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Alexandersson BT, Jones MP, Forsberg A, Hedin CRH, Järbrink‐Sehgal E, Walter S, Talley NJ, Agreus L, Andreasson A, Schmidt PT. Uncomplicated Diverticulosis Is Not Associated With Abdominal Pain or Abnormal Bowel Habit-A Population-Based Swedish Cohort Study. Neurogastroenterol Motil 2025; 37:e70000. [PMID: 39962642 PMCID: PMC12075898 DOI: 10.1111/nmo.70000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 01/25/2025] [Accepted: 01/28/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND Whether uncomplicated diverticulosis gives rise to symptoms is controversial. Diary-based studies of abdominal pain and stool habits in general populations are scarce, and we therefore investigated symptom patterns in diverticulosis from prospectively collected symptom diaries in a random sample of the general population who completed a research colonoscopy. METHODS In the Swedish population-based colonoscopy (PopCol) study, 745 individuals from the general population underwent a colonoscopy of which 130 had diverticulosis, and none had diverticulitis. Seven-day symptom diaries were completed by 258 participants (age 54, women 64%) of which 50 had diverticulosis. The frequency and location of abdominal pain, bowel habit and other gastrointestinal symptoms were compared between individuals with and without diverticulosis using logistic regression. KEY RESULTS Diverticulosis was not associated with abdominal pain (OR 1.24, CI 0.61-2.55) or left lower quadrant (LLQ) abdominal pain (OR 1.59, CI 0.73-3.49). Pain duration and severity were not associated with diverticulosis. When individuals with diverticulosis had pain, it was more often in the LLQ (OR 2.45, CI 1.02-5.86) compared with those without diverticulosis. Diverticulosis was not linked to altered bowel habits. Irritable bowel syndrome prevalence was 16% in the diverticulosis group and 19% in the non-diverticulosis group. CONCLUSIONS AND INFERENCES Participants with diverticulosis did not report more abdominal pain or more LLQ abdominal pain than participants without diverticulosis. Bowel habit was not abnormal in diverticulosis. Our results do not support that uncomplicated diverticulosis cause symptoms in individuals without a history of acute diverticulitis.
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Affiliation(s)
| | - Michael P. Jones
- School of Psychological SciencesMacquarie UniversityNorth RydeAustralia
| | - Anna Forsberg
- Department of Medicine SolnaKarolinska InstitutetStockholmSweden
| | - Charlotte R. H. Hedin
- Department of Medicine SolnaKarolinska InstitutetStockholmSweden
- Department of Gastroenterology, Dermatovenereology and RheumatologyCentre for Digestive Health, Karolinska University HospitalStockholmSweden
| | - Ellionore Järbrink‐Sehgal
- Department of Medicine SolnaKarolinska InstitutetStockholmSweden
- Gastroenterology, Hepatology and Nutrition DepartmentUT MD Anderson Cancer CenterHoustonTexasUSA
| | - Susanna Walter
- Department of Health, Medicine and Caring Sciences (HMV)Linköping UniversityLinköpingSweden
| | - Nicholas J. Talley
- School of Medicine and Public HealthUniversity of NewcastleNewcastleNew South WalesAustralia
| | - Lars Agreus
- Department of Neurobiology, Care Sciences and SocietyKarolinska InstitutetHuddingeSweden
| | - Anna Andreasson
- School of Psychological SciencesMacquarie UniversityNorth RydeAustralia
- Department of Health, Medicine and Caring Sciences (HMV)Linköping UniversityLinköpingSweden
- Department of PsychologyStockholm UniversityStockholmSweden
- Department of Medical SciencesUppsala UniversityUppsalaSweden
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de Silva AP, Nuwanshika N, Dassanayake U, Niriella MA, Ranasinghe P, de Silva HJ. Colonic diverticular disease revisited. Expert Rev Gastroenterol Hepatol 2024; 18:745-752. [PMID: 39648791 DOI: 10.1080/17474124.2024.2438708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Revised: 11/24/2024] [Accepted: 12/03/2024] [Indexed: 12/10/2024]
Abstract
INTRODUCTION Diverticular disease, including diverticulosis and diverticulitis, presents a significant health concern globally, with increasing prevalence in Western societies and emerging trends in Asia. The incidence of diverticulitis, is on the rise, leading to significant morbidity and healthcare costs. AREAS COVERED A literature search was conducted using the PubMed database, and studies published between 1995 and 2024 were selected based on their relevance to the overall understanding of disease. This review investigates the clinical spectrum, classification, and management strategies of diverticular disease, focusing particularly on evolving trends in diagnosis and treatment. Discussions regarding the prevalence of diverticulosis, the identification of risk factors associated with disease progression, recent advancements in research, and the utilization of biomarkers in disease monitoring and treatment decision-making are considered in detail. EXPERT OPINION The discourse on diverticular disease underscores the pressing need for tailored management strategies and innovative treatments. Understanding the intricacies of the disease's pathophysiology is paramount for effective intervention. Recent advances in diagnostic imaging and biomarker identification are promising, yet more research is imperative to further refine patient care. Advances in these areas hold the potential for significantly improving outcomes in disease management.
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Affiliation(s)
| | - Nilushi Nuwanshika
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Uditha Dassanayake
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Madunil Anuk Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Poornima Ranasinghe
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - H Janaka de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Carabotti M, Marasco G, Sbarigia C, Cuomo R, Barbara G, Pace F, Sarnelli G, Annibale B. Site and duration of abdominal pain discriminate symptomatic uncomplicated diverticular disease from previous diverticulitis patients. Intern Emerg Med 2024; 19:1235-1245. [PMID: 38671294 PMCID: PMC11364589 DOI: 10.1007/s11739-024-03588-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/16/2024] [Indexed: 04/28/2024]
Abstract
Abdominal pain in patients with diverticular disease (DD) can be challenging in clinical practice. Patients with symptomatic uncomplicated diverticular disease (SUDD) and patients with a previous acute diverticulitis (PD) may share a similar clinical pattern, difficult to differentiate from irritable bowel syndrome (IBS). We used standardized questionnaires for DD (short and long lasting abdominal pain) and IBS (following Rome III Criteria) to assess clinical features of abdominal pain, in terms of presence, severity and length, in SUDD and PD patients. One hundred and forty-eight SUDD and 118 PD patients completed all questionnaires. Short-lasting pain was more frequent in SUDD than PD patients (p = 0.007). Number of long-lasting pain episodes was higher in SUDD (6.6 ± 11.9) compared to PD patients (3.4 ± 6.9) (p < 0.001). PD patients reported long-lasting pain more frequently in the lower left abdomen (p < 0.001), while in SUDD it was more frequently diffuse (p = 0.002) or localized in the lower right quadrant (p = 0.009). Features associated with long-lasting pain (fever, confinement to bed, consultations, antibiotic therapy, hospitalization) were more often reported in PD patients. IBS criteria were reported in 28.2% of patients and were more frequent in SUDD than PD patients (37.2% vs 17.1%, p < 0.001). SUDD and PD patients presented different pattern of abdominal pain (length, number of long lasting episodes, site and associated features), with a third reporting overlap with IBS. Further observational studies are needed to better characterize abdominal symptoms in DD patients, especially in those not fulfilling IBS criteria.Trial registration: The REMAD Registry is registered as an observational study in ClinicalTrial.gov (ID: NCT03325829).
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Affiliation(s)
- Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, 40138, Bologna, Italy
| | - Caterina Sbarigia
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Rosario Cuomo
- UOC of Gastroenterology, AORN Sant'Anna e San Sebastiano, 81100, Caserta, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, 40138, Bologna, Italy
| | - Fabio Pace
- UOC of Gastroenterology, Bolognini Hospital, 24068, Seriate, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131, Naples, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
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Ritieni C, Sbarigia C, Scalamonti S, Annibale B, Carabotti M. Symptomatic uncomplicated diverticular disease: a critical appraisal. Expert Rev Gastroenterol Hepatol 2024; 18:315-323. [PMID: 39093005 DOI: 10.1080/17474124.2024.2388797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/26/2024] [Accepted: 08/01/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Symptomatic uncomplicated diverticular disease (SUDD) is a clinical condition included in the spectrum of symptomatic diverticular disease. The symptom profile associated with SUDD is highly heterogeneous, as there are currently discordant definitions, that encompass many clinical scenarios. AREAS COVERED We conducted a narrative review to assess the symptom profile and diagnostic criteria of SUDD based on the available evidence. A thorough literature search was performed on PubMed following the SANRA scale. Abdominal pain, regardless of its duration and location, emerges as the cardinal symptom of SUDD, suggesting that it should be central to its diagnosis. Although abdominal bloating and changes in bowel habits are commonly reported, they do not appear to be specifically attributable to SUDD. Other issues considered are the possible overlap with irritable bowel syndrome and the identification of a subcategory of SUDD patients with chronic symptoms following an episode of acute diverticulitis. EXPERT OPINION The future agenda should include the development of shared diagnostic criteria for SUDD, including well-defined inclusion and exclusion clinical features and symptom patterns.
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Affiliation(s)
- Camilla Ritieni
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Caterina Sbarigia
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Silvia Scalamonti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Bruno Annibale
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Marilia Carabotti
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
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Holmer C. Behandlungsstrategien und Operationsindikationen bei chronischer Divertikulitis. COLOPROCTOLOGY 2023; 45:159-162. [DOI: 10.1007/s00053-023-00699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 01/05/2025]
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Calini G, Abd El Aziz MA, Paolini L, Abdalla S, Rottoli M, Mari G, Larson DW. Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management. Clin Exp Gastroenterol 2023; 16:29-43. [PMID: 37013200 PMCID: PMC10066719 DOI: 10.2147/ceg.s340929] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/18/2023] [Indexed: 04/05/2023] Open
Abstract
Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.
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Affiliation(s)
- Giacomo Calini
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Medical Area, University of Udine, Udine, Italy
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Internal Medicine Department, MercyOne North Iowa, Mason City, IA, USA
| | - Lucia Paolini
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Solafah Abdalla
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Oncologic and Digestive Surgery, Le Kremlin-Bicêtre University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Matteo Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giulio Mari
- Department of Laparoscopic and Oncological General Surgery, ASST Brianza, Desio Hospital, Desio, Italy
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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Ivashkin VT, Shelygin YA, Baranskaya EK, Achkasov SI, Belous SS, Belousova EA, Beniashviili AG, Vasiliev SV, Grigoriev EG, Kostenko NV, Moskalev AI, Kashnikov VN, Loranskaya ID, Lyashenko OS, Poluektova EA, Rumyantsev VG, Timerbulatov VM, Chashkova EY, Shapina MV, Sheptulin AA, Shifrin OS, Zolnikova OY, Baranovsky AY, Korochanskaya NV, Mammaev SN, Alekseeva OP, Khlynov IB, Tsukanov VV, Alekseenko SA. Irritable bowel syndrome. KOLOPROKTOLOGIA 2022; 21:10-25. [DOI: 10.33878/2073-7556-2022-21-1-10-25] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
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Ivashkin VT, Maev IV, Shelygin YA, Baranskaya EK, Belous SS, Belousova EA, Beniashvili AG, Vasilyev SV, Veselov AV, Grigoryev EG, Kostenko NV, Kashnikov VN, Kulikovskiy VF, Loranskaya ID, Lyashenko OS, Poluektova EA, Rumyantsev VG, Timerbulatov VM, Fomenko OY, Khubezov DA, Chashkova EY, Chibisov GI, Shapina MV, Sheptulin AA, Shifrin OS, Trukhmanov AS, Alekseeva OP, Alekseenko SA, Baranovsky AY, Zolnikova OY, Korochanskaya NV, Mammayev SN, Khlynov IB, Tsukanov VV. Diagnosis and Treatment of Irritable Bowel Syndrome: Clinical Recommendations of the Russian Gastroenterological Association and Association of Coloproctologists of Russia. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2022; 31:74-95. [DOI: 10.22416/1382-4376-2021-31-5-74-95] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
Aim. Current clinical recommendations accentuate current methods for the diagnosis and treatment of irritable bowel syndrome (IBS).Key points.IBS is a functional bowel disorder manifested with recurrent, at least weekly, abdominal pain with the following attributes (any two leastwise): link to defecation, its frequency or stool shape. The symptoms are expected to persist for at minimum three months in a total six-month follow-up. Similar to other functional gastrointestinal (GI) disorders, IBS can be diagnosed basing on the patient symptoms compliance with Rome IV criteria, provided the absence of potentially symptom-causative organic GI diseases. Due to challenging differential diagnosis, IBS can be appropriately established per exclusionem, with pre-examination as follows: general and biochemical blood tests; tissue transglutaminase IgA/IgG antibody tests; thyroid hormones test; faecal occult blood test; hydrogen glucose/ lactulose breath test for bacterial overgrowth; stool test for enteric bacterial pathogens and Clostridium difficile A/B toxins; stool calprotectin test; abdominal ultrasound; OGDS, with biopsy as appropriate; colonoscopy with biopsy. The IBS sequence is typically wavelike, with alternating remissions and exacerbations often triggered by psychoemotional stress. Treatment of IBS patients includes dietary and lifestyle adjustments, various-class drug agents prescription and psychotherapeutic measures.Conclusion. Adherence to clinical recommendations can facilitate timely diagnosis and improve medical aid quality in patients with different clinical IBS variants.
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Affiliation(s)
- V. T. Ivashkin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I. V. Maev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | | | - E. K. Baranskaya
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S. S. Belous
- Ryzhikh National Medical Research Centre for Coloproctology
| | | | | | | | - A. V. Veselov
- Ryzhikh National Medical Research Centre for Coloproctology
| | | | | | | | | | | | - O. S. Lyashenko
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E. A. Poluektova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | - O. Yu. Fomenko
- Ryzhikh National Medical Research Centre for Coloproctology
| | - D. A. Khubezov
- Ryazan State Medical University named after Acad. I.P. Pavlov
| | | | | | - M. V. Shapina
- Ryzhikh National Medical Research Centre for Coloproctology
| | - A. A. Sheptulin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O. S. Shifrin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - A. S. Trukhmanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | | | - O. Yu. Zolnikova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | | | | | - V. V. Tsukanov
- Research Institute for Medical Problems in the North — Division of Krasnoyarsk Scientific Centre of the Siberian Branch of the RAS
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Sabo CM, Dumitrascu DL, Bjarnason I. Symptomatic Uncomplicated Diverticular Disease. COLONIC DIVERTICULAR DISEASE 2022:87-97. [DOI: 10.1007/978-3-030-93761-4_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Tursi A, Franceschi M, Elisei W, Picchio M, Mario FD, Brandimarte G. The natural history of symptomatic uncomplicated diverticular disease: a long-term follow-up study. Ann Gastroenterol 2020; 34:208-213. [PMID: 33654361 PMCID: PMC7903564 DOI: 10.20524/aog.2020.0560] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/09/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Symptomatic uncomplicated diverticular disease (SUDD) affects about 20% of patients who have diverticulosis. However, the natural history of SUDD is not yet completely understood. Our aim was to assess the outcomes of a cohort of SUDD patients during a long-term follow up. METHODS One hundred eighty-five patients suffering from SUDD were identified from a large electronic database. Symptoms assessed were abdominal pain, bloating, bowel movement/day, each of which was scored using a visual analogic scale (VAS); the symptom score was calculated by considering the value of the worst symptom present during assessment. Another VAS was used to assess patients' quality of life (QoL). Patients were treated at the physician's discretion (with rifaximin, mesalazine, probiotics, spasmolytics) only when symptoms occurred during the follow up. Follow-up visit was performed every year or whenever patients consider it necessary. RESULTS During the follow up (156 months, interquartile range 9-171), 47 patients were lost to follow up. Among these, 9 died from causes not related to SUDD. Acute diverticulitis occurred in 14 patients (7.6% of the overall population): 6 patients (3.2% of the overall population) underwent surgery, and 2 patients (1.1% of the overall population) died because of peritonitis. Both the symptom score and the QoL score were substantially unmodified during the study period. CONCLUSIONS SUDD is an important disease able to affect patients significantly in the long term. Acute diverticulitis may sometimes occur in these patients, often leading to surgery with possible severe complications.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, ASL BAT, Andria, BT (Antonio Tursi)
| | - Marilisa Franceschi
- Digestive Endoscopy Unit, AULSS7 “Pedemontana”, Santorso, VI (Marilisa Franceschi)
| | - Walter Elisei
- Division of Gastroenterology, “S. Camillo” Hospital, Rome (Walter Elisei)
| | - Marcello Picchio
- Division of Surgery, “P. Colombo” Hospital, ASL RM6, Velletri, Rome (Marcello Picchio)
| | - Francesco Di Mario
- Department of Medicine and Surgery, University of Parma, Parma (Francesco Di Mario)
| | - Giovanni Brandimarte
- Division of Internal Medicine and Gastroenterology, “Cristo Re” Hospital, Rome (Giovanni Brandimarte), Italy
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Andreev PS, Katorkin SE, Davydova OE. Pregnancy and Healthy Childbirth in a 37 Year-Old Patient with Diverticular Disease. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2020; 30:58-62. [DOI: 10.22416/1382-4376-2020-30-5-58-62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
Abstract
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.
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Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, Chabok A, Consten ECJ, van Dijk ST, Johanssen A, Kruis W, Lambrichts D, Post S, Ris F, Rockall TA, Samuelsson A, Di Saverio S, Tartaglia D, Thorisson A, Winter DC, Bemelman W, Angenete E. European Society of Coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis 2020; 22 Suppl 2:5-28. [PMID: 32638537 DOI: 10.1111/codi.15140] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
AIM 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. METHODS 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 than 90% 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. RESULTS This guideline contains 38 evidence based consensus statements on the management of diverticular disease. CONCLUSION 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.
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Affiliation(s)
- J K Schultz
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - N Azhar
- Colorectal Unit, Department of Surgery, Skåne University Hospital Malmö, Malmö, Sweden.,Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - G A Binda
- Colorectal Surgery, BioMedical Institute, Genova, Italy
| | - G Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - S Biondo
- Department of General and Digestive Surgery - Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Chabok
- Colorectal Unit, Department of Surgery, Centre for Clinical Research Uppsala University, Västmanlands Hospital Västerås, Västerås, Sweden
| | - E C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands.,Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S T van Dijk
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Johanssen
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - W Kruis
- Faculty of Medicine, University of Cologne, Cologne, Germany
| | - D Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Post
- Mannheim Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - F Ris
- Division of Visceral Surgery, Geneva University hospitals and Medical School, Geneva, Switzerland
| | - T A Rockall
- Minimal Access Therapy Training Unit (mattu), Royal Surrey County Hospital NHS Trust, Guildford, UK
| | - A Samuelsson
- Department of Surgery, NU-Hospital Group, Region Västra Götaland, Trollhättan, Sweden.,Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.,Department of General Surgery, ASST Sette Laghi, University Hospital of Varese, University of Insubria, Varese, Italy
| | - D Tartaglia
- Emergency Surgery Unit, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - A Thorisson
- Department of Radiology, Västmanland's Hospital Västerås, Västerås, Sweden.,Centre for Clinical Research of Uppsala University, Västmanland's Hospital Västerås, Västerås, Sweden
| | - D C Winter
- St Vincent's University Hospital, Dublin, Ireland
| | - W Bemelman
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - E Angenete
- Department of Surgery, SSORG - 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/Östra, Gothenburg, Sweden
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14
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Lahat A, Fidder HH, Ben-Horin S. Development and validation of a diverticular clinical score for symptomatic uncomplicated diverticular disease after acute diverticulitis in a prospective patient cohort. Therap Adv Gastroenterol 2020; 13:1756284820913210. [PMID: 32523619 PMCID: PMC7236576 DOI: 10.1177/1756284820913210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Following an attack of acute diverticulitis (AD), many patients continue to suffer from a complex of symptoms, titled 'symptomatic uncomplicated diverticular disease (SUDD)'. To date, there is no validated clinical score for standardized assessment of patients with SUDD, thereby hampering the interpretation of observational studies and the conductance of clinical trials.We aimed to develop a validated SUDD clinical score. METHODS Data from previous prospective study of patients after AD was used to devise the score's first version. Validation was first performed using a focus group of patients after AD SUDD who underwent a structured cognitive personal interview. Thereafter, the diverticular clinical score (DICS) was applied for a second validation cohort. DICS scores of validation cohort were compared with physicians' global assessment for disease severity and inflammatory markers. RESULTS In DICS second validation using 48 patients prospectively recruited after AD SUDD, a correlation matrix demonstrated strong correlation between total questionnaire's score and the presence of elevated inflammatory markers (ρ = 0.84). Mean score in patients with elevated inflammatory markers compared with those without inflammation was 17.8 versus 6.2, respectively, p < 0.001. Cronbach's α for measuring internal consistency was 0.91. DICS discriminated accurately between patients with/without active disease, as gauged by the physicians global assessment (area under the curve receiver operating characteristic = 0.989). CONCLUSIONS Patients suffering from post-AD SUDD exhibit a wide range of symptoms. The newly developed DICS accurately and reproducibly quantitates SUDD-related symptom severity. The DICS may prove useful for monitoring SUDD in clinical practice and in research settings, as well as facilitating patient stratification and therapeutic decisions.
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Affiliation(s)
| | - Herma H Fidder
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, GA Utrecht, Netherlands
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center, Sackler School of Medicine, Tel Hashomer, Tel Aviv University, Israel
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15
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Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nat Rev Dis Primers 2020; 6:20. [PMID: 32218442 PMCID: PMC7486966 DOI: 10.1038/s41572-020-0153-5] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
Diverticula are outpouchings of the intestinal wall and are common anatomical alterations detected in the human colon. Colonic diverticulosis (the presence of diverticula in the colon; referred to as diverticulosis) remains asymptomatic in most individuals but ~25% of individuals will develop symptomatic diverticulosis, termed colonic diverticular disease (also known as diverticular disease). Diverticular disease can range in severity from symptomatic uncomplicated diverticular disease (SUDD) to symptomatic disease with complications such as acute diverticulitis or diverticular haemorrhage. Since the early 2000s, a greater understanding of the pathophysiology of diverticulosis and diverticular disease, which encompasses genetic alterations, chronic low-grade inflammation and gut dysbiosis, has led to improvements in diagnosis and management. Diagnosis of diverticular disease relies on imaging approaches, such as ultrasonography, CT and MRI, as biomarkers alone are insufficient to establish a diagnosis despite their role in determining disease severity and progression as well as in differential diagnosis. Treatments for diverticular disease include dietary fibre, pharmacological treatments such as antibiotics (rifaximin), anti-inflammatory drugs (mesalazine) and probiotics, alone or in combination, and eventually surgery. Despite being effective in treating primary disease, their effectiveness in primary and secondary prevention of complications is still uncertain.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, Azienda Sanitaria Locale Barletta-Andria-Trani, Andria, Italy.
| | - Carmelo Scarpignato
- Faculty of Health Sciences, LUdeS Lugano Campus, Lugano, Switzerland
- United Campus of Malta, Birkirkara, Msida, Malta
| | - Lisa L Strate
- Division of Gastroenterology, Department of Medicine, Harborview Medical Center, University of Washington Medical School, Seattle, WA, USA
| | - Angel Lanas
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, University of Zaragoza, IIS Aragón (CIBERehd), Zaragoza, Spain
| | | | - Adi Lahat
- Department of Gastroenterology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center - IRCCS -, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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16
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Zullo A, Gatta L, Vassallo R, Francesco VD, Manta R, Monica F, Fiorini G, Vaira D. Paradigm shift: the Copernican revolution in diverticular disease. Ann Gastroenterol 2019; 32:541-553. [PMID: 31700230 PMCID: PMC6826076 DOI: 10.20524/aog.2019.0410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
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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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo)
| | - Luigi Gatta
- Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore (Luigi Gatta)
| | - Roberto Vassallo
- Gastroenterology and Digestive Endoscopy; “Buccheri la Ferla, Fatebenefratelli”, Hospital, Palermo (Roberto Vassallo)
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia (Vincenzo De Francesco)
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, “Generale” Hospital, Perugia (Raffaele Manta)
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste (Fabio Monica)
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
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17
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Role of Inflammation in the Pathogenesis of Diverticular Disease. Mediators Inflamm 2019; 2019:8328490. [PMID: 31001067 PMCID: PMC6437747 DOI: 10.1155/2019/8328490] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/13/2019] [Accepted: 02/04/2019] [Indexed: 12/19/2022] Open
Abstract
Diverticulosis of the colon is the most common condition in Western societies and it is the most common anatomic alteration of the human colon. Recurrent abdominal pain is experienced by about 20% of patients with diverticulosis, but the pathophysiologic mechanisms of its occurrence are not completely understood. In the last years, several fine papers have showed clearly the role of low-grade inflammation both in the occurrence of symptoms in people having diverticulosis, both in symptom persistence following acute diverticulitis, even if the evidence available is not so strong. We do not know yet what the trigger of this low-grade inflammation occurrence is. However, some preliminary evidence found colonic dysbiosis linked to low-grade inflammation and therefore to symptom occurrence in those patients. The aim of this paper is to summarize current evidences about the role of inflammation in symptom occurrence in symptomatic uncomplicated diverticular disease and in symptom persistence after an episode of acute diverticulitis.
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18
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Zullo A. Medical hypothesis: speculating on the pathogenesis of acute diverticulitis. Ann Gastroenterol 2018; 31:747-749. [PMID: 30386127 PMCID: PMC6191870 DOI: 10.20524/aog.2018.0315] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 09/09/2018] [Indexed: 12/21/2022] Open
Abstract
The pathogenetic process of acute diverticulitis remains speculative. According to the most widely accepted theory, the mechanism involved is “traumatic” damage to the mucosa due to fecolith impaction, as occurs in large diverticula. However, not uncommonly, diverticulitis develops in young patients with only few and small diverticula, where fecolith trapping is very unlikely. Therefore, another theory is necessary to clarify this process. A possible explanation could be “ischemic” damage. According to this theory, an ischemic lesion is caused by the compression of vascular structures in the neck of the diverticular task, as a result of prolonged and/or recurrent contractile spikes related to neuromuscular alterations in the diverticular tract. Clearly, the “traumatic” and “ischemic” mechanisms of acute diverticulitis are not mutually exclusive, and may act in different patients. The existing data corroborating these theories are presented and different potential therapeutic approaches are briefly discussed.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
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19
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Carabotti M, Cuomo R, Barbara G, Pace F, Andreozzi P, Cremon C, Annibale B. Demographic and clinical features distinguish subgroups of diverticular disease patients: Results from an Italian nationwide registry. United European Gastroenterol J 2018; 6:926-934. [PMID: 30023071 PMCID: PMC6047280 DOI: 10.1177/2050640618764953] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/22/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND 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. OBJECTIVE 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. METHODS 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). RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Roma, Italy
| | - Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Unit of Gastroenterology, “Bolognini” Hospital, Bergamo, Italy
| | - Paolo Andreozzi
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Cesare Cremon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Roma, Italy
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20
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Elisei W, Tursi A. The Pathophysiology of Colonic Diverticulosis: Inflammation versus Constipation? Inflamm Intest Dis 2018; 3:55-60. [PMID: 30733948 DOI: 10.1159/000489173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/12/2018] [Indexed: 12/18/2022] Open
Abstract
Background Diverticulosis of the colon is the most common anatomic alteration of the human colon, but the pathophysiologic mechanisms of its occurrence are not completely understood. Summary Constipation has been considered the key factor for diverticulosis occurrence. However, several fine papers questioned this pathogenetic hypothesis, showing on the contrary an inverse relationship between low number of bowel movements and diverticulosis occurrence. In the last years, several papers have showed the role of low-grade inflammation in the occurrence of symptoms in people having diverticulosis, as well as its role on symptom persistence following acute diverticulitis, even if the evidence available is not so strong. Although the trigger of this low-grade inflammation is currently under debate, some preliminary evidence found colonic dysbiosis linked to symptom occurrence in those patients. Key Messages Constipation no longer seems the leading cause for diverticulosis occurrence, while low-grade inflammation could play a role in symptom occurrence.
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Affiliation(s)
- Walter Elisei
- Gastroenterology Unit, ASL Roma 6, Albano Laziale, Italy
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21
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Scarpignato C, Barbara G, Lanas A, Strate LL. Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017. Therap Adv Gastroenterol 2018; 11:1756284818771305. [PMID: 29844795 PMCID: PMC5964860 DOI: 10.1177/1756284818771305] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/21/2018] [Indexed: 02/04/2023] Open
Abstract
Diverticulosis is a common anatomical condition, which appears to be age-dependent. Individuals who develop chronic gastrointestinal symptoms or complications are referred to as having diverticular disease. Although the diagnosis of this condition can be relatively straightforward, randomized controlled trials are scarce and management often follows tradition rather than principles of evidence-based medicine. This report deals with the topics discussed during a symposium held during the United European Gastroenterology Week (Barcelona, October 2017). During the meeting, the role of dysbiosis in the pathogenesis of diverticular disease and its treatment were thoroughly discussed, by examining the efficacy and mechanisms of action of the currently used drugs. Recent studies have shown the presence of dysbiosis in patients with diverticular disease and suggest an imbalance in favor of bacteria with pro-inflammatory and pathogenetic potential. These microbiota changes correlate with mucosal immune activation, mirrored by a marked increase of macrophages in colonic mucosa, both in the diverticular region and at distant sites. The low-grade inflammation, driven by bacteria-induced immune activation, could be involved in the pathophysiology of symptoms. As a consequence, pharmacological approaches targeting enteric bacteria (with poorly absorbed antibiotics, like rifaximin, or probiotics) or intestinal inflammation (with 5-ASA derivatives or rifaximin) have shown capability of controlling symptoms and also preventing complications, albeit more research is needed to establish the optimal regimen (daily dose and duration) of therapy. Well-designed randomized-controlled trials (RCTs), including homogeneous populations of patients, are therefore needed. The future of management of many GI diseases, including symptomatic uncomplicated diverticular disease, will rely on the so-called 'microbiota-directed therapies'.
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Affiliation(s)
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Angel Lanas
- Clinic Hospital Lozano Blesa, University of Zaragoza, Zaragoza, Spain
| | - Lisa L. Strate
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
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22
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Carabotti M, Annibale B. Treatment of diverticular disease: an update on latest evidence and clinical implications. Drugs Context 2018; 7:212526. [PMID: 29623099 PMCID: PMC5866096 DOI: 10.7573/dic.212526] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Diverticular disease (DD) is a common condition, especially in Western countries. In about 80% of patients, colonic diverticula remain asymptomatic (diverticulosis), while approximately 20% of patients may develop abdominal symptoms (symptomatic uncomplicated diverticular disease, SUDD) and, eventually complications as acute diverticulitis (AD). The management of this condition has been improved, and in the last five years European countries and the USA have published guidelines and recommendations. SCOPE To summarize the latest evidence and clinical implication in treatment of DD focusing the attention either on the treatment of diverticulosis, SUDD and AD together with the primary and secondary prevention of diverticulitis. FINDINGS The present review was based on the latest evidence in the treatment of DD in the last 10 years. In the last 5 years, six countries issued guidelines on DD with differences regarding covered topics and recommendations regarding treatments. At present there is a lack of rationale for drug use in patients with asymptomatic diverticulosis, but there are limited indications to suggest an increase in dietary fibre to reduce risk of DD. To achieve symptomatic relief in SUDD patients, several therapeutic strategies with fibre, probiotics, rifaximin and mesalazine have been proposed even if a standard therapeutic approach remained to be defined. Agreement has been reached for the management of AD, since recent guidelines showed that antibiotics can be used selectively, rather than routinely in uncomplicated AD, although use of antibiotics remained crucial in the management of complicated cases. With regard to treatment for the primary and secondary prevention of AD, the efficacy of rifaximin and mesalazine has been proposed although with discordant recommendations among guidelines. CONCLUSION Treatment of DD represented an important challenge in clinical practice, especially concerning management of SUDD and the primary and secondary prevention of AD.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, Sapienza, Rome
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Hospital Sant'Andrea, Sapienza, Rome
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23
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Linninge C, Roth B, Erlanson-Albertsson C, Molin G, Toth E, Ohlsson B. Abundance of Enterobacteriaceae in the colon mucosa in diverticular disease. World J Gastrointest Pathophysiol 2018; 9:18-27. [PMID: 29487763 PMCID: PMC5823699 DOI: 10.4291/wjgp.v9.i1.18] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/10/2017] [Accepted: 12/06/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare gut bacterial diversity and amount of Enterobacteriaceae in colonic mucosa between patients with and without diverticular disease (DD). METHODS Patients in a stable clinical condition with planned elective colonoscopy were included. Blood samples and colon mucosa biopsies were collected at the colonoscopy. Study questionnaires including questions about gastrointestinal symptoms were completed by the patients and physicians. DNA from mucosa samples was isolated and the amount of Enterobacteriaceae was estimated using PCR assay. Terminal restriction fragment length polymorphism was applied to assess microbial diversity. Diversity was estimated by calculations of richness (number of terminal restriction fragments) and Shannon-Wiener and Simpson's indices. RESULTS A total of 51 patients were included, 16 patients with DD [68 (62-76) years] and 35 controls [62 (40-74) years] without any diverticula. Patients with DD had significantly higher levels of Enterobacteriaceae than those without DD (P = 0.043), and there was an inverse relationship between the amount of Enterobacteriaceae and the Simpson's index (rs = -0.361, P = 0.033) and the Shannon-Wiener index (rs = -0.299, P = 0.081). The Simpson's index (P = 0.383), Shannon-Wiener index (P = 0.401) or number of restrictions fragments (P = 0.776) did not differ between DD and controls. The majority of patients experienced gastrointestinal symptoms, and 22 patients (43.1%) fulfilled the criteria for irritable bowel syndrome, with no difference between the groups (P = 0.212). Demography, socioeconomic status, lifestyle habits, inflammatory biomarkers, or symptoms were not related to the amount of Enterobacteriaceae or bacterial diversity. CONCLUSION Patients with DD had higher amount of Enterobacteriaceae in the colon mucosa compared to patients without diverticula.
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Affiliation(s)
- Caroline Linninge
- Department of Food Technology, Engineering and Nutrition, Lund University, Lund S-223 63, Sweden
| | - Bodil Roth
- Department of Internal Medicine, Skåne University Hospital, Lund University, Malmö S-205 02, Sweden
| | | | - Göran Molin
- Department of Food Technology, Engineering and Nutrition, Lund University, Lund S-223 63, Sweden
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, Malmö S-205 02, Sweden
| | - Bodil Ohlsson
- Department of Internal Medicine, Skåne University Hospital, Lund University, Malmö S-205 02, Sweden
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24
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Maconi G. Diagnosis of symptomatic uncomplicated diverticular disease and the role of Rifaximin in management. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:25-32. [PMID: 28467330 PMCID: PMC6166204 DOI: 10.23750/abm.v88i1.6360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 12/12/2022]
Abstract
Patients with diverticulosis who develop persistent abdominal pain, bloating and changes in bowel habits not associated with overt inflammation may have symptomatic uncomplicated diverticular disease (SUDD). The severity and frequency of SUDD symptoms may have an impact on daily activities and severely affect quality of life. Effective management of SUDD should follow a three part strategy: divert, tackle and maintain. Divert to make the correct diagnosis: several symptoms of SUDD are common to other conditions that require different therapeutic approaches. However, several key differences should be used to diagnose SUDD. Pain in SUDD is normally in the iliac fossa, persistent, often lasting more than 24 hrs, and is not relieved by bowel movement, as is often the case with irritable bowel syndrome. Another difference is in the timing: the prevalence of SUDD increases with age, and patients under the age of 40 years are less likely to have diverticula. It is useful to establish whether a patient has diverticulosis, especially if the patient is relatively young; lack of diverticula excludes SUDD. Cross-sectional imaging is indicated; however, recent archival image data or ultrasonography may be useful alternatives. Laboratory tests should be ordered to exclude overt inflammation. Once the diagnosis of SUDD is made, the patient should receive effective therapy to tackle the condition. This should include dietary fibre supplementation and cyclic treatment with rifaximin 400 mg twice daily for 7 days per month. Once symptom control is achieved, it should be maintained by continuing therapy for at least 12 months.
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Affiliation(s)
- Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy.
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25
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Uno Y, van Velkinburgh JC. Logical hypothesis: Low FODMAP diet to prevent diverticulitis. World J Gastrointest Pharmacol Ther 2016; 7:503-512. [PMID: 27867683 PMCID: PMC5095569 DOI: 10.4292/wjgpt.v7.i4.503] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/04/2016] [Accepted: 08/16/2016] [Indexed: 02/06/2023] Open
Abstract
Despite little evidence for the therapeutic benefits of a high-fiber diet for diverticulitis, it is commonly recommended as part of the clinical management. The ongoing uncertainty of the cause(s) of diverticulitis confounds attempts to determine the validity of this therapy. However, the features of a high-fiber diet represent a logical contradiction for colon diverticulitis. Considering that Bernoulli’s principle, by which enlarged diameter of the lumen leads to increased pressure and decreased fluid velocity, might contribute to development of the diverticulum. Thus, theoretically, prevention of high pressure in the colon would be important and adoption of a low FODMAP diet (consisting of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help prevent recurrence of diverticulitis.
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26
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Abstract
Diverticulosis of the colon is a widespread disease, and its prevalence is increasing especially in the developing world. The underlying pathological mechanisms that cause the formation of colonic diverticula remain unclear but are likely to be the result of complex interactions among age, diet, genetic factors, colonic motility, and changes in colonic structure. The large majority of patients remain asymptomatic throughout their life, one fifth of them become symptomatic (developing the so-called 'diverticular disease') while only a minority of these will develop acute diverticulitis. The factors predicting the development of symptoms remain to be identified. Again, it is generally recognized that diverticular disease occurrence is probably related to complex interactions among colonic motility, diet, lifestyle, and genetic features. Changes in intestinal microflora due to low-fiber diet and consequent low-grade inflammation are thought to be one of the mechanisms responsible for symptoms occurrence of both diverticular disease and acute diverticulitis. Current therapeutic approaches with rifaximin and mesalazine to treat the symptoms seem to be promising. Antibiotic treatment is currently advised only in acute complicated diverticulitis, and no treatment has currently proven effective in preventing the recurrence of acute diverticulitis. Further studies are required in order to clarify the reasons why diverticulosis occurs and the factors triggering occurrence of symptoms. Moreover, the reasons why rifaximin and mesalazine work in symptomatic diverticular disease but not in acute diverticulitis are yet to be elucidated.
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Affiliation(s)
- Antonio Tursi
- Gastroenterology Service, ASL BAT, Via Torino, 49, 76123 Andria (BT), Italy
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27
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Lahner E, Annibale B. Symbiotics, Probiotics, and Fiber Diet in Diverticular Disease. PROBIOTICS, PREBIOTICS, AND SYNBIOTICS 2016:501-514. [DOI: 10.1016/b978-0-12-802189-7.00035-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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28
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Bassotti G, Villanacci V, Sidoni A, Nascimbeni R, Dore MP, Binda GA, Bandelloni R, Salemme M, Del Sordo R, Cadei M, Manca A, Bernardini N, Maurer CA, Cathomas G. Myenteric plexitis: A frequent feature in patients undergoing surgery for colonic diverticular disease. United European Gastroenterol J 2015; 3:523-528. [PMID: 26668745 PMCID: PMC4669510 DOI: 10.1177/2050640614563822] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 11/17/2014] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Diverticular disease of the colon is frequent in clinical practice, and a large number of patients each year undergo surgical procedures worldwide for their symptoms. Thus, there is a need for better knowledge of the basic pathophysiologic mechanisms of this disease entity. OBJECTIVES Because patients with colonic diverticular disease have been shown to display abnormalities of the enteric nervous system, we assessed the frequency of myenteric plexitis (i.e. the infiltration of myenteric ganglions by inflammatory cells) in patients undergoing surgery for this condition. METHODS We analyzed archival resection samples from the proximal resection margins of 165 patients undergoing left hemicolectomy (60 emergency and 105 elective surgeries) for colonic diverticulitis, by histology and immunochemistry. RESULTS Overall, plexitis was present in almost 40% of patients. It was subdivided into an eosinophilic (48%) and a lymphocytic (52%) subtype. Plexitis was more frequent in younger patients; and it was more frequent in those undergoing emergency surgery (50%), compared to elective (28%) surgery (p = 0.007). All the severe cases of plexitis displayed the lymphocytic subtype. CONCLUSIONS In conclusion, myenteric plexitis is frequent in patients with colonic diverticular disease needing surgery, and it might be implicated in the pathogenesis of the disease.
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Affiliation(s)
- Gabrio Bassotti
- Department of Medicine, University of Perugia School of Medicine, Perugia, Italy
| | | | - Angelo Sidoni
- Department of Experimental Medicine, University of Perugia School of Medicine, Perugia, Italy
| | - Riccardo Nascimbeni
- Department of Medical and Surgical Sciences, University of Brescia School of Medicine, Brescia, Italy
| | - Maria P Dore
- Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
- Baylor College of Medicine, Houston, TX, USA
| | - Gian A Binda
- Department of General Surgery, Galliera Hospital, Genova, Italy
| | | | | | - Rachele Del Sordo
- Department of Experimental Medicine, University of Perugia School of Medicine, Perugia, Italy
| | - Moris Cadei
- Pathology Institute, Spedali Civili, Brescia, Italy
| | - Alessandra Manca
- Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Nunzia Bernardini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Gieri Cathomas
- Hospital of Baselland, University of Basel, Liestal, Switzerland
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29
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Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, Gervaz P, Annibale B. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Tech Coloproctol 2015; 19:615-626. [PMID: 26377584 DOI: 10.1007/s10151-015-1370-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 02/05/2023]
Abstract
The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.
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Affiliation(s)
- G A Binda
- Department of Surgery, Galliera Hospital, Genoa, Italy.
| | - R Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - A Laghi
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - R Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - A Serventi
- Department of Surgery, Galliera Hospital, Genoa, Italy
| | - D Bellini
- Department of Radiological Sciences, Oncology and Pathology, Rome I.C.O.T. Hospital, La Sapienza University, Latina, Italy
| | - P Gervaz
- Coloproctology Unit, La Colline Clinic, Geneva, Switzerland
| | - B Annibale
- Division of Gastroenterology, Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy
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30
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Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014; 2:413-442. [PMID: 25360320 PMCID: PMC4212498 DOI: 10.1177/2050640614547068] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, AOU Careggi, Florence, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Fiocca
- Pathology Unit, IRCCS San Martino-IST University Hospital, Genoa, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, La ‘Sapienza' University, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, L. Sacco University Hospital, Milan, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Parma, Italy
| | | | - Bruno Annibale
- Medical-Surgical and Translational Medicine Department, La Sapienza University, Rome, Italy
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