended as a form of conservative therapy in patients with acute uncomplicated diverticulitis despite no supporting evidence. This meta-analysis aims to assess the difference in outcomes between observational therapy and antibiotics regime in patients with acute uncomplicated diverticulitis.

METHODS

Medline and Embase electronic databases were reviewed. A comparative meta-analysis in odds ratios (ORs) or mean difference (MD) was conducted using a random effects model for dichotomous and continuous outcomes, respectively. Randomized controlled trials comparing outcomes in patients with acute uncomplicated diverticulitis on observational therapy compared to antibiotics regime were selected. Outcomes of interest included all-cause mortality, complications, emergency surgery rates, length of stay, and recurrence.

RESULTS

A total of 7 articles looking at 5 different randomized controlled trials were included. A total of 2959 patients with acute uncomplicated diverticulitis comprising of 1485 patients on antibiotics therapy and 1474 patients on observational therapy were included in the comparison. We found that there was no statistically significant difference in all-cause mortality (OR = 0.98; 95% CI 0.53;1.81; p = 0.68), complications (OR = 1.04; 95% CI 0.36;3.02; p = 0.51), emergency surgery (OR = 1.24; 95% CI 0.70;2.19, p = 0.92), length of stay (M.D: -0.14, 95% CI -0.50;0.23, p < 0.001), and recurrent diverticulitis (OR 1.01; 95% CI 0.83;1.22, p < 0.91) between the two arms.

CONCLUSION

This systemic review and meta-analysis found that there is no statistically significant difference in outcomes between patients with acute uncomplicated diverticulitis who were put on observational therapy compared to the antibiotics regime. This suggests that observational therapy is an equally safe and effective therapy as compared to antibiotics therapy.

KƏSKİN PERFORATİV DİVERTİKULİTİ VƏ İRİNLİ PERİTONİTİ OLAN XƏSTƏLƏRİN CƏRRAHİ MÜALİCƏSİNİN ERKƏN VƏ UZAQ NƏTİCƏLƏRİ

Представлены результаты исследования проведенного с целью оценить непосредственные и отдаленные результаты хирургического лечения пациентов с перфоративным дивертикулитом и гнойным перитонитом, которым были выполнены резекции ободочной кишки из лапароскопического и открытого доступов. В ретроспективное сравнительное исследование, в период с 2013 г. по 2020 г., было включено 86 пациентов с перфоративным дивертикулитом и гнойным перитонитом. В основную группу вошли 40 пациентов, которым была выполнена резекция ободочной кишки с формированием колостомы из лапароскопического доступа. В контрольную – 46 пациентов, у которых резекция была выполнена из открытого доступа. Исследование показало, что частота развития послеоперационных осложнений оказалась ниже в основной группе (32,5% против 56,5%, р<0,05). Частота выполнения реконструктивно-восстановительных операций после лапароскопической резекции была выше (84,2% против 36,6%, р<0,001). Рецидив осложнений дивертикулярной болезни после лапароскопической резекции встречался в 18,4%, после открытой резекции – в 61% (р<0,001). Таким образом, применение лапароскопического доступа при резекции ободочной кишки у пациентов с перфоративным дивертикулитом продемонстрировал более высокие показатели безопасности и эффективности по сравнению с резекцией из открытого доступа.

Məqalədə perforativ divertikulitə və irinli peritonitə görə çənbər bağırsağın laparoskopik və açıq rezeksiyası əməliyyatına məruz qalmış xəstələrdə cərrahi müalicənin yaxın və uzaq nəticələrini öyrənmək məqsədilə aparılmış tədqiqat işi haqqında məlumat verilmişdir. Retrospektiv müqayisəli tədqiqata 2013-2020-ci illər ərzində perforativ divertikulit və irinli peritonitə görə müalicə almış 86 xəstə daxil edilmişdir. Əsas qrupa laparoskopik üsulla yoğun bağırsağı rezeksiya edilmiş və kolostoma yaradılmış 40 xəstə, kontrol qrupuna isə açıq üsulla rezeksiya həyata keçirilmiş 46 xəstə daxil edilmişdir. Tədqiqat göstərmişdir ki, əməliyyatdansonrakı ağırlaşmaların tezliyi əsas qrupda kontrol qrupa nisbətdə aşağı olmuşdur (32,5% və 56,5%, p<0,05). Laparoskopik rezeksiyadan sonra rekonstruktiv və bərpaedici əməliyyatların aparılma tezliyi daha yüksək olmuşdur (36,6%-ə və 84,2%, p<0,001). Laparoskopik rezeksiyadan sonra divertikul xəstəliyinin ağırlaşmalarının residivi 18,4%, açıq rezeksiyadan sonra 61% (p<0,001) təşkil etmişdir. Beləliklə, perforativ divertikuliti olan xəstələrdə yoğun bağırsağın açıq üsulla rezeksiyası ilə müqayisədə laparoskopik üsul daha təhlükəsiz və yüksək effektiv olmuşdur.

This article presents the results of an investigation aimed at evaluating the early and late outcomes of surgical treatment in patients with perforated diverticulitis and purulent peritonitis who underwent laparoscopic or open colon resection. A retrospective non-randomized comparative study was conducted on 86 patients. The main group consisted of 40 patients who underwent laparoscopic colon resection with stoma formation, while the control group included 46 patients who underwent open surgery. The investigations revealed that the incidence of postoperative complications was lower in the main group (32.5% versus 56.5%, p<0.05). The frequency of reconstructive and restorative operations after laparoscopic resection was higher (84.2% versus 36.6%, p<0.001). The recurrence of complications of diverticular disease after laparoscopic resection occurred in 18.4%, while after open resection, it was 61% (p<0.001). Thus, the use of laparoscopic access for colon resection in patients with perforated diverticulitis demonstrated higher safety and efficacy compared to open resection.

Diverticular disease, diverticulitis and the impact on continence

Diverticulosis and the subsequent progression to diverticular disease and diverticulitis is becoming more prevalent in western countries. The cause for this progression is not known. Diverticulitis is a significant health burden - both financially to healthcare systems, and to the patients it affects in terms of morbidity. There is a dearth of research pertaining to diverticulitis and its impact on continence. This article examines the parallels between irritable bowel syndrome and diverticular disease, which have many symptom similarities, the overlap between the conditions, and the impact on continence. Current studies regarding the role of fibre in managing diverticular disease are also discussed.

Lactobacillus paracasei CNCM I 1572: A Promising Candidate for Management of Colonic Diverticular Disease

Diverticular disease (DD) is a common gastrointestinal condition. Patients with DD experience a huge variety of chronic nonspecific symptoms, including abdominal pain, bloating, and altered bowel habits. They are also at risk of complications such as acute diverticulitis, abscess formation, hemorrhage, and perforation. Intestinal dysbiosis and chronic inflammation have recently been recognized as potential key factors contributing to disease progression. Probiotics, due to their ability to modify colonic microbiota balance and to their immunomodulatory effects, could present a promising treatment option for patients with DD. Lactobacillus paracasei CNCM I 1572 (LCDG) is a probiotic strain with the capacity to rebalance gut microbiota and to decrease intestinal inflammation. This review summarizes the available clinical data on the use of LCDG in subjects with colonic DD.