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1
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Sinclair E, Magnusson MK, Angenete E, Prytz M, Tasselius V, Öhman L, Haglind E. Laparoscopic lavage in a purulent peritonitis model: impact on inflammatory proteins. Eur J Med Res 2025; 30:180. [PMID: 40102905 PMCID: PMC11917159 DOI: 10.1186/s40001-025-02445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Accepted: 03/10/2025] [Indexed: 03/20/2025] Open
Abstract
BACKGROUND Laparoscopic lavage is an effective, safe, and feasible treatment in patients with perforated diverticulitis with purulent peritonitis. Laparoscopic lavage was introduced without any detailed knowledge regarding the mechanisms of action. The aim of this study was to validate the reproducibility of an animal model of purulent peritonitis and to study the effect of laparoscopic lavage on inflammatory proteins in this model. METHODS Forty rats, divided into eight groups (n = 5) were operated. Six groups underwent cecal ligation and puncture (CLP) causing peritonitis and two groups underwent sham surgery. Three CLP and one sham group received laparoscopic lavage, while the remaining groups acted as time-matched controls. Samples of abdominal fluid and blood were collected after 1, 2 or 3 h and analyzed regarding 92 inflammatory proteins using Olink Target 96 Mouse exploratory panel. RESULTS Animals with peritonitis had higher levels of inflammatory proteins such as CCL3, IL17A and IL6 in abdominal fluid and serum compared to sham. The groups treated with laparoscopic lavage had lower levels of inflammatory proteins in both abdominal fluid and serum compared with untreated peritonitis groups, results were most distinct sampled after one hour. CONCLUSION Our animal model is reproducible, and mimics perforated diverticulitis with purulent peritonitis with increased levels of inflammatory proteins in abdominal fluid and serum. The levels of several inflammatory proteins were lower following laparoscopic lavage treatment perhaps indicating the physiological effect of laparoscopic lavage. This model can be used to further explore the mechanisms involved in peritonitis and laparoscopic lavage treatment.
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Affiliation(s)
- Erik Sinclair
- Department of Surgery, Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Surgery, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden.
- Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden.
| | - Maria K Magnusson
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Prytz
- Department of Surgery, Region Västra Götaland, NU-Hospital Group, Trollhättan, Sweden
- Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden
| | - Viktor Tasselius
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Lena Öhman
- Department of Microbiology and Immunology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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2
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Wada M, Nishizawa T, Kato M, Hirai Y, Kinoshita S, Mori H, Nakazato Y, Fujimoto A, Kikuchi M, Uraoka T, Kanai T. Colonic diverticular bleeding and predictors of the length of hospitalization: An observational study. J Gastroenterol Hepatol 2019; 34:1351-1356. [PMID: 30636058 DOI: 10.1111/jgh.14603] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/18/2018] [Accepted: 01/07/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM A significant percentage of patients with colonic diverticular bleeding (CDB) experience bleeding that is severe enough to necessitate prolonged hospitalization. Prolonged hospitalization causes deterioration in patients' quality of life, as well as difficulties with cost-effective utilization of medical resources, and is a financial burden to the society. Therefore, we investigated the factors associated with the length of hospitalization for the optimal management of patients hospitalized with CDB. METHODS This study included patients who were hospitalized for the treatment of CDB and underwent colonoscopy between July 2008 and February 2016. Logistic regression analysis was performed to investigate the association between the length of hospitalization and the patients' baseline characteristics, in-hospital procedures performed, and the clinical outcomes. RESULTS The study included 223 patients. Diabetes mellitus (odds ratio [OR] 3.4, P = 0.014) and blood transfusion (OR 3.1, P = 0.0006) were identified as risk factors for prolonged hospitalization (≥ 8 days). Urgent colonoscopy (OR 0.41, P = 0.0072) predicted a shorter length of hospitalization (≤ 7 days). The study also indicated that endoscopic treatment showed a stronger association with urgent colonoscopy (OR 7.8, P < 0.0001) than with elective colonoscopy and that urgent colonoscopy was not associated with an increased rate of adverse events or re-bleeding. CONCLUSIONS Compared with elective colonoscopy, urgent colonoscopy shortens the length of hospitalization in patients with CDB. Moreover, it is not associated with an increased rate of adverse events. Urgent colonoscopy may be impracticable in a few cases; however, if possible, aggressive urgent colonoscopy should be considered for the efficient management of the patient's hospital stay.
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Affiliation(s)
- Michiko Wada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiro Nishizawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology and Hepatology, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshihiro Nakazato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Ai Fujimoto
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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3
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Alaburda P, Lukosiene JI, Pauza AG, Rysevaite-Kyguoliene K, Kupcinskas J, Saladzinskas Z, Tamelis A, Pauziene N. Ultrastructural changes of the human enteric nervous system and interstitial cells of Cajal in diverticular disease. Histol Histopathol 2019; 35:147-157. [PMID: 31187871 DOI: 10.14670/hh-18-136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In spite of numerous advances in understanding diverticular disease, its pathogenesis remains one of the main problems to be solved. We aimed to investigate the ultrastructural changes of the enteric nervous system in unaffected individuals, in asymptomatic patients with diverticulosis and in patients with diverticular disease. METHODS Transmission electron microscopy was used to analyse samples of the myenteric, outer submucosal and inner submucosal plexuses from patients without diverticula (n=9), asymptomatic patients with diverticulosis (n=7) and in patients with complicated diverticular disease (n=9). We described the structure of ganglia, interstitial cells of Cajal and enteric nerves, as well as their relationship with each other. The distribution and size of nerve processes were analysed quantitatively. RESULTS In complicated diverticular disease, neurons exhibited larger lipofuscin-like inclusions, their membranous organelles had larger cisterns and the nucleus showed deeper indentations. Nerve remodeling occurred in every plexus, characterised by an increased percentage of swollen and fine neurites. Interstitial cells of Cajal had looser contacts with the surrounding cells and showed cytoplasmic depletion and proliferation of the rough endoplasmic reticulum. In asymptomatic patients with diverticulosis, alterations of enteric nerves and ICC were less pronounced. CONCLUSIONS In conclusion, the present findings suggest that most ultrastructural changes of the enteric nervous system occur in complicated diverticular disease. The changes are compatible with damage to the enteric nervous system and reactive remodeling of enteric ganglia, nerves and interstitial cells of Cajal. Disrupted architecture of enteric plexuses might explain clinical and pathophysiological changes associated with diverticular disease.
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Affiliation(s)
- Paulius Alaburda
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jaune I Lukosiene
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audrys G Pauza
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Present address: Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol, United Kingdom
| | | | - Juozas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Algimantas Tamelis
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Neringa Pauziene
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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4
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Choe EK, Lee JE, Chung SJ, Yang SY, Kim YS, Shin ES, Choi SH, Bae JH. Genome-wide association study of right-sided colonic diverticulosis in a Korean population. Sci Rep 2019; 9:7360. [PMID: 31089239 PMCID: PMC6517584 DOI: 10.1038/s41598-019-43692-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 04/27/2019] [Indexed: 02/06/2023] Open
Abstract
Diverticulosis results from complex interactions related to aging, environmental factors and genetic predisposition. Despite epidemiologic evidence of genetic risk factors, there has been no attempt to identify genes that confer susceptibility to colonic diverticulosis. We performed the first genome-wide association study (GWAS) on susceptibility to diverticulosis in a Korean population. A GWAS was carried out in 7,948 healthy individuals: 893 patients and 1,075 controls comprised the test set, and 346 patients and 305 controls comprised the replication set. Diverticulosis was diagnosed by colonoscopy during comprehensive medical check-ups, and single-nucleotide polymorphisms (SNPs) related to diverticulosis were detected with the Affymetrix Axiom KORV1.1-96 Array. In all, 9 SNPs were identified in three SNP aggregates in the test set (P < 10−3, within 200 kb) after adjusting for sex. All the SNPs were replicated in the replication set (P < 0.05). Three SNPs were near the WNT4 gene, four near the RHOU gene, and two in the OAS1/3 genes. The top SNP associated with right-sided colonic diverticulosis was rs22538787, located near the WNT4 gene [combined set, P-value = 3.128 × 10−6, odds ratio = 1.415 (95% confidence interval: 1.223–1.637)]. These 9 novel SNP alleles associated with the WNT4, RHOU, and OAS1/3 genes are possibly involved in the underlying genetic susceptibility to right-sided diverticulosis. Our results provide basic knowledge about the development of diverticulosis in an Asian population.
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Affiliation(s)
- Eun Kyung Choe
- Department of Surgery, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | | | - Su Jin Chung
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | - Sun Young Yang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | - Young Sun Kim
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | | | - Seung Ho Choi
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea
| | - Jung Ho Bae
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam, Seoul, Korea.
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Wada M, Kato M, Hirai Y, Kubosawa Y, Sunata Y, Abe K, Hirata T, Takada Y, Banno S, Takatori Y, Kinoshita S, Mori H, Takabayashi K, Kikuchi M, Kikuchi M, Suzuki M, Kanai T, Uraoka T. Initial Management of Colonic Diverticular Bleeding: Observational Study. Digestion 2018; 98:41-47. [PMID: 29672291 DOI: 10.1159/000487264] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 01/26/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Although colonic diverticular bleeding (CDB) often ceases spontaneously, re-bleeding occurs in about 30%. Bleeding diverticulum can be treated directly by endoscopic hemostasis; however, it is difficult to perform colonoscopy in all cases with limited medical resource and certain risks. The aim of this study was to clarify who should undergo colonoscopy as well as appropriate methods of initial management in CDB patients. METHODS A total of 285 patients who were diagnosed as CDB and underwent colonoscopy from March 2004 to October 2015 were retrospectively analyzed. First, the association between re-bleeding and various factors including patients' background and initial management were analyzed. Second, the examination conditions that influenced bleeding point identification were analyzed. RESULTS Of 285 patients, 187 were men and 98 were women. Median age was 75 years, and the median observation period was 17.5 months. Re-bleeding was observed in 79 patients (28%). A history of CDB (OR 2.1, p = 0.0090) and chronic kidney disease (CKD; OR 2.3, p = 0.035) were risk factors, and bleeding point identification (OR 0.20, p = 0.0037) was a preventive factor for re-bleeding. Bleeding point identification significantly reduced approximately 80% of re-bleeding. Furthermore, extravasation on CT (OR 3.7, p = 0.031) and urgent colonoscopy (OR 5.3, p < 0.001) were predictors for identification of bleeding point. Compared to bleeding point identification of 11% in all patients who underwent colonoscopy, identification rate in those who had extravasation on CT and underwent urgent colonoscopy was as high as 70%. CONCLUSIONS Contrast-enhanced CT upon arrival is suggested, and patients with extravasation on CT would be good candidates for urgent colonoscopy, as well as patients who have a history of CDB and CKD.
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Affiliation(s)
- Michiko Wada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoko Kubosawa
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yukie Sunata
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Keiichiro Abe
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Tetsu Hirata
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoshiaki Takada
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Shigeo Banno
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yusaku Takatori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideki Mori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Kaoru Takabayashi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Miho Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masahiro Kikuchi
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masayuki Suzuki
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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6
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Tomizawa M, Shinozaki F, Hasegawa R, Shirai Y, Motoyoshi Y, Sugiyama T, Yamamoto S, Ishige N. Association between colon diverticula and hemoglobin, triglyceride and uric acid levels. Exp Ther Med 2015; 10:2157-2160. [PMID: 26668609 DOI: 10.3892/etm.2015.2804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 09/24/2015] [Indexed: 11/06/2022] Open
Abstract
Colon diverticula cause bleeding and acute diverticulitis. The present study analyzed laboratory test variables, aiming to predict the presence of diverticula. Patient records from between April 2011 and March 2014 were analyzed retrospectively (1,520 patients) and a one-way analysis of variance was performed to analyze the association between the presence of diverticula and each variable. A χ2 test was then used to assess the correlation between the prevalence of diverticula and the percentage of patients with uric acid (UA) levels ≥5.1 mg/dl. A receiver operating characteristic (ROC) analysis was performed to determine the threshold values required to predict the presence of diverticula. Hemoglobin (Hb) levels were lower in patients with diverticula than in those without diverticula (P=0.0027), and compared with patients without diverticula, UA and triglyceride (TG) levels were higher in patients with diverticula (P=0.0066 and P=0.0136, respectively). The patients were divided into two groups, as follows: Patients with UA levels ≥5.1 mg/dl (the median value) and those with UA levels <5.1 mg/dl. The prevalence of diverticula was significantly higher in patients with UA levels ≥5.1 mg/dl than in those with UA levels <5.1 mg/dl (P=0.0004). ROC analysis demonstrated that the threshold values of Hb, TG and UA were 12,400, 146 and 5.1 mg/dl, respectively. The sensitivity of the Hb and UA levels at the threshold values was 76.5 and 71.0%, respectively. The prevalence of diverticula was associated with low Hb levels, and high TG and UA levels.
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Affiliation(s)
- Minoru Tomizawa
- Department of Gastroenterology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Fuminobu Shinozaki
- Department of Radiology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Rumiko Hasegawa
- Department of Surgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Yoshinori Shirai
- Department of Surgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Yasufumi Motoyoshi
- Department of Neurology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Takao Sugiyama
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Shigenori Yamamoto
- Department of Pediatrics, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
| | - Naoki Ishige
- Department of Neurosurgery, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba 284-0003, Japan
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7
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Matsuura M, Inamori M, Nakajima A, Komiya Y, Inoh Y, Kawasima K, Naitoh M, Fujita Y, Eduka A, Kanazawa N, Uchiyama S, Tani R, Kawana K, Ohtani S, Nagase H. Effectiveness of therapeutic barium enema for diverticular hemorrhage. World J Gastroenterol 2015; 21:5555-5559. [PMID: 25987779 PMCID: PMC4427678 DOI: 10.3748/wjg.v21.i18.5555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/03/2014] [Accepted: 01/16/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effectiveness of barium impaction therapy for patients with colonic diverticular bleeding.
METHODS: We reviewed the clinical charts of patients in whom therapeutic barium enema was performed for the control of diverticular bleeding between August 2010 and March 2012 at Yokohama Rosai Hospital. Twenty patients were included in the review, consisting of 14 men and 6 women. The median age of the patients was 73.5 years. The duration of the follow-up period ranged from 1 to 19 mo (median: 9.8 mo). Among the 20 patients were 11 patients who required the procedure for re-bleeding during hospitalization, 6 patients who required it for re-bleeding that developed after the patient left the hospital, and 3 patients who required the procedure for the prevention of re-bleeding. Barium (concentration: 150 w%/v%) was administered per the rectum, and the leading edge of the contrast medium was followed up to the cecum by fluoroscopy. After confirmation that the ascending colon and cecum were filled with barium, the enema tube was withdrawn, and the patient’s position was changed every 20 min for 3 h.
RESULTS: Twelve patients remained free of re-bleeding during the follow-up period (range: 1-19 mo) after the therapeutic barium enema, including 9 men and 3 women with a median age of 72.0 years. Re-bleeding occurred in 8 patients including 5 men and 3 women with a median age of 68.5 years: 4 developed early re-bleeding, defined as re-bleeding that occurs within one week after the procedure, and the remaining 4 developed late re-bleeding. The DFI (disease-free interval) decreased 0.4 for 12 mo. Only one patient developed a complication from therapeutic barium enema (colonic perforation).
CONCLUSION: Therapeutic barium enema is effective for the control of diverticular hemorrhage in cases where the active bleeding site cannot be identified by colonoscopy.
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8
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Strate LL, Erichsen R, Horváth-Puhó E, Pedersen L, Baron JA, Sørensen HT. Diverticular disease is associated with increased risk of subsequent arterial and venous thromboembolic events. Clin Gastroenterol Hepatol 2014; 12:1695-701.e1. [PMID: 24316104 DOI: 10.1016/j.cgh.2013.11.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/26/2013] [Accepted: 11/12/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Diverticular disease and cardiovascular disease share several risk factors. Inflammation associated with diverticular disease could predispose to cardiovascular disease. We assessed the association between a diagnosis of diverticular disease and subsequent arterial and venous thromboembolic events, adjusting for related comorbidities to explore a possible causal relationship. METHODS We identified 77,065 incident cases of diverticular disease from 1980-2011 from Danish nationwide medical registries; these were matched for age and sex with 302,572 population comparison cohort members. Individuals with a history of cardiovascular disease were excluded. We used Cox proportional hazards regression to compute incidence rate ratios, comparing the incidence of acute myocardial infarction, stroke, venous thromboembolism, and subarachnoid hemorrhage in patients with diverticular disease with those of the population cohort members, adjusting for age, sex, obesity, diabetes, hyperlipidemia, chronic obstructive pulmonary disease, connective tissue disease, renal disease, and treatments and medications. RESULTS The adjusted incidence rate ratios for patients with diverticular disease, compared with population cohort members, were 1.11 (95% confidence interval [CI], 1.07-1.14) for acute myocardial infarction, 1.11 (95% CI, 1.08-1.15) for overall stroke, 1.36 (95% CI, 1.30-1.43) for overall venous thromboembolism, and 1.27 (95% CI, 1.09-1.48) for subarachnoid hemorrhage. The relative risk of each event remained increased after we adjusted for changes in aspirin use or for endoscopy or colorectal surgery after the diagnosis of diverticular disease. These findings also held after excluding the first year of follow-up and limiting the analysis to patients with diverticulitis. CONCLUSIONS On the basis of an analysis of Danish medical registries, a diagnosis of diverticular disease is associated with a modest increase in risk of arterial and venous thromboembolic events after adjustment for related disorders.
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Affiliation(s)
- Lisa L Strate
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - John A Baron
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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9
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The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875-85. [PMID: 24703084 DOI: 10.1016/j.gie.2013.10.039] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023]
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Abstract
Diverticular disease is prevalent in Western countries and yet its pathogenesis remains poorly understood. The common theories of the cause of diverticular disease have focused on colonic motility, the structural aspects of the colonic wall, and the role of dietary factors, particularly fiber.
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Affiliation(s)
- Kristina G Hobson
- Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA 01805, USA
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11
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Abstract
Colonic diverticulosis is a common, usually asymptomatic, entity of Western countries, with an incidence that increases with age. When these diverticula become infected and inflamed, patients can present with a wide variety of clinical manifestations. Management of acute, uncomplicated diverticulitis can often be treated successfully with antibiotics alone and the decision to proceed with more aggressive measures such as surgical intervention is made on a case-by-case basis. The treatment algorithm for diverticular disease continues to evolve as the pathophysiology, etiology, and natural history of the disease becomes better understood.
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Affiliation(s)
- John G Touzios
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 66905, USA
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12
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Abstract
Diverticula of the large intestine constitute a common source of lower gastrointestinal (GI) bleeding both occult and massive and are a particular common cause of right-sided colonic hemorrhage. Bleeding in all cases is due to rupture of the underlying vasa rectum. In all cases, rupture of the artery is not circumferential, but eccentric having occurred toward the lumen of the diverticula. It is rare to see either acute or chronic diverticulitis associated with this situation. Lower GI bleeding is frequent in the elderly secondary to diverticular disease and occurs in about 10% to 30% GI bleeds and actually is much less frequent than upper GI bleeding. Diverticular disease actually is uncommon in people under the age of 40. However, by the age of 50 almost one-third of the population has diverticulosis. Ninety percent of the diverticula are in the left colon, but bleeding is from the right colon at least 50% of the time. Diverticular hemorrhage will cease spontaneously in about 90% cases. Most often, there is no inflammatory process around the diverticular bleeding. Hypertension even may be a predisposing factor. Also anticoagulation, diabetes mellitus, and ischemic heart disease are associated with diverticular hemorrhage. As far as treatment is concerned, conservative therapy is usually the best approach. One would like to avoid angiography and surgery if at all possible. There is a significant recurrence of bleeding in those patients who are treated even with angiography and with surgery. Etiology of the bleeding is not really well understood and the diagnosis and treatment is quite difficult in some situations.
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13
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Colon, Rectum, and Anus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Funaki B. Microcatheter embolization of lower gastrointestinal hemorrhage: an old idea whose time has come. Cardiovasc Intervent Radiol 2004; 27:591-9. [PMID: 15578134 DOI: 10.1007/s00270-004-0243-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early attempts of using embolization for lower gastrointestinal hemorrhage were fraught with complications, most notably ischemic colitis or bowel infarction. Embolotherapy was eventually abandoned in favor of catheter-directed vasoconstriction (i.e., vasopressin infusion). This latter therapy is time and labor intensive. With the advent of microcatheter technology, superselective embolization emerged and is rapidly becoming the endovascular therapy of choice for patients with severe lower gastrointestinal hemorrhage refractory to medical management. Numerous studies on the subject have consistently reported high clinical success with low ischemic complications. This article will review the current status of co-axial microcatheter embolization with an emphasis on the technical aspects of the procedure.
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Affiliation(s)
- Brian Funaki
- Section of Vascular and Interventional Radiology and Section of Abdominal Imaging, University of Chicago Hospitals, 5840 S. Maryland Ave MC 2026, Chicago, IL 60637, USA.
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Simpson PW, Nguyen MH, Lim JK, Soetikno RM. Use of endoclips in the treatment of massive colonic diverticular bleeding. Gastrointest Endosc 2004; 59:433-7. [PMID: 14997150 DOI: 10.1016/s0016-5107(03)02711-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Peter W Simpson
- Endoscopy Unit, Veterans Affairs Palo Alto Health Care System, Palo Alto, California 94304-1290, USA
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16
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Affiliation(s)
- T M Young-Fadok
- Division of Colon and Rectal Surgery, Mayo Medical School, Rochester, Minnesota, USA
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Tagliacozzo S, Tocchi A. Antimesenteric perforations of the colon during diverticular disease: possible pathogenetic role of ischemia. Dis Colon Rectum 1997; 40:1358-61. [PMID: 9369113 DOI: 10.1007/bf02050823] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED The pathogenesis of free perforations occurring on the antimesenteric border of the pelvic colon during the course of diverticular disease has received little attention, with most being generically referred to as diverticular perforations. PURPOSE This study was designed to identify the pathogenetic factors responsible for free perforations that may occur in the antimesenteric intertenial area during the course of diverticular disease. METHODS Vascular alterations of the colonic wall associated with diverticula and open antimesenteric perforations were analyzed. RESULTS Previous data on the site of diverticula formation and related intramural vascular alterations were confirmed. A subserosal vascular network developed in the antimesenteric intertenial area in instances of multiple bilateral diverticula. Free perforations occurred in the antimesenteric haustral area only with multiple bilateral diverticula. CONCLUSIONS Alterations of the intramural vascular pattern secondary to the presence of multiple and bilateral diverticula may predispose the colonic wall to acute vascular injury. These changes may be enhanced by an episodic increase of intraluminal pressure and consequent distention of the colonic wall occurring in the course of diverticular disease.
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Affiliation(s)
- S Tagliacozzo
- Rome La Sapienza University Medical School, First Department of Surgery, Italy
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Wong SK, Ho YH, Leong AP, Seow-Choen F. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997; 40:344-8. [PMID: 9118752 DOI: 10.1007/bf02050427] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of the study was to characterize the clinical entity of multiple right-sided (RS) diverticular disease, which is uniquely common in Asians. METHODS Patients hospitalized with proven diverticular disease from June 1989 to January 1996 were reviewed. Data were retrieved from a prospectively collected computerized database. RESULTS One hundred eighty consecutive patients were admitted to the Department of Colorectal Surgery, Singapore General Hospital, with multiple diverticular disease. Average age was 65.1 (standard error of the mean, 13.9) years. There were 96 men and 84 women. Women presented, on average, 8.4 years later than men (P < 0.005). Eighty-five patients (47 percent) had massive rectal bleeding, 65 (36 percent) had diverticulitis, 21 (12 percent) had obstructive symptoms, and 9 (15 percent) had enteric fistulas. The diverticula were RS in 76 patients(42 percent), left-sided (LS) in 62 patients (34 percent), and on both sides in 42 patients (24 percent). RS diverticulosis tended to present with massive rectal bleeding (42/76; 55 percent) more often than LS disease (14/62; 23 percent; P < 0.005). Surgery for bleeding was also required more often for RS (17/42; 41 percent) than for LS disease (1/14; 7 percent; P < 0.05); however, diverticulitis was more common on the left (RS, 25/76, 33 percent; LS, 32/62, 52 percent; P < 0.05). Seventy-eight patients (43 percent) required surgery for these complications of diverticular disease. At a mean follow-up of 15.2 (standard error of the mean, 2) months, mortality was 2 in 78 patients who underwent surgery (3 percent), and morbidity was 15 percent. CONCLUSIONS In comparison with LS, RS diverticular disease tended to present more often with massive bleeding than with diverticulitis and fistulation. This bleeding was often more severe and required surgical intervention.
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Affiliation(s)
- S K Wong
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Ramirez FC, Johnson DA, Zierer ST, Walker GJ, Sanowski RA. Successful endoscopic hemostasis of bleeding colonic diverticula with epinephrine injection. Gastrointest Endosc 1996; 43:167-70. [PMID: 8635718 DOI: 10.1016/s0016-5107(06)80126-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- F C Ramirez
- Department of Medicine, Carl T. Hayden VA Medical Center, Phoenix, AZ 85012, USA
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Savides TJ, Jensen DM. Colonoscopic hemostasis for recurrent diverticular hemorrhage associated with a visible vessel: a report of three cases. Gastrointest Endosc 1994; 40:70-3. [PMID: 8163141 DOI: 10.1016/s0016-5107(94)70014-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- T J Savides
- Department of Medicine, UCLA Center for the Health Sciences 90024-1684
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23
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Abstract
The basic motor function of the colon is to mix and knead its contents, propel them slowly in the caudad direction, hold them in the distal colon until defecation, and provide a strong propulsive force during defecation. Infrequently, it also produces mass movements in the proximal colon. These motor functions are achieved in most species by three different types of contractions: the individual phasic contractions that include the short- and long-duration contractions, organized groups of contractions that include the migrating and nonmigrating motor complexes, and special propulsive contractions (giant migrating contractions). The spatial and temporal patterns of all of these contractions are controlled by myogenic, neural, and chemical control mechanisms. The individual phasic contractions are highly disorganized in time and space in the colon. For this reason, they are effective in mixing and kneading and slow distal propulsion. The underlying cause of the disorganization of short duration contractions is the irregularity in the frequency and waveshape of colonic electrical control activity and its phase unlocking throughout the colon. The individual contractions in many species occur in cyclic bursts called contractile states. At least in some species, these contractile states exhibit mostly caudad and sometimes orad migration. However, there are also nonmigrating or randomly migrating contractile states in the colon. These two patterns of contractile states are called colonic migrating motor complexes and colonic nonmigrating motor complexes, respectively. The giant migrating contractions provide the strong propulsive force for defecation and mass movements. The neural control of colonic contractions is organized at three levels--enteric, autonomic, and central. The enteric nervous system contains cholinergic and peptidergic neurons and plays a major role in the control of colonic contractions. The autonomic nerves, the vagi, pelvic, lumbar colonic, hypogastric, and splanchnic nerves, seem to continuously monitor the state of the colon and provide a modulatory input when necessary. These nerves play a major role in the reflexive control of colonic motor function. The voluntary input from the central nervous system coordinates the motor activity of the colon, rectum, anal canal and sphincters for orderly evacuation of feces during defecation. The role of acetylcholine, nonadrenaline, and the yet to be completely identified nonadrenergic, noncholinergic neurotransmitter, possibly VIP, in the control of contractions is fairly well established. Besides these, there are several other peptides and chemicals that are localized in the colonic wall; their physiological roles remain unknown. Colonic motor activity has been studied in several disease states. The findings have not always been consistent.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- S K Sarna
- Department of Surgery, Medical College of Wisconsin, Milwaukee 53295
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Gould RJ, Crampton AR, Schwartz D, Rushovich AM. Massive hemorrhage into a periappendiceal abscess: case report. Cardiovasc Intervent Radiol 1986; 9:25-7. [PMID: 3085938 DOI: 10.1007/bf02576980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
A case of significant hemorrhage into an ileal wall periappendiceal abscess in a 62-year-old man is described. Pathologic correlation of an unusual collection of contrast seen at the distal end of a branch of the ileocolic artery during angiography is discussed and illustrated.
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25
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Feldberg MA, Hendriks MJ, van Waes PF. Role of CT in diagnosis and management of complications of diverticular disease. GASTROINTESTINAL RADIOLOGY 1985; 10:370-7. [PMID: 4054506 DOI: 10.1007/bf01893134] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The clinical complications of diverticular disease may be unclear. Seven patients with complicated diverticulitis of the transverse, descending, and sigmoid colon were examined with computed tomography. Exact knowledge of the anatomical relationships of the transverse, descending, and sigmoid colon and neighboring structures are a prerequisite for understanding and interpreting the extensions of peridiverticular disease. Computed tomography proved to be useful in evaluating the presence and extent of sequelae of perforations, and, as a consequence, influenced the planning and timing of treatment.
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Sugihara K, Muto T, Morioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum 1984; 27:531-7. [PMID: 6468190 DOI: 10.1007/bf02555517] [Citation(s) in RCA: 135] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Of 615 patients with diverticular disease of the colon, 429 had diverticula in the cecum and ascending colon, 98 in the sigmoid and descending colon and 88 in both the right- and left-side colon. The right-sided type was more common in younger people and more predominant in men, whereas the left-sided type was more common in the elderly and showed no difference in numbers between men and women. More than 50 per cent of patients were asymptomatic and 25 per cent complained of disturbed bowel function. The frequency of diverticulitis was not related to location, but to the number of diverticula. Seventy-seven were complicated by acute inflammation (right-sided diverticulitis, 61, and left-sided diverticulitis, 16). Many patients with right-sided diverticulitis improved with medical treatment and the operative procedure of choice was drainage of the inflamed area with supplemental appendectomy.
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Abstract
This paper reports a retrospective study of 28 patients undergoing emergency laparotomy and colonic resection for acute colonic haemorrhage out of a total of 292 patients admitted with the condition. The paper concludes that in those cases where the bleeding site cannot be accurately localized angiographically prior to laparotomy, the preferred surgical procedure should be total abdominal colectomy with ileoproctostomy as more limited colonic resection leads to an unacceptably high morbidity and mortality.
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Heuck F. [X-ray findings in diverticulitis (author's transl)]. LANGENBECKS ARCHIV FUR CHIRURGIE 1976; 342:421-30. [PMID: 1086943 DOI: 10.1007/bf01267404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The frequency of congenital and acquired diverticula is discussed with reference to geographical aspects, their location and the function of the colon in diverticular disease. The X-ray findings in the presence of complications are demonstrated. Radiological differential diagnosis is discussed with special reference to cinematographic analysis of function. The possiblity of the simultaneous appearance of polyposis and carcinoma in diverticular diseases is indicated. A sensitive radiologic diagnostic procedure is important for planning of the optimal treatment.
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Becker V. [Pathologic-anatomic aspects of the formation and complications of diverticula (author's transl)]. LANGENBECKS ARCHIV FUR CHIRURGIE 1976; 342:401-9. [PMID: 994658 DOI: 10.1007/bf01267401] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Diverticulosis is favored by general (erect posture), diatetic (low-roughage diet) and anatomic factors (discontinuity and particularly spiral arrangement of the musculature). A pouch of mucous membrane passes through the bowel wall in some cases, which makes comparison to the false diverticula of the so-called trabecular urinary bladder understandable. An important feature of the pathogenesis is the displaceable layer between mucosa and musculature. Diverticulosis is the basis of a disease, i.e. diverticulitis: this begins with stercoraceous pressure ulcers, and causes granulation tissue local peridiverticulitis. In peridiverticulitis, confluated inflammation sometimes involves all the sigmoid ensheathing it, with pernicious fomation of scars, i.e. perisigmoiditis. In this way, a disease of the intestinal wall becomes a disease of the intestine. The symptoms of perisigmoiditis are similar to those of carcinoma of the sigma.
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Nakanishi H. Experimental gut anastomoses and their revascularization. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1975; 45:309-14. [PMID: 1101871 DOI: 10.1111/j.1445-2197.1975.tb05217.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A study was made of the healing and revascularization of intestinal anastomoses in the small and large intestines of rabbits. Single-layer and double-layer suture, techniques were used and compared, and revascularization of the anastomoses was particularly examined after devascularization of their distal segments. The anastomotic segments were removed at intervals after construction varying from one to six weeks and studied histologically after haemotoxylin and eosin staining, by xylol-clear thick sections and by angiography, a gelatin Micropaque emulsion being used to fill the vascular network. Forty-four rabbit intestinal anastomoses were studied. Inverted intestinal anastomoses took about two weeks to develop continuous mucosa on the luminal side, and were completely healed after six weeks. Revascularization began after eight days with both single-layer and double-layer anastomoses, proceeding from the submucosal and the surrounding muscular layers. The vascular pattern mirrored the healing stage of the anastomosis. Irregular fine vessels crossing the anastomoses were seen in specimens examined at the second week. After three or four weeks, the vascular patterns of the anastomoses showed an irregularity of calibre and direction because of the presence of residual scar tissue, and the mucosal surfaces were covered with regenerating epithelium. Healing and revascularization were complete after six weeks.
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Pheils MT. The complications of diverticular disease. Med J Aust 1975; 1:707-11. [PMID: 1080234 DOI: 10.5694/j.1326-5377.1975.tb111653.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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37
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HUGHES L. Complications of Diverticular Disease: Inflammation, Obstruction and Bleeding. ACTA ACUST UNITED AC 1975. [DOI: 10.1016/s0300-5089(21)00102-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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