Symptomatic Diverticular Disease Research Articles

Segmental Colectomy in Ulcerative Colitis.

Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity. To identify ulcerative colitis patients who underwent segmental colectomy and assess their postoperative and long-term outcomes. Retrospective case series. A tertiary-care inflammatory bowel disease center. Ulcerative colitis patients who underwent surgery between 1995 and 2022. Segmental colectomy. Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates and stoma at follow-up. Fifty-five patients were included [20 (36.4%) female; 67.8 (57.4-77.1) years of age at surgery; body mass index 27.7 (24.2-31.1) kg/m2; median follow-up 37.3 months]. ASA score was III in 32 (58.2%) patients, 48 (87.3%) had at least one comorbidity, 48 (87.3%) had Mayo endoscopic subscore of 0-1. Patients underwent right hemicolectomy (28, 50.9%), sigmoidectomy (17, 30.9%), left hemicolectomy (6, 10.9%), low anterior resection (2, 3.6%), or a non-anatomic resection (2, 3.6%) for; endoscopically unresectable polyps (21, 38.2%), colorectal cancer (15, 27.3%), symptomatic diverticular disease (13, 23.6%), and stricture (6, 10.9%). Postoperative complications occurred in 16 (29.1%) patients [7 (12.7%) Clavien-Dindo Class III-V]. Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. 4 (7.3%) patients underwent subsequent completion proctocolectomy with ileostomy. Six (10.9%) patients had stoma at the follow-up. Two and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively. Retrospective study, small sample size. Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications for colectomy. See Video Abstract.

Comprehensive Study of Diverticulitis: A Literature Review

Abstract: Diverticulitis is a symptomatic diverticular disease characterized by inflammation of the diverticulum. Until now, the pathophysiology of diverticulitis is not known with certainty. Interactions between factors such as genetic factors, colonic structure and motility, colonic microbiota, age, and diet are thought to play a role in the occurrence of the disease. Diverticulitis should be considered as a differential diagnosis of acute abdominal pain specifically in the lower left part of the abdomen. Diagnostic criteria in cases of diverticulitis are the presence of inflamed diverticula, intestinal wall thickening exceeding 3 or 5 mm, and increased contrast absorbing medium on CT Scan and MRI examinations. Any perforation, obstruction, fistulization, and abscess detected on any imaging examination can be a sign of complicating diverticulitis. The prognosis in patients with diverticulitis depends on age, the presence of comorbidities, and the severity of the disease.
 Keywords: Diverticulitis; Diverticular Disease; Acute Lower Left Abdominal Pain; Diverticulum

Diverticular Disease Worsening Is Associated with Increased Oxidative Stress and Gut Permeability: New Insights by Circulating Biomarkers.

Diverticular disease (DD) management is impaired by its pathogenesis, which is still not completely defined, with an unmet clinical need for improved therapies. Ex vivo DD human models demonstrated the presence of a transmural oxidative imbalance that supports an ischemic pathogenesis. This study aimed to assess, with the use of circulating biomarkers, insights into DD pathogenesis and possible therapeutic targets. Nox2-derived peptide, H2O2, antioxidant capacity, isoprostanes, thromboxanes, TNF-α, LPS and zonulin were evaluated by ELISA in healthy subjects (HS) and asymptomatic and symptomatic DD patients. Compared to HS, DD patients presented low antioxidant capacity and increase in sNox2-dp, H2O2 and isoprostanes paralleled to a TNFα increase, lower than that of oxidative markers. TxB2 production correlated to Nox2 and isoprostanes, suggesting platelet activation. An increase in zonulin and LPS highlighted the role of gut permeability and LPS translocation in DD pathogenesis. The increase of all the markers statistically correlated with DD severity. The present study confirmed the presence of a main oxidative imbalance in DD and provides evidence of platelet activation driven by LPS translocation. The use of circulating biomarkers could represent a new clinical tool for monitoring disease progression and validate therapeutic strategies never tested in DD as antioxidant supplementation.

Do Colonic Mucosal Tumor Necrosis Factor Alpha Levels Play a Role in Diverticular Disease? A Systematic Review and Meta-Analysis.

Diverticular disease (DD) is the most frequent condition in the Western world that affects the colon. Although chronic mild inflammatory processes have recently been proposed as a central factor in DD, limited information is currently available regarding the role of inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-α). Therefore, we conducted a systematic review and meta-analysis aiming to assess the mucosal TNF-α levels in DD. We conducted a systematic literature search using PubMed, Embase, and Scopus to identify observational studies assessing the TNF-α levels in DD. Full-text articles that satisfied our inclusion and exclusion criteria were included, and a quality assessment was performed using the Newcastle-Ottawa Scale (NOS). The principal summary outcome was the mean difference (MD). The results were reported as MD (95% confidence interval (CI)). A total of 12 articles involving 883 subjects were included in the qualitative synthesis, out of which 6 studies were included in our quantitative synthesis. We did not observe statistical significance related to the mucosal TNF-α levels in symptomatic uncomplicated diverticular disease (SUDD) vs. the controls (0.517 (95% CI -1.148-2.182)), and symptomatic vs. asymptomatic DD patients (0.657 (95% CI -0.883-2.196)). However, the TNF-α levels were found to be significantly increased in DD compared to irritable bowel disease (IBS) patients (27.368 (95% CI 23.744-30.992)), and segmental colitis associated with diverticulosis (SCAD) vs. IBS patients (25.303 (95% CI 19.823-30.784)). Between SUDD and the controls, as well as symptomatic and asymptomatic DD, there were no significant differences in the mucosal TNF-α levels. However, the TNF-α levels were considerably higher in DD and SCAD patients than IBS patients. Our findings suggest that TNF-α may play a key role in the pathogenesis of DD in specific subgroups and could potentially be a target for future therapies.

The role of microbiota and its modulation in colonic diverticular disease.

Diverticular disease (DD) is a common condition in Western countries. The role of microbiota in the pathogenesis of DD and its related symptoms has been frequently postulated since most complications of this disease are bacteria-driven and most therapies rely on microbiota modulation. Preliminary data showed fecal microbial imbalance in patients with DD, particularly when symptomatic, with an increase of pro-inflammatory and potentially pathogenetic bacteria. In addition, bacterial metabolic markers can mirror specific pathways of the disease and may be even used for monitoring treatment effects. All treatments currently suggested for DD can affect microbiota structure and metabolome compositions. Sparse evidence is available linking gut microbiota perturbations, diverticular disease pathophysiology, and symptom development. We aimed to summarize the available knowledge on gut microbiota evaluation in diverticular disease, with a focus on symptomatic uncomplicated DD, and the relative treatment strategies.

Health-Related Quality of Life and Stress-Related Disorders in Patients with Complicated Diverticular Disease under Conservative Management.

Diverticular disease is a common gastrointestinal disorder with increasing prevalence in advanced age. This study aimed to investigate the impact of age and complexity of diverticulitis on health-related quality of life (HRQoL) and stress-related disorders. A cross-sectional study was conducted on 180 patients, including adults (18-64 years) with complicated diverticular disease, the elderly (≥65 years) with complicated diverticular disease, and a control group with uncomplicated symptomatic diverticular disease. HRQoL and stress-related disorders were assessed using the SF-36, GIQLI, HADS, and PHQ-9 questionnaires at baseline and six months after the initial episode of diverticulitis. At diagnosis, the adult group had significantly lower mean physical and mental scores compared with the elderly and control groups (p < 0.001). At the 6-month follow-up, the mean physical score increased for all groups, but the difference between adults and the elderly remained significant (p = 0.028). The adult group had a significantly lower mean GIQLI score at diagnosis compared with the elderly and control groups (p < 0.001), although after 6 months it increased and the difference became insignificant. Anxiety scores at diagnosis were significantly higher in the adult group compared with the control group (p = 0.009). The complexity of diverticulitis and age significantly impacted HRQoL at diagnosis, with adults having lower physical and mental scores compared with elderly patients and controls. Although improvements were observed after 6 months, the difference between adults and the elderly remained significant for physical HRQoL scores. This highlights the need for tailored management strategies and psychosocial support to optimize patient outcomes across age groups and diverticulitis complexity.

Diverticular Disease and Rifaximin: An Evidence-Based Review

There have been considerable advances in the treatment of diverticular disease in recent years. Antibiotics are frequently used to treat symptoms and prevent complications. Rifaximin, a non-absorbable antibiotic, is a common therapeutic choice for symptomatic diverticular disease in various countries, including Italy. Because of its low systemic absorption and high concentration in stools, it is an excellent medicine for targeting the gastrointestinal tract, where it has a beneficial effect in addition to its antibacterial properties. Current evidence shows that cyclical rifaximin usage in conjunction with a high-fiber diet is safe and effective for treating symptomatic uncomplicated diverticular disease, while the cost-effectiveness of long-term treatment is unknown. The use of rifaximin to prevent recurrent diverticulitis is promising, but further studies are needed to confirm its therapeutic benefit. Unfortunately, there is no available evidence on the efficacy of rifaximin treatment for acute uncomplicated diverticulitis.

Recurrent diverticulitis after elective surgery.

Elective sigmoid resection is proposed as a treatment for symptomatic diverticular disease for the possible improvement in quality of life achievable. Albeit encouraging results have been reported, recurrent diverticulitis is still a concern deeply affecting quality of life. The aim of this study is to determine the rate of recurrent diverticulitis after elective sigmoid resection and to look for possible perioperative risk factors. Patients who underwent elective resection for DD with at least a 3-year follow-up were included. Postoperative recurrence was defined as left-sided or lower abdominal pain, with CT scan-confirmed findings of diverticulitis. Twenty of 232 (8.6%) patients developed CT-proven recurrent diverticulitis after elective surgery. All the 20 recurrent diverticulitis were uncomplicated and did not need surgery. Eighty-five percent of the recurrences occurred in patients with a preoperative diagnosis of uncomplicated DD, 70% in patients who had at least 4 episodes of diverticulitis, and 70% in patients with a history of diverticulitis extended to the descending colon. Univariate analysis showed that recurrence was associated with diverticulitis of the sigmoid and of the descending colon (p = 0.04), with a preoperative diagnosis of IBS (p = 0.04) and with a longer than 5years diverticular disease (p = 0.03). Multivariate analysis was not able to determine risks factors for recurrence. Our study showed that patients with a preoperative diagnosis of IBS, diverticulitis involving the descending colon, and a long-lasting disease are more likely to have recurrent diverticulitis. However, these variables could not be assumed as risk factors.

Diagnosis and Treatment of Colonic Diverticular Disease

Colonic diverticulosis is one of the most common conditions of the digestive system and patients generally remain asymptomatic. However, about 20% of patients develop symptomatic diverticular disease such as acute diverticulitis or diverticular hemorrhage, and these have become a huge burden on healthcare systems worldwide. Recent understanding of the pathophysiology of diverticulosis and diverticular disease suggests the role of multiple factors including genetic and environment. Based on this understanding, a preventive strategy to reduce the risk factors of diverticulosis and diverticular disease is highly recommended. The diagnosis of the acute diverticulitis relies on imaging modalities such as an abdominal-pelvic CT scan together with symptoms and signs. Treatment of diverticular disease should be individualized and include modification of lifestyle, use of antibiotics, and surgery. Recent guidelines recommend pursuing less aggressive treatment for patients with acute diverticulitis. This review will provide an overview of both the existing and evolving understanding regarding colonic diverticulosis and diverticular disease and can help clinicians in the management of their patients with diverticular disease.

Potential risks and treatment options for colonic diverticular disease Novelties based on international guidelines

The prevalence of colonic diverticulosis is growing worldwide due to dietary and lifestyle changes. Colonic diverticulosis does not cause any complaints in a significant proportion of individuals; therefore, it is usually diagnosed by accident and does not require any treatment. Diverticular disease, which constitutes about 25% of the cases, is associated with presenting symptoms, and has various forms based on the course and severity of the disease. From the early 2000s, the better understanding of the pathophysiologic pathways which play a role in the development of the diverticular disease (genetic background, low-grade chronic inflammation and intestinal dysbiosis) promoted prevention, diagnostics and finding treatment options. The main conclusions: It is a challenge to distinguish uncomplicated but symptomatic diverticular disease from irritable bowel syndrome. The prevalence of acute diverticulitis is lower than it was previously assumed. The role of diagnostic imaging, mainly abdominal computer tomography, has become more important to aid the rapid and correct diagnosis of acute diverticulitis and to determine its severity. Although a high-fiber diet may be recommended for general health purposes, there is little evidence that it benefits recovery during acute diverticulitis episodes or prevents recurrent episodes. Traditional antibiotic therapy as the mainstay of treatment of acute uncomplicated diverticulitis such as routine hospital admission has been challenged recently. In an acute episode of diverticulitis, performing colonoscopy should be avoided as it is associated with an increased risk of colonic perforation. If there was no screening colonoscopy within 3 years, it is strongly recommended at least 6 weeks after the acute episode to exclude colorectal carcinoma. Routine colonoscopy may be omitted in certain cases. Complicated acute diverticulitis should not necessarily be treated by emergency surgery. In thecase of hemodynamically stable and immunocompetent patients, resection with primary anastomosis may be preferred over a Hartmann's procedure for the treatment of perforated diverticulitis and diffuse peritonitis. With this review, the authors intend to facilitate providing up-to-date and customized treatment of diverticular disease in the daily practice.

Preserving Inferior Mesenteric Artery during Elective Laparoscopic Sigmoidectomy for Diverticulitis

Background: To evaluate results after Laparoscopic Sigmoid Resection (LSR) with Inferior Mesenteric Artery Preservartion (IMAP) and Superior Rectal Artery Preservation (SRAP), regarding the incidence of anastomotic leakages, denervation of the hypogastric nerves with consequent genitourinary and defecation alterations. Methods: A retrospective PUBMED research from January 2000 to January 2020 was conducted enrollying studies about patients with symptomatic diverticular disease and a surgical indication. Results: A total of 1685 patients with IMAP and SRAP were included in the study. Conclusion: This retrospective review showed that patietns with IMAP-SRAP demonstrated lower leakage rate with reduced incidence of stoma, lower incidence of defecation disorders and a good Quality of Life (QoL) compared with laparoscopic left colectomy with no IMAP.

Diverticula of the colon: Review of related entities

Diverticulosis, Diverticular Disease, and Diverticulitis, comprising different entities, pose increasing burdens for health care systems. The introduction of new scientific knowledge into daily clinical work is challenging for attending physicians. This review is related to case presentations and currently debated questions are discussed such as definitions: Which entities are meant by the term "Diverticular Disease", is "uncomplicated symptomatic Diverticular Disease"(SUDD) reality? To classify diverticula related diseases targeted diagnosis including imaging is necessary. The question is ultrasound or computed tomography, or the combination and in which order?Lastly, open questions of treatment have to be addressed: Outpatient care or hospitalisation, always antibiotics or only in defined situations, relapse prevention, indications to operate upon?The present review comes along with revised German guidelines, which will be published later this year on S3-level.

EP.WE.802Are we over-zealous in our management of acute diverticulitis?

AimsOf the 25% of people with diverticula who develop symptomatic diverticular disease, approximately 75% will have at least one episode of diverticulitis. However according to the latest NICE guidance those with diverticulitis who are not systemically unwell may not require either admission or antibiotics. In the financially austere environment facing the NHS within the COVID 19 pandemic, prudence in such resource allocation is of vital importance. We aim to review management of patients with acute diverticulitis over a 6-month period in a district general hospital against the 2019 NICE guidelines.Methods29 patients presenting with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed. Biochemical markers, lactate and vital signs were used to assess if attending patients were systemically unwell.Results23 patients were admitted and 6 managed as outpatients via the surgical ambulatory unit. Of the 29 patient cohort, 9 (31%) were systemically unwell. All 9 unwell patients received antibiotics. Of the 20 patients not considered systemically unwell, 11 (55%) received antibiotics. 16 (80%) that were admitted did not require admission on retrospective review.ConclusionPrompt administration of intravenous antibiotics for septic patients with diverticulitis reduces associated morbidity and mortality and the observed adherence to this principle is encouraging. For systemically well patients, increased clinical discernment is required to consider managing patients in the surgical ambulatory setting, avoiding unnecessary admissions. Similar caution must be used in appropriate use of antimicrobials to avoid unnecessary adverse consequences.

Functional and Short-term Outcomes in Elective Laparoscopic Colectomy for Symptomatic Diverticular Disease With Either Low Ligation or Inferior Mesenteric Artery Preservation: A Randomized Trial.

The current treatment of symptomatic diverticular disease is left colectomy/sigmoidectomy with low ligation of the inferior mesenteric artery versus the inferior mesenteric artery preservation. Up to now, there is no strong evidence in favor of one of the 2 strategies. The aim of this study is to compare the bowel-specific quality of life and functional outcomes between these 2. Between June 2015 and February 2019, patients were randomly assigned to inferior mesenteric artery low ligation or inferior mesenteric artery preservation during elective laparoscopic sigmoidectomy for diverticular disease. Gastrointestinal, genitourinary functions and surgical outcomes were compared postoperatively between groups. One-hundred sixty-eight patients were randomized providing 2 homogenous groups. Gastrointestinal and genitourinary functions were not significantly different between groups after 1 and 6 months postoperative. In both groups, the function was restored to the preoperative level 6 months after surgery. There was no statistically significant difference in terms of conversion rate, blood loss, length of surgery, between groups. There was no difference in the overall complication rate and the anastomotic leak rate among groups. Inferior mesenteric artery low ligation or inferior mesenteric artery preservation during elective laparoscopic sigmoidectomy for a diverticular disease can be considered equivalent in affecting the postoperative bowel-related quality of life, genitourinary function, and surgical outcomes.

Enfermedad diverticular del intestino grueso

Colonic diverticulosis is a very common disease in our setting and one of the most common findings during colonoscopy. The pathogenesis of diverticular disease is multifactorial and includes genetic and environmental factors, among which the intestinal microbiota plays a prominent role. Clinical forms of the disease include asymptomatic diverticulosis, symptomatic diverticular disease without complications, acute diverticulitis and diverticular bleeding. The management of the complications of diverticulosis is continuously evolving. For acute diverticulitis, the selective, nongeneralised use of antibiotics is indicated. Prophylactic surgical resection has been relegated to more advanced stages and specific complications.

Course of the Diverticular Disease: What is changing?

In this session several critical issues in diverticular disease were considered, including "It is Symptomatic Diverticular Disease or Irritable Bowel Syndrome?", "What do determine evolution to diverticulitis, bowel habits alteration or inflammation?", and "Prevention of acute diverticulitis: Is it at all possible?". The first talking compared symptoms and laboratory findings between Symptomatic Uncomplicated Diverticular Disease (SUDD) and Irritable Bowel Syndrome (IBS). Although both disease share some symptoms, and although IBS can occur in patients having diverticulosis, SUDD and IBS can be differentiate using a combination of symptoms and laboratory tools. The second talking debated what are the most important risk factors for the evolution towards acute diverticulitis. Current data seem to exclude a significant role of bowel habits alteration, while inflammation seems to have a stronger role, especially in causing acute diverticulitis recurrence. The third talking analyzed about the acute diverticulitis prevention. Primary prevention seem to be little better when using mesalazine, while no definite conclusion can be drawn about the use of fiber and rifaximin. About the secondary prevention, no drugs can be currently advised due to lacking of definite results. At the same time, surgery should be advised on case-by-case basis.

Microbiota in the etiopathogenesis and treatment of the symptomatic diverticular disease of the large bowel

Microbiota in the etiopathogenesis and treatment of the symptomatic diverticular disease of the large bowel

Долгосрочная эффективность рифаксимина в лечении симптоматической неосложненной дивертикулярной болезни толстой кишки

Долгосрочная эффективность рифаксимина в лечении симптоматической неосложненной дивертикулярной болезни толстой кишки

Italian nationwide survey of pharmacologic treatments in diverticular disease: Results from the REMAD registry.

Although diverticular disease is a common condition, its effective treatment is challenging in clinical practice. The objective of this article is to assess pharmacological management in different clinical settings of diverticular disease and factors associated with treatment using the Italian registry Registro Malattia Diverticolare (REMAD). At study enrolment, patients were categorised into subgroups: diverticulosis, symptomatic uncomplicated diverticular disease and previous diverticulitis. We registered demographic, clinical and lifestyle factors, quality of life and the use of treatments for diverticular disease in the last year. Logistic regression analysis assessed the association between clinical factors and treatment consumption. A total of 500 of the 1206 individuals included had had at least one treatment for diverticular disease in the last year: 23.6% (166/702) of patients with diverticulosis, 55.9% (165/295) of patients with symptomatic diverticular disease, and 80.9% (169/209) of patients with previous diverticulitis (p < 0.001). In multivariate analysis, the following factors were significantly associated with treatment use: female gender, family history of colonic diverticula, organic digestive comorbidity and impaired physical quality of life components. Individuals with diverticular disease take medications based on the different clinical settings of disease. We identified different features associated with treatment use in the distinct clinical entities of diverticular disease.ClinicalTrial.gov Identifier: NCT03325829.

Cyclic rifaximin and soluble dietary fiber therapy for symptomatic diverticular disease: effective prevention of complications

The article discusses the current issues of managing patients with colonic diverticular disease. The prevalence of pathology is steadily increasing, which is due to the more frequent diagnosis of the disease and the increase in life expectancy of the population. Meanwhile, the wrong approaches to the management of this category of patients can result in the development of serious complications that often result in fatal outcomes. The paper presents data on the efficacy of rifaximin therapy of colonic diverticular disease, including using cyclic courses that significantly reduce the risk of complications. Particular attention is paid to the role of dietary fiber in the prevention of the inflammation development in the diverticular disease, including dietary fiber combined with rifaximin.