Management Of Diverticular Disease Research Articles

Symptomatic uncomplicated diverticular disease management: an innovative food-grade formulation of Curcuma longa and Boswellia serrata extracts

BackgroundThe treatment of symptomatic uncomplicated colonic diverticular disease (SUDD) is still under debate, and new data show a pathogenic role of dysbiosis and low-grade inflammation in intestinal mucosa. Recent research has highlighted the anti-inflammatory effects of botanical extracts such as Curcuma longa L. and Boswellia serrata Roxb. ex Colebr. The aim of this work is to investigate the potential role of a new delivery formulation of the association of curcumin and boswellia phytosome extracts (CBP) in SUDD.MethodsIn a 30-day one-group longitudinal explanatory study, patients (men and women) were treated with an innovative association of CBP standardized extracts, 500 mg bid.ResultsTreatment of SUDD with the association of CBP was followed by a significant decrease in abdominal pain (p<0.0001). The study group showed that CBP supplementation was efficacious within 10 days and that efficacy was maintained almost constant until the 30th day of intervention.ConclusionA phytosome of curcumin and boswellia extracts may be useful for the relief of SUDD pain. However, controlled studies should be performed for final conclusions to be drawn.

Pregnancy and Healthy Childbirth in a 37 Year-Old Patient with Diverticular Disease

Aim.To describe a clinical case of pregnancy and healthy labour in a young female patient with uncomplicated diverticular disease (DD).Key points.In recent years, DD is more frequently observed in younger patients. A 37-yo woman manifested the symptoms of periodic intense abdominal pain and constant abdominal discomfort. Colonic DD was diagnosed with irrigoscopy. A high-fibre diet, rifaximin-α at 400 mg twice a day for one week, once a month for six months, and topical anti-inflammatory therapy were prescribed. Clinical symptoms were eradicated upon the treatment. Unaware of pregnancy, the patient had another course of rifaximin-α at the second week of gestation, after which the therapy was stopped. Rifaximin-α, which has a poor intestinal absorption, did not affect the foetal development. A caesarean childbirth was healthy, the newborn was delivered on term with no complications (Apgar score 8).Conclusion.DD should be included in differential diagnosis for patients with non-specific symptoms (abdominal pain, bloating and discomfort), regardless of young age. No protocols are currently accepted for the DD management during gestation. In the clinical case reported, a patient having diverticular disease and a rifaximin-α therapy at an early term of gestation proceeded without complications for herself and the foetus.

Optimizing medical management for diverticular disease: A systematic review and gap analysis

BackgroundResolution of acute diverticulitis is often associated with ongoing gastrointestinal symptoms and risk for recurrent episodes. Surgical guidelines recommend individualized treatment options but medical management strategies have been inconsistently implemented in surgical practice. This study reviews the evidence for medical management to reduce episodes or decrease gastrointestinal symptoms to inform shared decision-making discussions with patients and identifies key evidence gaps for the medical management of diverticular disease. MethodsPubMed, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched to identify randomized clinical trials on recurrent acute diverticulitis and symptomatic uncomplicated diverticular disease that studied medical treatment strategies including fiber supplementation, probiotics, mesalamine, and rifaximin. Two independent researchers screened references and assessed articles for eligibility. Outcomes of interest included patient-reported symptom improvement and diverticulitis recurrence. Results27 of 485 unique articles identified in the electronic research met eligibility for inclusion. Three focused on fiber, three on probiotics, twelve on mesalamine, and nine on rifaximin with conflicting results. ConclusionMedical management options are available and may be helpful in some patients following resolution of acute diverticulitis to improve symptom burden and recurrent episodes of diverticulitis. Further investigation is needed to inform which subpopulation of patients are likely to benefit from different treatment strategies.

Recommendations for treatment of diverticular disease

Diverticular disease is of major clinical and health economic importance in Germany. Treatment recommendations in many international guidelines have changed significantly in recent years. The German national S2k guidelines are currently being revised. To summarize the most important clinical aspects in the management of diverticular disease from asurgical perspective. The recommendations were compiled based on current national and international guidelines and aselective literature search. Acute uncomplicated diverticulitis without risk factors can be treated on an outpatient basis without antibiotics. For patients with complicated diverticulitis, hospital admission with parenteral antibiotic treatment is recommended. In the case of abscess formation >5 cm, percutaneous drainage can be performed. The indications for immediate sigmoid resection are free perforation and failure of conservative treatment. Elective resection is indicated in chronic recurrent diverticulitis with complications; all other indications are increasingly based on the individual quality of life of the patient. Uncomplicated diverticulitis is increasingly being treated on an outpatient basis and without antibiotics. Apart from emergency settings, the indications for surgery are increasingly dependent on the quality of life. Elective sigmoid resection should be performed as laparoscopic surgery with primary anastomosis after obtaining results of computed tomography and total colonoscopy.

European Society of Coloproctology: guidelines for the management of diverticular disease of the colon.

The goal of this European Society of Coloproctology (ESCP) guideline project is to give an overview of the existing evidence on the management of diverticular disease, primarily as a guidance to surgeons. The guideline was developed during several working phases including three voting rounds and one consensus meeting. The two project leads (JKS and EA) appointed by the ESCP guideline committee together with one member of the guideline committee (WB) agreed on the methodology, decided on six themes for working groups (WGs) and drafted a list of research questions. Senior WG members, mostly colorectal surgeons within the ESCP, were invited based on publication records and geographical aspects. Other specialties were included in the WGs where relevant. In addition, one trainee or PhD fellow was invited in each WG. All six WGs revised the research questions if necessary, did a literature search, created evidence tables where feasible, and drafted supporting text to each research question and statement. The text and statement proposals from each WG were arranged as one document by the first and last authors before online voting by all authors in two rounds. For the second voting ESCP national representatives were also invited. More than90% agreement was considered a consensus. The final phrasing of the statements with <90% agreement was discussed in a consensus meeting at the ESCP annual meeting in Vienna in September 2019. Thereafter, the first and the last author drafted the final text of the guideline and circulated it for final approval and for a third and final online voting of rephrased statements. This guideline contains 38 evidence based consensus statements on the management of diverticular disease. This international, multidisciplinary guideline provides an up to date summary of the current knowledge of the management of diverticular disease as a guidance for clinicians and patients.

NICE on the management of diverticular disease

NICE's guideline on the management of diverticular disease in adults (NG147) aims to improve diagnosis and care, and to help patients get timely advice about symptoms and when to seek help. This article provides an overview of the guidance.

Diet in colonic diverticulosis: is it useful?

Diverticulosis of the colon is the most common anatomic alteration of the human colon. Diet may be important in the management of diverticular disease (DD). It is known that high‑fiber diet does not prevent diverticulosis, and there are conflicting data on the prevention and treatment of DD and acute diverticulitis. No association has been reported between nut, corn, or popcorn consumption and the development of diverticulosis, DD, and acute diverticulitis. However, there seems to be a mild association between high alcohol intake and diverticulosis, whereas alcohol dependence seems to be related to a lower risk of in‑hospital mortality due to acute diverticulitis. Higher consumption of red meat was associated with a mild increase in the risk of acute diverticulitis, especially when consumed as unprocessed red meat (defined as consumption of "beef or lamb as main dish," "pork as main dish," "hamburger," and "beef, pork or lamb as a sandwich or mixed dish"). On the other hand, higher consumption of poultry (white meat) was not associated with the risk of acute diverticulitis. Finally, higher fish intake was associated with a reduced risk of diverticulitis in an age‑adjusted model but not after adjustment for other potential confounders.

Expert Commentary on Complicated Diverticulitis.

Complicated diverticulitis encompasses a variety of clinical scenariors as outlined in the well-written and succinct review by Drs Mendez and Garcia-Henriquez. These range from acute presentations, such as abscesses and free perforations with peritonitis, to more chronic, insidious sequelae such as fistulas and strictures.The contemporary surgical management of diverticular disease has evolved considerably with better appreciation of the pathophysiology and natural history. Just as in uncomplicated diverticulitis, there has been a significant shift toward a less aggressive surgical strategy in complicated diverticulitis, aided further with improved diagnostic and interventional radiology.I would like to add a few salient points for each listed complication.

Diverticular disease management in primary care: How do estimates from community-dispensed antibiotics inform provision of care?

BackgroundThe literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed.AimTo estimate how often DDI is managed in primary care, using antibiotics dispensing data.Design and settingHospitalisation records of New Zealand residents aged 30+ years during 2007–2016 were individually linked to databases of community-dispensed oral antibiotics.MethodPatients with an index hospital admission 2007–2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007–2016 for these people with ten individually-matched non-DDI residents, taking the case’s index date. Multivariable negative binomial models were used to estimate rates of antibiotic use.ResultsFrom almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation.ConclusionDDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.

Modern management of diverticular disease in men

The presentation of diverticular disease and its complications are varied: it is common and most people with diverticulosis are asymptomatic. In this article the authors review the burden of diverticular disease and its causes, and present two clinical cases of complicated diverticulitis with a urology theme.

A Worldwide Perspective on Diagnosis and Management of Diverticular Disease: Understanding Similarities and Differences

The epidemiology of diverticular disease (DD) is changing, with an increasing prevalence in younger patients from Europe and the USA, and changing disease patterns also seen in Asian populations. This epidemiological shift has substantial implications for disease management policy and healthcare costs. Most (75–80%) patients with diverticulosis never develop symptoms. Around 5% develop acute diverticulitis or other complications, while 10–15% develop symptomatic uncomplicated DD (SUDD) with symptoms resembling irritable bowel syndrome (IBS). However, most available guidelines highlight the importance of diverticulitis, with less emphasis on and often limited discussion about SUDD and its management. Recent data suggest an important relationship between gut microbiota and DD, including SUDD. In healthy individuals, the gut microbiota exists in harmony (eubiosis); in individuals with disease, quantitative and qualitative changes in microbial diversity (dysbiosis) may adversely influence colonic metabolism and homeostasis. Addressing this imbalance and restoring a healthier microbiota via eubiotic or probiotic therapy may be of value. In SUDD, clinical benefit has been seen with the use of rifaximin, which acts by multiple mechanisms: direct antibiotic activity, a modulatory eubiotic effect with an increase in muco-protective Lactobacillus and Bifidobacterium organisms, and anti-inflammatory effects, among others. Clinical studies have demonstrated symptom improvement and reduction in complications in patients with SUDD, with a favourable safety and tolerability profile and no evidence of microbial resistance. Evidence for other agents in DD is less robust. Mesalamine is not effective at preventing recurrence of acute diverticulitis, although it may provide some symptom improvement. At present, there is insufficient evidence to recommend the use of probiotics in SUDD symptom management.

An Atypical Case of Transverse Diverticulitis and the Changing Management of Diverticular Disease

Diverticulitis is an inflammation of an out pouching of the lower gastrointestinal tract, particularly in the large intestine. Although the condition is taught to medical students as typically occurring in the left lower quadrant of the abdomen, right-sided and transverse forms diverticulitis can occur. Uncomplicated, e.g., non-perforated, diverticulitis is usually treated with antibiotics. Complicated, e.g. perforated, is usually treated with surgery. The purpose of this case report is to present an atypical case of perforated diverticulitis and review current recommendations for this condition. This was a case of transverse diverticulitis in a man in his late 40’s who recovered with non-operative treatment. The widespread use of computerized tomography (CT) scans makes diagnosing diverticular disease relatively simple, but treatment is evolving. The case summarized here shows that less invasive measures can be used in treating both complicated and uncomplicated diverticular disease. After an uncomplicated in-patient admission for intravenous antibiotics, the patient was discharged in stable condition with a prescription for oral antibiotics and clinic follow-up. Classic medical school teaching concerning treatments for complicated and uncomplicated forms of diverticulitis have been updated but require further research testing.

Overview on the management of diverticular disease by Italian General Practitioners

BackgroundAlthough very common in Western countries, poor epidemiological data on diverticular disease (DD) is available from the family practice. AimsTo evaluate the behavior of Italian General Practitioners (GPs) on approaching DD. MethodsHealth Search Database was analyzed retrospectively. ResultsOn a population of 975,523 individuals, 33,597 patients had a registered diagnosis of DD (“lifetime” prevalence = 3.4%, M = 3.2%, F = 3.7%; higher values are found in females over-65 years old; low rates of complications: diverticulitis = 0.3%, bleeding = 0.002%). As risk factors, NSAIDs and ASA were taken by 14.8% and 26.5% respectively, opioids by 7.5%, corticosteroids by 5.2%; as protective factors, 30.4% were under statins and 17.7% under calcium-antagonists. Approximately 13% of patients were referred to specialists. Colonoscopy and abdominal CT were prescribed to 48.5% and to 13% of already diagnosed patients. Among DD sufferers, 27% experienced hospitalization, but only 3.4% of cases were for a DD-linked problem. Treatment included rifaximin (61%), mesalazine (14.7%), probiotics (12.4%), ciprofloxacin (7.6%). ConclusionDD has a large impact in general practice with a higher prevalence in the elderly. GPs are required to pay particular attention to risk factors both for disease development and for its complications in order to reduce the costs deriving from diagnostic procedures, referral and hospitalization.

Demographic and clinical features distinguish subgroups of diverticular disease patients: Results from an Italian nationwide registry.

Clinical features and lifestyle factors associated with diverticulosis compared to diverticular disease (DD), either symptomatic uncomplicated diverticular disease (SUDD) or in patients who have had previous diverticulitis (PD), are unclear. The objective of this article is to compare cross-sectionally demographic and clinical features and quality of life (QoL) in diverticulosis, SUDD and PD patients. The REMAD Registry is a prospective, observational, multicentre, cohort study. Patients were categorised according to: diverticulosis; SUDD (recurrent abdominal symptoms attributed to diverticula in absence of overt inflammation) and PD (≥1 previous diverticulitis). A total of 1217 patients (57.9% diverticulosis, 24.7% SUDD and 17.4% PD) were included. Compared to diverticulosis, female gender was associated to SUDD (OR 1.94; 95% CI: 1.43-2.62) and PD (OR 1.79; 95% CI: 1.24-2.56); age ≤ 60 years was associated to PD (OR 2.10; 95% CI: 1.42-3.08 vs diverticulosis, OR 1.57; 95% CI: 1.01-2.45 vs SUDD). PD patients showed an association with past bleeding (OR 29.29; 95% CI: 8.17-104.98 vs diverticulosis, OR 16.84; 95% CI: 3.77-75.25 vs SUDD). Compared to diverticulosis, family history for diverticula was associated to PD (OR 1.88; 95% CI: 1.27-2.78). Patients with diverticulosis showed higher QoL scores, both physical (p = 0.0001 and 0.0257) and mental (p < 0.0001 and 0.0038), in comparison to SUDD and PD. Family history for diverticula and history of bleeding distinguish diverticulosis from DD. These clinical features should be kept in mind in the management of DD.

Management of Diverticular Disease in the Setting of Other Colorectal Pathology: Data on Simultaneous Issues in Segmental Colitis, Inflammatory Bowel Disease, Cancer, and Complications

Diverticulosis of the colon is a very common anatomical condition. In the Western world, it affects more than 70% of over 65 years old population and represents the fifth most important gastrointestinal disease in terms of health care costs in Western countries. The diagnosis of diverticular disease and diverticulitis can be challenging. Often, there is overlap with other colonic pathologies, such as segmental colitis, ischemia, inflammatory bowel disease, cancer, or infectious colitis. Management of diverticular disease in these settings might be different.

Considerations and Changes in the Evaluation, Management, and Outcomes in the Management of Diverticular Disease: The Diagnosis, Pathology, and Treatment of Diverticular Colitis.

Diverticular colitis, also known as segmental colitis associated with diverticulosis, is a colonic inflammatory disorder on the spectrum of inflammatory bowel disease (IBD). The disease consists of macroscopic and microscopic inflammation affecting inter-diverticular mucosa, sparing peri-diverticular mucosa, with inflammation confined to the descending and sigmoid colon. The disease likely arises from the altered immune response of an individual, genetically susceptible to the IBD spectrum of diseases. Patients with segmental colitis associated with diverticulosis (SCAD) are typically older, and likely represent a subgroup of IBD-susceptible patients who lacked an environmental trigger until that point in their life. Most patients remain in remission with initial treatments of mesalamine or topical steroids, and maintenance mesalamine afterwards. Only the most severe form of the disease necessitates immunomodulatory therapy and the consideration of surgery.

Current Options for the Emergency Management of Diverticular Disease and Options to Reduce the Need for Colostomy

This article reviews the current options and recommendations for the emergency management of acute diverticulitis, including the spectrum of antibiotics, percutaneous drainage, laparoscopic lavage, and surgical options for resection with the restoration of bowel continuity.

Surgical Management of Diverticular Disease in the Elective Setting.

Diverticulosis is a common condition that has increased in prevalence in industrialized countries over the past century. Estimates of developing diverticular disease in the United states range from 5% by 40 years of age up, to over 80% by age 80. It is estimated that approximately 20% of patients with diverticulosis develop diverticulitis over the course of their lifetime. Diverticular disease can be divided into simple and chronic diverticulitis with various sub categories. There are various instances and circumstances where elective resection is indicated for both complex and simple forms of this disease process. When planning surgery there are general preoperative considerations that are important to be reviewed prior to surgery. There are also more specific considerations depending on secondary problem attributed to diverticulitis, that is, fistula vs stricture. Today, treatment for elective resection includes open, laparoscopic and robotic surgery. Over the last several years we have moved away from open surgery to laparoscopic surgery for elective resection. With the advent of robotic surgery and introduction of 3D laparoscopic surgery the discussion of superiority, equivalence between these modalities, is and should remain an important discussion topic.

Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease.

The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.

Medical Management of Diverticular Disease.

This article reviews the current literature supporting the non-surgical options for treatment in acute uncomplicated diverticulitis, complicated diverticulitis, and options for prevention of recurrent diverticulitis.