Paradigm shift: the Copernican revolution in diverticular disease

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Abstract

Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a “curative” endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of “Copernican revolution” in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.

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Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis.

Rebecca M. Lovell, Alexander Ford (2012)

Many cross-sectional surveys have reported the prevalence of irritable bowel syndrome (IBS), but there have been no recent systematic review of data from all studies to determine its global prevalence and risk factors. MEDLINE, EMBASE, and EMBASE Classic were searched (until October 2011) to identify population-based studies that reported the prevalence of IBS in adults (≥15 years old); IBS was defined by using specific symptom-based criteria or questionnaires. The prevalence of IBS was extracted for all studies and based on the criteria used to define it. Pooled prevalence, according to study location and certain other characteristics, odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Of the 390 citations evaluated, 81 reported the prevalence of IBS in 80 separate study populations containing 260,960 subjects. Pooled prevalence in all studies was 11.2% (95% CI, 9.8%-12.8%). The prevalence varied according to country (from 1.1% to 45.0%) and criteria used to define IBS. The greatest prevalence values were calculated when ≥3 Manning criteria were used (14%; 95% CI, 10.0%-17.0%); by using the Rome I and Rome II criteria, prevalence values were 8.8% (95% CI, 6.8%-11.2%) and 9.4% (95% CI, 7.8%-11.1%), respectively. The prevalence was higher for women than men (OR, 1.67; 95% CI, 1.53-1.82) and lower for individuals older than 50 years, compared with those younger than 50 (OR, 0.75; 95% CI, 0.62-0.92). There was no effect of socioeconomic status, but only 4 studies reported these data. The prevalence of IBS varies among countries, as well as criteria used to define its presence. Women are at slightly higher risk for IBS than men. The effects of socioeconomic status have not been well described. Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.

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Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage.

Klaus M E Jensen, R Jutabha, Gustavo A Machicado … (2000)

Although endoscopy is often used to diagnose and treat acute upper gastrointestinal bleeding, its role in the management of diverticulosis and lower gastrointestinal bleeding is uncertain. We studied the role of urgent colonoscopy in the diagnosis and treatment of 121 patients with severe hematochezia and diverticulosis. All patients were hospitalized, received blood transfusions as needed, and received a purge to rid the colon of clots, stool, and blood. Colonoscopy was performed within 6 to 12 hours after hospitalization or the diagnosis of hematochezia. Among the first 73 patients, those with continued diverticular bleeding underwent hemicolectomy. For the subsequent 48 patients, those requiring treatment received therapy, such as epinephrine injections or bipolar coagulation, through the colonoscope. Of the first 73 patients, 17 (23 percent) had definite signs of diverticular hemorrhage (active bleeding in 6, nonbleeding visible vessels in 4, and adherent clots in 7). Nine of the 17 had additional bleeding after colonoscopy, and 6 of these required hemicolectomy. Of the subsequent 48 patients, 10 (21 percent) had definite signs of diverticular hemorrhage (active bleeding in 5, nonbleeding visible vessels in 2, and adherent clots in 3). An additional 14 patients in this group (29 percent) were presumed to have diverticular bleeding because although they had no stigmata of diverticular hemorrhage, no other source of bleeding was identified. The other 24 patients (50 percent) had other identified sources of bleeding. All 10 patients with definite diverticular hemorrhage were treated endoscopically; none had recurrent bleeding or required surgery. Among patients with severe hematochezia and diverticulosis, at least one fifth have definite diverticular hemorrhage. Colonoscopic treatment of such patients with epinephrine injections, bipolar coagulation, or both may prevent recurrent bleeding and decrease the need for surgery.

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Treatment of perforated diverticular disease of the colon.

K. P. Schaal, J Hinchey, William Richards (1977)

Diverticular disease of the colon now is recognized to be functional disease resulting from altered neuromuscular activity in the colon. Inflammatory complications, when they occur, usually result from inflammation around a single diverticulum. This may lead to the formation of a pericolic or pelvic abscess. Free perforation of these leads to purulent peritonitis. The original communication with the lumen of the bowel usually is obliterated. More rarely, with either rapid evolution or failure of the diverticular neck to obliterate, a free communication develops between the bowel lumen and the peritoneal cavity, leading to fecal peritonitis. Fecal peritonitis results in an extremely high mortality rate. The operative approach for a patient with perforated diverticular disease should be individualized and depends on the stage of the disease present, the general condition of the patient, the experience of the surgeon in colon surgery and the availability of facilities and personnel to provide intensive care. In larger institutions when these conditions are optimal, primary resection of the diseased bowel with or without anastomosis is becoming the procedure of choice. In smaller institutions or if conditions are not optimal, right transverse colostomy with drainage of the perforated segment can be relied on to control the disease with a mortality rate compared to that of primary resection. If free perforation and fecal peritonitis are present, exteriorization or primary resection of the perforated segment must be carried out. We would not recommend primary anastomosis under these circumstances.

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Author and article information

Journal

Journal ID (nlm-ta): Ann Gastroenterol

Journal ID (iso-abbrev): Ann Gastroenterol

Title: Annals of Gastroenterology

Publisher: Hellenic Society of Gastroenterology (Greece )

ISSN (Print): 1108-7471

ISSN (Electronic): 1792-7463

Publication date (Print): Nov-Dec 2019

Publication date (Electronic): 02 August 2019

Volume: 32

Issue: 6

Pages: 541-553

Affiliations

[a ]Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo)

[b ]Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore (Luigi Gatta)

[c ]Gastroenterology and Digestive Endoscopy; “Buccheri la Ferla, Fatebenefratelli”, Hospital, Palermo (Roberto Vassallo)

[d ]Section of Gastroenterology, Department of Medical Sciences, University of Foggia (Vincenzo De Francesco)

[e ]Gastroenterology and Digestive Endoscopy, “Generale” Hospital, Perugia (Raffaele Manta)

[f ]Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste (Fabio Monica)

[g ]Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy

Author notes

Correspondence to: Dr. Angelo Zullo, Gastroenterologia ed Endoscopia Digestiva, Ospedale Nuovo Regina Margherita, Via Emilio Morosini, 00153 Rome, Italy, e-mail: angelozullo66@ 123456yahoo.it

Article

Publisher ID: AnnGastroenterol-32-541

DOI: 10.20524/aog.2019.0410

PMC ID: 6826076

PubMed ID: 31700230

SO-VID: 3a05aaf3-e359-4dcf-8f2f-96bdbef0a824

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Paradigm shift: the Copernican revolution in diverticular disease

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Hematology and Oncology Discovery

Most cited references 131

Global prevalence of and risk factors for irritable bowel syndrome: a meta-analysis.

Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage.

Treatment of perforated diverticular disease of the colon.

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