Diverticulitis In Patients Research Articles

Measurement of visceral fat on preoperative computed tomography predicts complications after sigmoid colectomy for diverticular disease

BackgroundVisceral and subcutaneous abdominal fat parameters have been associated with worse surgical outcomes in colorectal cancer but have not been investigated in diverticulitis. MethodsVolumetric fat parameters were measured on preoperative computed tomography scans from 211 diverticulitis patients. Primary outcome was a serious postoperative complication (Clavien-Dindo grades 2-4). Variables including age, disease duration, American Society of Anesthesiology score, ostomy, immunosuppression, body mass index, and volumetric fat parameters were examined. SPSS was used for statistics. ResultsThe serious postoperative complication rate was 12.7%. On univariate analysis, several factors including older age (P = .0001), ostomy creation (P = .02), higher visceral fat (VF, P = .01), emergent surgery (P = .05), and higher American Society of Anesthesiology score (P = .05) were associated with complications. On multivariate regression analysis, only VF was independently associated with complications. ConclusionsDiverticulitis patients with high VF are more likely to develop complications after sigmoidectomy. VF measurement may potentially be used as a tool to assist in surgical decision making and prediction of outcomes.

Caecal diverticulitis: Presentation and management.

IntroductionWhile left sided colonic diverticular disease is common in Western countries, right sided colonic diverticular disease is rare. With increasing migration from Asia, many western countries including Australia, are now seeing more right sided diverticular disease, of which caecal diverticulitis is the commonest. This study aims to determine the incidence of caecal diverticulitis in patients presenting with colonic diverticulitis, as well as identify the symptoms and clinical features that may aid in making a pre-operative diagnosis.MethodsData was collected using the Queen Elizabeth II Hospital medical records database identifying patients diagnosed with colonic diverticulitis and, more specifically, those with caecal diverticulitis from January 2007 to December 2013. Only those patients who had confirmed caecal diverticulitis on imaging studies or at laparoscopy on their first admission were included in this study.ResultsA total of 632 patients with colonic diverticulitis were admitted to our institution over a seven-year period, of which 13 patients had caecal diverticulitis (2.06%). Of the 13 patients, twelve were of Asian background and ten were considered young (≤50 years of age). The main complaints were right sided abdominal pain (n = 11, 84.6%) and diarrhoea (n = 5, 38.5%). Nine were diagnosed using computed tomography (n = 9/10, 90%), three on laparoscopy and one using ultrasound (n = 1/2, 50%). Ten patients were treated successfully by conservative means.DiscussionA high index of suspicion in Asian patients with atypical symptoms of appendicitis, especially diarrhoea, may provide the diagnosis of caecal diverticulitis.

The incidence of colon cancer among patients diagnosed with left colonic or sigmoid acute diverticulitis is higher than in the general population

Considering the low incidence of colon cancer after an initial episode of colonic diverticulitis in some categories of patients, some authors suggested to exempt them from colonoscopy. However, this incidence has never been compared to that of a reference population, and predictors of cancer are still poorly investigated. We aimed to determine the 1-year incidence of colon cancer at the site of diverticulitis in patients diagnosed with left colonic or sigmoid acute diverticulitis, to compare this incidence to a reference population to state whether endoscopy is required or not, and to identify predicting factors of cancer to better target subpopulations needing that examination. All patients admitted at the University Hospitals of Geneva for left colonic or sigmoid acute diverticulitis were included. Patients with a previous history of colon cancer or non-available for follow-up were excluded. Demographic data, haemoglobin values, and the Hinchey score were documented. This cohort was matched with the Geneva Cancer Registry to look for cancer occurrence at the site of diverticulitis within 1year. Predictors of cancer were assessed using univariate logistic regression and the risk of cancer by comparing observed cases to a reference population using standardized incidence ratios. The final cohort included 506 patients. Eleven (2.2%) had a diagnosis of cancer at the site of diverticulitis within 1year. The mean age was significantly different between patients with cancer and others. No predictor of cancer could be identified, except a trend for an increased risk with advancing age (p=0.067). The standardized incidence ratios showed a 44-fold increased risk of cancer among the cohort compared to the reference population. Colonoscopy should be continued after an initial diagnosis of left colonic or sigmoid acute diverticulitis, irrespective of the clinical or radiological presentations.

Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis.

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown. To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis. Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs. Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]). Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.

Ūminio komplikuoto divertikulito gydymo protokolas

TikslasAtlikus literatūros apžvalgą ir remiantis jos duomenimis pasiūlyti ūminio komplikuoto divertikulito gydymo protokolą.MetodikaNaudojant „PubMed“, „Medline“, „Embase“, „Cochrane“, „Medscape“ elektronines duomenų bazes peržiūrėta ūminio divertikulito gydymo tematikos literatūra, publikuota 2008–2013 metais. Paieškai naudoti raktiniai žodžiai: divertikulitas, perforacija, peritonitas, Hartmano operacija, pirminė anastomozė, laparoskopinis lavažas, Hinchey. Analizei atrinkti straipsniai, kuriuose pateikti duomenys remiantis atsitiktinių imčių bei lyginamųjų studijų rezultatais. Tinkamumo kriterijai buvo nustatyti prieš pradedant literatūros apžvalgą – tirta ne mažiau kaip 100 ligonių, naudojama Hinchey klasifikacija, išvados paremtos statistiškai patikimais rezultatais. Analizuojant atrinktus straipsnius nagrinėti ir jų literatūros sąraše pateikti literatūros šaltiniai, siekiant įvertinti aktualias studijas, nepasiūlytas pirminėje paieškoje.RezultataiIš viso nagrinėta 11 straipsnių. Hinchey I–II klasių ligoniams rekomenduojamas konservatyvus gydymas – antibiotikų terapija arba perkutaninis pūlinių drenavimas, kai pūlinys didesnis negu 5 cm. Hinchey III–IV klasių ligoniams indikuojamas operacinis gydymas. Lyginant storosios žarnos rezekciją su perforacijos užsiuvimu ir drenavimu, statistiškai patikimo skirtumo negauta. Lyginant storosios žarnos rezekciją su pirmine anastomoze (PA) ir Hartmano operacija (HP), gauti statistiškai patikimi rodikliai: mirštamumas – PA 9,7 %, o HP 21,95 %, reintervencijos dažnis – PA 6,6 %, HP 15,3 %, hospitalizacijos trukmė – PA grupėje 8,65, HP grupėje 15,08 dienos. Lyginant PA su laparoskopiniu pilvo ertmės lavažu (LPD), gautas statistiškai patikimas hospitalizacijos trukmės skirtumas – po LPD 8 dienos, po PA 17 dienų. Mirčių nebuvo abiejose grupėse. Po LPD 71,43 % ligonių planine tvarka atliktos laparoskopinės rezekcinės operacijos (LR), tačiau bendra hospitalizacijos trukmė po LPD ir LR buvo mažesnė už hospitalizacijos trukmę po PA.IšvadosHinchey I–II klasės divertikulitą rekomenduojame gydyti konservatyviai plataus veikimo spektro antibiotikais arba minimaliai invazyviniais gydymo metodais – perkutaniniu pūlinio drenavimu kontroliuojant procedūrą ultragarsu (UG) ar kompiuterine tomografija (KT). Esant aukštesnės klasės komplikuotam divertikulitui tikslingas chirurginis gydymas. Hinchey III klasės divertikulito gydymui indikuojamas LPD, laparoskopinis perforacijos užsiuvimas, PA, o Hinchey IV klasės komplikuotam divertikulitui gydyti – laparotomija su PA arba HP. Ateityje tikslinga atlikti atsitiktinių imčių tyrimus įvairiems ūminio komplikuoto divertikulito gydymo metodams palyginti.

Identification of diverticulitis patients at high risk for recurrence and poor outcomes.

Currently, the indications for elective surgery for patients who have recovered from an acute diverticulitis (AD) are controversial. We examined the natural history of AD in New York and identified risk factors for recurrent admissions and poor outcome to create a simple model to produce risk stratification groups. Poor outcome was defined as complicated disease, emergency surgery, or mortality during any recurrent admission. Data on adult diverticulitis admissions between 1985 and 2006 were extracted from the state discharge database; recurrences were monitored using unique identifiers. Survivors of nonoperative management who did not undergo subsequent elective surgery were considered eligible for recurrence. Clinical variables from the first admission with significant association with poor outcomes or recurrence were identified using multivariable analysis and were used to create risk stratification groups. A total of 237,879 individuals were identified. Of the 181,115 patients eligible for recurrence after one admission, 8.7% recurred; of the patients eligible for recurrence after two admissions, 23.2% recurred. Complicated AD or abscess and age less than 50 years allowed the creation of discrete risk groups for both recurrence and poor outcome. The majority of patients (91.3%) had no further admissions for AD. However, patients admitted for recurrence were increasingly likely to require subsequent admissions. Patients with complicated AD at the first admission, specifically abscess, had a high risk of recurrence and poor outcome and should be offered surgery. Younger patients also had higher recurrence and poor outcomes. We provide a risk stratification model to help identify patients at high risk for recurrence and poor outcome. Therapeutic study, level IV; epidemiologic/prognostic study, level III.

Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis: a comparative cohort study.

Current guidelines recommend routine follow-up colonoscopy after acute diverticulitis to confirm the diagnosis and exclude malignancy. Its value, however, has recently been questioned because of contradictory study results. Our objective was to compare the colonoscopic detection rate of advanced colonic neoplasia (ACN), comprising colorectal cancer (CRC) and advanced adenoma (AA), in patients after a CT-proven primary episode of uncomplicated acute diverticulitis with average risk participants in a primary colonoscopy CRC screening program. A retrospective comparison was performed of prospectively collected data from cohorts derived from two multicenter randomized clinical trials executed in the Netherlands between 2009 and 2013. 401 uncomplicated diverticulitis patients and 1,426 CRC screening participants underwent colonic evaluation by colonoscopy. Main outcome was the diagnostic yield for ACN, calculated as number of diverticulitis patients and screening participants with ACN relative to their totals, with differences expressed as odds ratios (OR). The histopathology outcome of removed lesions during colonoscopy was used as definitive diagnosis. AA detection was similar [5.5 vs. 8.7%; OR 0.62 (95% CI 0.38-1.01); P = 0.053]. CRC was detected in 1.2% (5/401) of diverticulitis patients versus 0.6% (9/1,426) of screening participants [OR 1.30 (95% CI 0.39-4.36); P = 0.673]. ACN was diagnosed in 6.7% (27/401) of diverticulitis patients versus 9.1% (130/1,426) of screening participants [OR 0.71 (95% CI 0.45-1.11); P = 0.134]. ORs were adjusted for age, family history of CRC, smoking, BMI, and cecal intubation rate. ACN detection does not differ significantly between patients with recent uncomplicated diverticulitis and average risk screening participants. Routine follow-up colonoscopy after primary CT-proven uncomplicated left-sided acute diverticulitis can be omitted; these patients can participate in CRC screening programs. Follow-up colonoscopy may be beneficial when targeted at high-risk patients, but such an approach first needs prospective evaluation.

Is it safe to send home an uncomplicated diverticulitis? The DIVER trial.

Hospitalization, bowel rest, intravenous fluids and antibiotic therapy are universally accepted as the first choice treatment for mild diverticulitis [1]. Even if hospital admission is presently considered essential, the majority of patients do not develop a complicated disease and are treated medically, with fewer than 15 % of patients requiring surgical intervention during the same admission [2]. For this reason, there is increasing interest in the ambulatory management of low-risk diverticulitis patients.

Colonic diverticulitis in chemotherapy patients: Should operative indications change? A retrospective cohort study

Introduction: Management of the immunosuppressed patient with diverticular disease remains controversial. We report the largest series of colon cancer patients undergoing chemotherapy and hospitalized for acute diverticulitis, to determine whether recent treatment with systemic chemotherapy is associated with increased risk for/increased severity of recurrent diverticulitis. Methods: Retrospective cohort study of adult patients hospitalized for an initial episode of acute colonic diverticulitis at Memorial Sloan Kettering Cancer Center, 1988–2004. Outcomes in patients receiving systemic chemotherapy within one month of admission for diverticulitis (“Chemo”) were compared to outcomes of patients not receiving chemotherapy within the past month (“No-chemo”). Results: A total 131 patients met inclusion criteria. Chemo patients did not differ significantly from No-chemo group in terms of severity of acute diverticulitis at index admission (13.2% vs. 4.4%, respectively, p = 0.12), resumption of chemotherapy (median 2 months), failure of non-operative management (13.2% vs 4.4%, respectively, p = 0.12), frequency of recurrence (20.5% vs 18.5%), hospital length of stay (p = 0.08), and likelihood of interval resection (24.0% vs. 16.2%, respectively, p = 0.39). Chemo patients recurred with more severe disease, were more likely to undergo emergent surgery (75.0% vs. 23.5%, respectively, p = 0.03), and were more likely to be diverted (100.0% vs. 25.0%, respectively, p = 0.03). Chemo patients were significantly more likely to incur a postoperative complication (100% vs 9.1% p < 0.01) following interval resection. Overall mortality was significantly higher in the Chemo vs. No-chemo group. Median survival in Chemo patients was 3.4 years; in No-chemo patients, median survival was not reached at 10 years.Conclusion: Our data do not support routine elective surgery for acute diverticulitis in patients receiving chemotherapy. Non-operative management in the acute or interval setting appears preferable whenever possible.

Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy.

Many of the treatment strategies for sigmoid diverticulitis are actually focusing on nonoperative and minimally invasive approaches. The aim of this systematic review was to evaluate the actual role of damage control surgery (DCS) in the treatment of generalized peritonitis caused by perforated sigmoid diverticulitis.A literature search was performed in PubMed and Google Scholar for articles published from 1960 to July 2013. Comparative and noncomparative studies that included patients who underwent DCS for complicated diverticulitis were considered.Acute Physiology and Chronic Health Evaluation score, duration of open abdomen, intensive care unit length of stay, reoperation, bowel resection performed at first operation, fecal diversion, method, and timing of closure of abdominal wall were the main outcomes of interest.According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses algorithm for the literature search and review, 10 studies were included in this systematic review. DCS was exclusively performed in diverticulitis patients with septic shock or requiring vasopressors intraoperatively. Two surgical different approaches were highlighted: limited resection of the diseased colonic segment with or without stoma or reconstruction in situ, and laparoscopic washing and drainage without colonic resection.Despite the heterogeneity of patient groups, clinical settings, and interventions included in this review, DCS appears to be a promising strategy for the treatment of Hinchey III and IV diverticulitis, complicated by septic shock. A tailored approach to each patient seems to be appropriate.

Comparison of two FFPE preparation methods using label-free shotgun proteomics: Application to tissues of diverticulitis patients

Formalin-fixed paraffin-embedded (FFPE) specimens of patients are useful sources of materials for clinical research and have recently gained interest for use in the discovery of clinical proteomic biomarkers. However, the critical step in this field is the ability to obtain an efficient and repeatable extraction using the limited quantities of material available for research in hospital biobanks. This work describes the evaluation of the peptide/protein extraction using FFPE sections treated by the following two methods before shotgun proteomic analysis: a commercial solution (FFPE-FASP) (filter aided sample preparation) and an antigen retrieval-derived protocol (On Slice AR). Their efficiencies and repeatabilities are compared using data-independent differential quantitative label-free analysis. FFPE-FASP was shown to be globally better both qualitatively and quantitatively than On Slice AR. FFPE-FASP was tested on several samples, and differential analysis was used to compare the tissues of diverticulitis patients (healthy and inflammatory tissues). In this differential proteomic analysis using retrospective clinical FFPE material, FFPE-FASP was reproducible and provided a high number of confident protein identifications, highlighting potential protein biomarkers. In clinical proteomics, FFPE is an important resource for retrospective analysis and for the discovery of biomarkers. The challenge for FFPE shotgun proteomic analysis is preparation by an efficient and reproducible protocol, which includes protein extraction and digestion. In this study, we analyzed two different methods and evaluated their repeatabilities and efficiencies. We illustrated the reproducibility of the most efficient method, FFPE-FASP, by a pilot study on diverticulitis tissue and on FFPE samples amount accessible in hospital biobanks. These data showed that FFPE is suitable for use in clinical proteomics, especially when the FFPE-FASP method is combined with label-free shotgun proteomics as described in the workflow presented in this work.

TNFSF15 mRNA Expression Is Upregulated in Sigmoid Tissue of Diverticulitis Patients

TNFSF15 mRNA Expression Is Upregulated in Sigmoid Tissue of Diverticulitis Patients

Diagnostic impact of routine colonoscopy following acute diverticulitis: A multicenter study in 808 patients and controls

The diagnosis of acute diverticulitis is mainly based on clinical, biological and computed tomography (CT)-scan findings. Elective colonoscopy is recommended after medical treatment, to rule out another diagnosis and to detect associated conditions; however, the relevance of this recommendation has been questioned. Between January 2005 and December 2011, we retrospectively identified in three referral centers the consecutive patients whom underwent a colonoscopy after the medical treatment of a CT scan-proven acute diverticulitis episode. We excluded from the analysis patients with haematochezia or recent change in bowel habits. Sex and age-matched asymptomatic patients undergoing a screening colonoscopy were chosen as a control group. We collected and compared the results of colonoscopy and histological findings in both groups. We matched 404 patients whom underwent a colonoscopy after an episode of acute diverticulitis with 404 control patients. Their mean age was 60.9 years, with 59% being women. Colorectal adenoma, advanced adenoma and cancer detection rates in acute diverticulitis patients were 12.1%, 2.7% and 0.25%, respectively; versus 14.6% (p = 0.35), 6.7% (p = 0.01) and 0.25% respectively, in control patients. Diagnosis rates for adenomas and for colorectal cancer during a colonoscopy scheduled after acute diverticulitis were similar than those of control patients undergoing a screening colonoscopy, while the detection rate of advanced adenomas was lower. We suggest that colonoscopy should be indicated only in selected patients, i.e. those presenting with reasonable doubt on initial CT-scan, those with alarm symptoms, and those with identified risk factors for colorectal cancer.

Fecal microbiome analysis as a diagnostic test for diverticulitis

Disease-specific variations in intestinal microbiome composition have been found for a number of intestinal disorders, but little is known about diverticulitis. The purpose of this study was to compare the fecal microbiota of diverticulitis patients with control subjects from a general gastroenterological practice and to investigate the feasibility of predictive diagnostics based on complex microbiota data. Thirty-one patients with computed tomography (CT)-proven left-sided uncomplicated acute diverticulitis were included and compared with 25 control subjects evaluated for a range of gastrointestinal indications. A high-throughput polymerase chain reaction (PCR)-based profiling technique (IS-pro) was performed on DNA isolates from baseline fecal samples. Differences in bacterial phylum abundance and diversity (Shannon index) of the resulting profiles were assessed by conventional statistics. Dissimilarity in microbiome composition was analyzed with principal coordinate analysis (PCoA) based on cosine distance measures. To develop a prediction model for the diagnosis of diverticulitis, we used cross-validated partial least squares discriminant analysis (PLS-DA). Firmicutes/Bacteroidetes ratios and Proteobacteria load were comparable among patients and controls (p = 0.20). The Shannon index indicated a higher diversity in diverticulitis for Proteobacteria (p < 0.00002) and all phyla combined (p = 0.002). PCoA based on Proteobacteria profiles resulted in visually separate clusters of patients and controls. The diagnostic accuracy of the cross-validated PLS-DA regression model was 84 %. The most discriminative species derived largely from the family Enterobacteriaceae. Diverticulitis patients have a higher diversity of fecal microbiota than controls from a mixed population, with the phylum Proteobacteria defining the difference. The analysis of intestinal microbiota offers a novel way to diagnose diverticulitis.

The TNFSF15 gene single nucleotide polymorphism rs7848647 is associated with surgical diverticulitis.

To determine if single nuclear polymorphisms (SNPs) in the TFNSF15 gene play a role in patients requiring surgery for diverticulitis. A role for a genetic predisposition in diverticulitis is suggested by its association with hereditary connective tissue disorders, youthful onset in some patients, and the observation of families with multiple affected individuals. The TNFSF15 gene has been associated with other inflammatory diseases affecting the colon such as medically refractory ulcerative colitis (UC), aggressive Crohn's disease (CD), and pouchitis after restorative proctocolectomy. In the discovery phase of this study, 21 sporadic surgical diverticulitis (SD) patients (9 female, mean age = 52 ± 5) and 5 individuals from a single family with surgically managed diverticulitis [familial diverticulitis (FD), 4 female, mean age = 51.1 ± 7] were studied. SD patients were age and sex matched with 3 separate groups of healthy, CD and UC control patients. All patients were genotyped for 5 known TNFSF15-associated SNPs. The SNP discovered to be associated with diverticulitis (rs7848647) was then confirmed in a separate test group composed of 34 additional patients (20 female, mean age 57.7 ± 2) who also underwent surgical treatment for diverticulitis. These patients were age matched to a new control cohort of patients having no history of diverticulitis (26 female). Patients were genotyped using a TaqMan assay. In the discovery phase, logistical regression on matched subjects was performed to determine an association of TNFSF SNP with diverticulitis versus the control groups. In the test phase, significance for the rs7848647 SNP was assessed by the Fischer's exact test. In the discovery phase, the TNFSF15 SNP rs7848647 was significantly associated with SD (p = 0.0003) versus all control groups studied. The risk allele for this SNP (G substituted for A) was found in all SD patients. The homozygous GG allele was found in 62% (13/21) of SD patients versus only 5% (1/21) of healthy controls (p = 0.001) and 24% (10/42) of all UC + CD controls (p = 0.002). All 5 members of the FD cohort were homozygous for the at-risk "G" allele. In the test group, the homozygous GG genotype was found in 56% of SD patients compared with 17% of healthy controls (p = 0.006). Risk of SD seemed to increase with number of the G alleles with 8% of SD patients having AA homozygosity, 35% of SD patients having AG heterozygosity, and 56% of SD patients having GG homozygosity. The SNP rs7848647 associated with the TNFSF15 gene is associated with surgical diverticulitis. This finding suggests a fundamental role for TNFSF15, a T-cell receptor gene involved in T-cell maturation, in the pathophysiology of diverticulitis requiring surgery. This SNP may be a marker of diverticular disease severity that might assist in surgical decision making.

Su2037 TRPV2 Knockout Mice Exhibit Enhanced Gastric Emptying

this is the case in patients with more severe and/or complicated disease. OBJECTIVE: To test the hypothesis that inhibitory neurotransmission to sigmoid colon CSM is impaired in patients with complicated diverticulitis. METHODS: Standard intracellular recordings were performed from sigmoid colon CSM of patients who underwent sigmoid resection because of complications of diverticulitis (n=4) and compared to control tissue obtained from patients having resection for cancer. Tissue adjacent to recording sites was also examined histologically for muscle layer thickness and density of innervation using SNAP-25 immunohistochemistry. Quantitative analysis of electrophysiological recordings, histology and immunohistochemistry were performed by ‘blinded' observers. Statistical significance was determined using t-tests with a p-value of <0.05 considered significant. RESULTS: Resting membrane potential was significantly more depolarized in CSM from diverticulitis patients vs controls (-39.0±0.9 vs -46.0±1.8 mV). In control tissue electrical stimulation (4 pulses, 0.5 ms) produced an inhibitory junction potential (IJP) of 11.0±1.3 mV that was markedly inhibited (to 1.5±0.7 mV) by application of the selective P2Y1 receptor antagonist MRS-2500. The magnitude of the IJP was markedly attenuated in diverticulitis patients vs controls (0.7±0.7 vs 11.0±1.3 mV). The CSM layer was on average 50% thicker in complicated diverticulitis patients versus controls (2.07 ± 0.65 mm vs 1.39 ± 0.23 mm) and this appeared to be due to muscular hypertrophy, as the average CSM cell number/length of tissue was significantly decreased in diverticulitis (0.84 ± 0.08 cells/100 μm in diverticulitis vs 1.6 ± 0.2 cells/100 μm in controls). Axon density was similar in the two groups (0.23 ± 0.06 axon intersections/CSM cell in controls vs 0.22 ± 0.03 axon intersections/CSM cell in diverticulitis). CONCLUSIONS: Purinergic inhibitory neurotransmission to sigmoid CSM appears markedly impaired in patients with complicated diverticulitis and resting membrane potential is also relatively depolarized. This is associated with hypertrophy of the CSM layer, but no apparent alteration in innervation density. Further studies are required to determine the mechanisms underlying this abnormality and how it may relate to the pathophysiology of diverticular disease.

The Risk for Diverticulitis in Patients with Diverticulosis

In patients who have diverticulosis, the risk for acute diverticulitis is often estimated at between 10% and 25%. However, this estimate is based on

Comparison of putative circulating cancer stem cell detection between the hepatic portal system and peripheral blood in colorectal cancer patients.

PurposeThe present pilot study was conducted to detect putative cancer stem cell (CSC) from the hepatic portal system and peripheral blood in the colorectal cancer patients and to compare them to healthy donor and diverticulitis patients.MethodsLaboratory study was performed to identify the expression of cell surface markers, epithelial cell adhesion molecule (EpCAM), cytokeratin (CK) 18, CK20, CD44, and CD133, on several colon cancer cell lines. Clinical pilot study was conducted to detect putative circulating CSC as EpCAM+CD133+ cell in colorectal cancer (n = 10), diverticulitis (n = 5), and four healthy donors, by using flow cytometry. Blood was drawn from the hepatic portal system and peripheral vein.ResultsOn laboratory study, EpCAM was expressed in whole colon cancer cell lines, and CD44 and CD133 were simultaneously expressed in 50% of the cell lines with stemness phenotype, but CK18 and CK20 were not expressed in most of the cell lines. On clinical study, the mean EpCAM+CD133+ cell counts of 11.6/105 in the hepatic portal system were somewhat lower than 15.4/105 in peripheral vein (P = 0.241). As for diverticulitis patients, EpCAM+CD133+ cells were also detected to have steeper dropped to near zero, after the surgery.ConclusionThe numbers of putative CSC were not statistically different between the detection sites of the portal vein and peripheral vein in the colon cancer patients. Therefore, we may not have benefitted by getting the cells from the hepatic portal system. In addition, the CD133+EpCAM+ cells in the colon cancer patients might contain normal stem cells from cancer inflammation similar to diverticulitis.

Nonoperative management of acute complicated diverticulitis.

See Article on Page 216-221 In the past, the majority of acute complicated diverticulitis patients were managed by using surgical intervention, such as a resection of the perforated bowel and the creation of an end colostomy. However, surgical intervention in cases of acute complicated diverticulitis is associated with high postoperative morbidity and mortality [1]. Although the optimal treatment for acute complicated diverticulitis is controversial, recently, with the evolution of surgical techniques and supportive medical care, such as the advances in the development of antibiotics, interventional radiology techniques, parenteral nutrition, and critical care medicine, significant changes in the treatment of acute complicated diverticulitis have taken place [2]. Computed tomography scans are able to accurately characterize the severity of the disease and to guide therapeutic percutaneous drainage of abscesses [3]. Because of the advances in the supportive medical care, the management of acute complicated diverticulitis can be changed from emergent surgery to elective surgery. Therefore, surgical intervention for acute complicated diverticulitis is needed only for patients in whom aggressive nonoperative management has failed or for patients who are hemodynamically unstable or present with generalized peritonitis. Dharmarajan et al. [4] hypothesized that management with bowel rest, parenteral nutrition, antibiotics, and percutaneous abscess drainage obviated the need for acute surgical intervention in the vast majority of cases. In this study, the authors showed that in their experience, the presence of recurrent attacks of acute diverticulitis was not a significant risk for emergent surgery. In fact, the first episode of complicated acute diverticulitis was the only risk factor for emergent surgery in patients managed in a conservative form [5]. If appropriate resources are available, aggressive nonoperative management of acute complicated diverticulitis is safe and effective in almost all hemodynamically-stable patients. The decision to use nonoperative management of acute complicated diverticulitis must be based on the patient's clinical physiologic state.

C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications

Diverticulitis is a common indication for surgical emergency room admission, often leading to abdominal computed tomography (CT) scanning for both diagnosis and staging. C-reactive protein (CRP) has been identified as a useful biomarker of inflammation. Aspirin and corticosteroids are known to down-regulate CRP production. In this study, we evaluated the usefulness of CRP as a biomarker for complicated diverticulitis and specifically in patients on anti-inflammatory medications: aspirin and corticosteroids. We analyzed the medical records of patients diagnosed at one medical center during a two-year period, with left-sided diverticulitis, according to clinical data and CT scan. Disease severity was assessed by the Hinchey score using the radiological findings detected by CT. A total of 295 patients were included in the study. Two hundred and forty-three (82%) were classified with uncomplicated (Hinchey 1a) and 52 (18%) with complicated disease (Hinchey>1a). Mean CRP levels were 133.5 and 63.5mg/ml for those with complicated and uncomplicated disease, respectively (p<0.001), and 139 and 60mg/ml, respectively (p<0.001) in the subgroup of patients taking aspirin (n=61). For 14 patients on corticosteroid treatment, the difference in mean CRP levels for complicated and uncomplicated disease was not statistically significant. CRP>90mg/ml had 88% sensitivity and 75% specificity for complicated disease. The CRP level distinguished between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment.