History Of Diverticulitis Research Articles

Clinical Predictors Associated with the Severity of Colonic Diverticulitis

대장게실은 노령화될수록 발생빈도가 증가하여 서구에서는 40세 이하에서 10% 이내, 80세 이상에서 50-66%의 유병률을 보이는 흔 한 질환이다. 최근 국내에서도 연령의 노령화, 식생활의 서구화, 대 장조영술 및 대장내시경검사 등 진단방법의 발달로 대장게실의 발생 빈도가 점차 증가하여 유병률이 10%를 넘었다고 보고되었다. 대장 게실염은 서양에서는 전체 게실 환자의 10-20%, 국내에서는 2.1% 에서 발생한다고 알려져 있다. 대장게실염에 따른 합병증은 천공, 농양, 누공, 폐색, 협착, 출혈 등 으로 게실 환자의 주된 사망요인이다. 합병증이 발생할 경우 수술 후 Background/Aims: Colonic diverticular diseases are increasing in Korea due to aging of the population and westernization of people’s lifestyle. The aim of this study was to investigate the clinical predictors associated with the severity of colonic diverticulitis in Korea. Methods: We retrospectively reviewed the medical records of 107 patients who were hospitalized with diverticulitis and underwent abdominopelvic computerized tomography at Dankook University Hospital between March 2002 and August 2011. The severity of colonic diverticulitis was evaluated by using Modified Hinchey classification, stage 0 to stage Ia were classified as mild group and stage Ib to stage IV were classified as severe group. Patients’ records were assessed for age, sex, underlying diseases, history of diverticulitis, associated symptoms, location of diverticulitis, white blood cells, and C-reactive protein (CRP). Results: Male to female ratio was 1.6:1 with the mean age of 43.1 years. Eighty-three patients (77.6%) were in the mild group and 24 patients (22.4%) were in the severe group. In multivariated analysis, the clinical predictors associated with the severity of colonic diverticulitis were left location (odds ratio [OR], 7.268; P=0.030), duration of symptoms (≥3 days; OR, 4.174; P=0.022), and elevated CRP (≥5 mg/dL; OR, 4.576; P=0.018). Conclusions: Left location, duration of symptom, and elevated CRP were the meaningful predictors for severity of colonic diverticulitis. When confronting with patients with these risk factors, we should keep in mind about the possibility of severe diverticulitis. (Intest Res 2013;11:23-27)

Factors associated with gastrointestinal perforation in a cohort of patients with rheumatoid arthritis

To estimate the incidence and risk factors for gastrointestinal (GI) perforation among patients with rheumatoid arthritis (RA). Claims from employer health insurance plans were used to identify RA patients and those hospitalized for upper or lower GI perforation. GI perforation cases were identified using both a sensitive and a specific definition. A Cox model using fixed and time-varying covariates was used to evaluate the risk of GI perforation. Among 143,433 RA patients, and using a maximally sensitive GI perforation definition, 696 hospitalizations with perforation were identified. The rate of perforation was 1.70 per 1,000 person years (PYs; 95% confidence interval [95% CI] 1.58-1.83), and most perforations (83%) occurred in the lower GI tract. The rate of perforation was lower when a more specific GI perforation definition was used (0.87; 95% CI 0.78-0.96 per 1,000 PYs). Age and diverticulitis were among the strongest risk factors for perforation (diverticulitis hazard ratio [HR] 14.5 [95% CI 11.8-17.7] for the more sensitive definition, HR 3.9 [95% CI 2.5-5.9] for the more specific definition). Among various RA medication groups and compared to methotrexate, the risk of GI perforation was highest among patients with exposure to nonsteroidal antiinflammatory drugs (NSAIDs), concomitant nonbiologic disease-modifying antirheumatic drugs, and glucocorticoids. Biologic agents without glucocorticoid exposure were not a risk factor for perforation. GI perforation is a rare but serious condition that affects patients with RA, most frequently in the lower GI tract. Clinicians should be aware of risk factors for GI perforation when managing RA patients, including age, history of diverticulitis, and use of glucocorticoids or NSAIDs.

Chronic Contained Abdominal Aortic Aneurysm Rupture After Suprarenal Fixation Fatigue Fracture

Chronic contained rupture (CCR) of an abdominal aortic aneurysm is a rare condition, and differential diagnosis might be difficult. We present a clinical case of a hemodynamically stable octogenarian who presented with intermittent pain in the left lower abdomen. The patient had a history of diverticulitis, and 6 years ago, he had undergone endovascular abdominal aortic aneurysm repair (EVAR) with a Talent bifurcated prosthesis. Additionally, 20 days before his admission to our hospital, he had undergone a secondary iliac limb extension for treatment of post-EVAR rupture. On admission, abdominal plain radiography identified suprarenal fixation fracture as a possible reason for CCR, but computed tomographic angiography failed to confirm any endoleak or "active" bleeding and rupture. The patient received medication treatment for possible diverticulitis and was kept under close monitoring for suspected failure of recently performed secondary endovascular procedure and CCR. A day later, the abdominal pain symptoms worsened, and a new computed tomographic angiography confirmed the suspected CCR. The patient was treated successfully by "open" repair using a Y prosthesis. To our knowledge, this is the first reported case of post-EVAR CCR due to suprarenal fixation fatigue fracture. Lifelong post-EVAR follow-up with high level of both clinical and imaging diagnostic accuracy is essential for the early recognition and proper treatment of EVAR pitfalls.

A 70-Year-Old Woman With Acute Right Ventricular Failure and Circulatory Collapse

70-year-old woman with osteoarthritis and a remote history of diverticulitis presented to her primary-care physician with intermittent fevers and dyspnea. These symptoms began 1 day after a recent visit to her family where she reported exposure to grandchildren who were sick with an upper respiratory infection. She was given a diagnosis of a viral infection and advised to take conservative measures. Two days later, the patient presented to the ED with persistent high-grade fevers, diffuse aches, and worsening dyspnea. Physical Examination On presentation, the patient’s vital signs were normal except for tachypnea, with a respiratory rate of 26 breaths/min. Pulse oximetry showed 100% saturation while breathing ambient air. General examination results were normal. Chest auscultation revealed bilateral coarse lung sounds with diffuse rhonchi. Cardiac auscultation revealed normal heart sounds with no murmurs, rubs, or gallops. The abdomen was soft, nontender, and nondistended without organomegaly.

Indications for Elective Sigmoid Resection in Diverticular Disease

To prevent an acute surgery, classic indications for elective sigmoid resections concerning diverticulitis have usually been based on the number of recurrent episodes. Since 2005 these indications have been challenged, primarily because the majority of patients first present themselves with acute complications at their first episode. Between 1990 and 2000, a cohort analysis was conducted involving all patients admitted to the VU University Medical Center with the diagnosis of diverticulitis, with a follow-up until January 2009. To identify those patients who might benefit from elective sigmoid resection, several risk factors were analyzed. Of 291 patients examined, 111 (38%) were treated conservatively and 180 (62%) underwent surgery, of which 108 acute and 72 elective. The conservatively treated episodes of diverticulitis showed a recurrence rate of 48% (88 patients). Indications for elective surgery were recurrent attacks of diverticulitis with persistent complaints (36%), complaints of stenosis (40%), fistula (14%), persistent abscesses (3%), and recurrent diverticular bleeding (7%). Of the 74% of the patients approached laparoscopically, the overall morbidity was 22% with no mortality. The main indication for an AO was perforation with general peritonitis, holding for 57% of the acutely operated patients. Other indications were abscesses (22%), stenosis with obstruction (11%), failure of conservative therapy (6%), or diverticular bleeding (4%). Hartmann's procedure was the most frequently performed procedure (58%). This acutely operated population was associated with high morbidity (56%) and mortality (13%), perforation leads to 10% mortality and other causes to 3%. Of those patients undergoing acute surgery, 20% had a history of diverticulitis. Moreover, risk factor analysis showed that those patients having one or more of the following indications: (1) using immunosuppression therapy, (2) having chronic renal failure, or (3) collagen-vascular diseases, had a significant 5-fold greater risk (36% vs. 7%) of a perforation in recurrent episodes of diverticulitis. In the treatment of diverticular disease, indications for an elective sigmoid resection should not be based on the number of episodes only. Clear indications for elective sigmoid resections are complaints of stenosis, fistulas, or recurrent diverticular bleeding. Furthermore, an elective sigmoid resection might be justified in high-risk patients, after a conservatively treated episode of diverticulitis, who use immunosuppression therapy and have chronic renal failure or collagen-vascular diseases.

Sweet Syndrome Associated with Celiac Disease

Neutrophilic dermatoses are a spectrum of diseases with varying presentations and similar clinical and histologic features. The association of neutrophilic dermatosis with celiac disease has not previously been described. We report a 43-year-old man with a history of diverticulitis who presented with mildly pruritic, ulcerating pustules of the dorsal hands, face, elbow, and neck, clinico-pathologically consistent with the neutrophilic dermatosis Sweet syndrome. Remission was achieved with prednisone taper, dapsone, and a gluten-free diet.

Laparoscopic Hartmann’s procedure: a viable option for treatment of acutely perforated diverticultis

A laparoscopic technique for acutely perforated diverticulitis (i.e., laparoscopic Hartmann's procedure) has not been described. The authors present their technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy. A retrospective review of patients with Hinchey III/IV diverticulitis who underwent a laparoscopic Hartmann's procedure was performed in this study. Laparoscopic takedown of sigmoid colostomy was performed 2 to 3 months later. Data from these procedures including estimated blood loss (EBL), length of the operative procedure, patient outcomes, and demographics were evaluated. Seven patients with a mean age of 49.7 years underwent laparoscopic sigmoid colectomy with end colostomy. None of these patients had a history of diverticulitis. Their mean EBL was 138 ml, and their mean operative time was 154 min. None of the procedures required conversion to use of a hand port or conversion to open procedure. The average time to return of bowel function was 3.7 days, with one patient experiencing a postoperative ileus. The mean postoperative hospital stay was 6.6 days. There were no complications. Laparoscopic Hartmann's takedown was performed for all the patients approximately 2 to 3 months later. The mean EBL was 107 ml, and the average operative time was 189 min. One patient had intraoperative anastomotic leak, which was successfully repaired and retested. Again, none of the procedures required the use of a hand port or a laparotomy. The average time to return of bowel function was 3.4 days. The average length of hospital stay was 5.3 days, with one patient experiencing a fat necrosis. Laparoscopic Hartmann's procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.

Isolation of the anaerobic intestinal spirochaete Brachyspira pilosicoli from long-term residents and Indonesian visitors to Perth, Western Australia

Brachyspira pilosicoli is an anaerobic spirochaete that colonizes the large intestine of humans and various species of animals and birds. The spirochaete is an important enteric pathogen of pigs and poultry, but its pathogenic potential in humans is less clear. In the current study, the occurrence of B. pilosicoli in faecal samples from 766 individuals in two different population groups in Perth, Western Australia, was investigated by selective anaerobic culture. Of 586 individuals who were long-term residents of Perth, including children, elderly patients in care and in hospital and individuals with gastrointestinal disease, only one was culture positive. This person had a history of diverticulitis. In comparison, faeces from 17 of 180 (9.4 %) Indonesians who were short- or medium-term visitors to Perth were positive for B. pilosicoli. The culture-positive individuals had been in the city for between 10 days and 4.5 years (median 5 months). Resampling of subsets of the Indonesians indicated that all negative people remained negative and that some positive individuals remained positive after 5 months. Two individuals had pairs of isolates recovered after 4 and 5 months that had the same PFGE types, whilst another individual had isolates with two different PFGE types that were identified 2 months apart. Individuals who were culture-positive were likely to have been either colonized in Indonesia before arriving in Perth or infected in Perth following contact with other culture-positive Indonesians with whom they socialized. Colonization with B. pilosicoli was not significantly associated with clinical signs at the time the individuals were tested, although faeces with wet-clay consistency were 1.5 times more likely (confidence interval 0.55-4.6) than normal faeces to contain B. pilosicoli.

Serotonin Signaling in Diverticular Disease

Diverticulosis is extremely common in Western societies and is associated with complications in up to 15%of cases. Altered motility is an important feature of the pathogenesis of diverticular disease, and serotonin (5-HT) release is a primary trigger of gut motility. This study aims to determine whether colonic 5-HT signaling is altered in patients with diverticulosis or diverticulitis, and whether differences in serotonin signaling may distinguish patients with asymptomatic diverticulosis from those who develop disease specific complications. Sigmoid colon biopsies were obtained from healthy control subjects, individuals with asymptomatic diverticulosis, and those with a history of CT-proven diverticulitis within the preceding 6 months. The key elements of 5-HT signaling including content, release, and 5-HT transporter (SERT) expression were analyzed. A significant decrease in SERT transcript levels was present in the mucosa of patients with a history of diverticulitis when compared with controls, but not in those with asymptomatic diverticulosis. Mucosal 5-HT content, enterochromaffin (EC) cell numbers, and TpH-1 mRNA levels were comparable amongst the groups, as were basal and stimulated 5-HT release. Alterations in 5-HT signaling do not appear to be responsible for the development of diverticula. However, patients with a recent history of acute diverticulitis have a significant attenuation in SERT expression and function, likely secondary to previous inflammation. Our findings may explain the persistent symptoms of pain and altered motility so often observed in patients with diverticulitis long after recovery from the acute inflammatory response.

Pemetrexed and carboplatin plus bevacizumab for advanced non-squamous non-small cell lung cancer (NSCLC): Preliminary results

7601 Background: Pemetrexed in combination with carboplatin has been shown to have promising activity and favorable toxicity profile in NSCLC. Bevacizumab has been shown to improve response rates and survival in pts with advanced non-squamous NSCLC when combined with carboplatin and paclitaxel. This study of pemetrexed and carboplatin plus bevacizumab was designed to evaluate the toxicity profile and to estimate the activity of the regimen in this pt population. Methods: Eligibility required that pts were chemotherapy-naive, had stage IIIB (effusion)/IV non-squamous NSCLC, PS 0–1, with no evidence of CNS metastases. Pts received pemetrexed 500 mg/m2 over 10 minutes, carboplatin AUC 6 over 30 minutes, and bevacizumab 15 mg/kg over 30–90 minutes on a 21-day cycle for 6 cycles. Pts with SD or PR received pemetrexed 500 mg/m2 and bevacizumab 15 mg/kg every 21 days until disease progression or toxicity. All pts received folic acid, vitamin B12 and steroid prophylaxis. Results: From 8/05 to 9/06, 39 pts (of planned 50) were enrolled: 20 M/19 F; median age 64 (range 41 - 80). One pt enrolled and subsequently refused treatment. Median number of cycles was 6 (range 1–22), and 25/38 (66%) completed at least 6 cycles of therapy. There was no grade 4 hematological toxicity. Grade 3 hematological toxicities were anemia (5%, N=2) and thrombocytopenia (3%, N=1). The most common grade 3/4 non-hematological toxicities included proteinuria (3%, N=1, gr 3), venous thrombosis (3%, N=1, gr 3), infection (3%, N=1, gr 4), and diverticulitis (11%: 8%, N=3, gr 3/3%, N=1, gr 4). 1 pt with diverticulitis experienced bowel perforation that required surgical intervention. The trial was temporally suspended and the group of pts with diverticulitis was analyzed separately. The only risk factor identified was previous history of diverticulitis. One CR, 20 PRs were observed for an overall response rate of 55% (95%, CI 43–75%). Conclusions: Treatment with pemetrexed and carboplatin plus bevacizumab in pts with advanced non-squamous NSCLC is feasible with an acceptable toxicity profile. The encouraging activity justifies further development of this regimen. However, pts with a prior history of diverticulitis should be excluded until this observation can be investigated further. No significant financial relationships to disclose.

Questions on the Natural History of Diverticulitis and the National Diverticulitis Study Group

Questions on the Natural History of Diverticulitis and the National Diverticulitis Study Group

Is a Recent Episode of Diverticulitis an Acceptable Indication for Colonoscopy?

Purpose: Patients are routinely referred for colonoscopy after experiencing an episode of diverticulitis. There is no evidence supporting this practice. The goal of this study is to compare the incidence of clinically significant lesions found during colonoscopy between a group of patients referred after an episode of diverticulitis and a group of average risk individuals undergoing screening colonoscopy. Method: Patients referred for colonoscopy after receiving the clinical diagnosis of diverticulitis were identified from our database (diverticulitis group). As our reference group we used consecutive average risk patients referred for screening colonoscopy without a history of diverticulitis (screening group). For this study, we considered all adenomatous polyps (small and large) and adenocarcinoma as significant lesions. The study was powered to detect a 10% difference in the incidence of significant lesions with an alpha of 95% and a beta of 80%. Results: From 1997 to 2003, we found 119 patients referred for colonoscopy after an episode of diverticulitis (75 females, 44 males, mean age 61, range 29-89). In this group, 16 patients (13.4%) had adenomas <1 cm, 8 (6.7%) had adenomas ≥1 cm and 2 (1.7%) had adenocarcinoma. The screening group consisted of 440 patients (294 females, 145 males, mean age 60, range 50-74). We found that 68 patients (15.5%) had adenomas <1 cm, 19 (4.3%) had adenomas ≥1 cm and 3 (0.7%) had adenocarcinoma. There was no statistical difference in the frequency of findings between both groups. In our subgroup analysis we noted that the prevalence of significant lesions was significantly greater in males when compared to females (p value = 0.04). This observation held true in both study groups. Conclusions: There is no difference in the prevalence of significant lesions identified during colonoscopy in patients with previous diverticulitis compared with average risk individuals. Patients with previous diverticulitis should therefore follow the normal colorectal screening guidelines.

Factors that predict incomplete colonoscopy

PURPOSE AND METHODS: Certain factors in a patient's history, such as prior abdominal surgery or complicated diverticular disease, have been reported to hinder cecal intubation during colonoscopy. Over a 16-month period, 1,047 consecutive colonoscopies were prospectively evaluated to determine whether these factors were indeed clinically relevant. RESULTS: Of the 90 patients (9 percent) who had incomplete intubation of the colon, there were significantly more women (66 percent) than men (34 percent) (P<0.001). Women with a history of abdominal hysterectomy had a significantly lower cecal intubation rate (P< 0.01). A history of diverticulitis did not alter the cecal intubation rate. In patients with incomplete colonic intubation, the most proximal extent of intubation was the sigmoid colon in women (31 percent) and the right colon in men (68 percent). Sixty-seven percent of patients with incomplete intubation of the colon had a prior colonoscopy completed to the cecum (67 percent women, 67 percent men), whereas 50 percent had a follow-up colonoscopy completed to the cecum (56 percent women, 40 percent men). CONCLUSIONS: Women, especially those with a history of abdominal hysterectomy, had a significantly lower cecal intubation rate usually because of an impassable sigmoid colon. Prior inability to complete colonoscopy to the cecum does not necessarily forecast future failure.

Factors that predict incomplete colonoscopy

Certain factors in a patient's history, such as prior abdominal surgery or complicated diverticular disease, have been reported to hinder cecal intubation during colonoscopy. Over a 16-month period, 1,047 consecutive colonoscopies were prospectively evaluated to determine whether these factors were indeed clinically relevant. Of the 90 patients (9 percent) who had incomplete intubation of the colon, there were significantly more women (66 percent) than men (34 percent) (P < 0.001). Women with a history of abdominal hysterectomy had a significantly lower cecal intubation rate (P < 0.01). A history of diverticulitis did not alter the cecal intubation rate. In patients with incomplete colonic intubation, the most proximal extent of intubation was the sigmoid colon in women (31 percent) and the right colon in men (68 percent). Sixty-seven percent of patients with incomplete intubation of the colon had a prior colonoscopy completed to the cecum (67 percent women, 67 percent men), whereas 50 percent had a follow-up colonoscopy completed to the cecum (56 percent women, 40 percent men). Women, especially those with a history of abdominal hysterectomy, had a significantly lower cecal intubation rate usually because of an impassable sigmoid colon. Prior inability to complete colonoscopy to the cecum does not necessarily forecast future failure.