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Diverticular Disease and Diverticulitis - 10/4/2012

posted Oct 4, 2012, 11:18 AM by Rohit Das   [ updated Dec 27, 2012, 6:46 AM by Purnema Madahar ]

Would like to talk about diverticular disease today, a topic originating from journal club this afternoon. Let’s go through the following points:

·   What is the incidence of diverticulosis, and one of its important complications, diverticulitis?

·         What is the pathophysiology and clinical manifestations of diverticulitis?

·         What is the management of uncomplicated vs. complicated disease? How does the article we talked about play into that decision…

What is the incidence of diverticulosis, and one of its important complications, diverticulitis?

·         Diverticular disease is incredibly common, with prevalence being around 20% at the age 40, and basically becoming the norm at age 60 (around 60%). Recent studies have shown that complications of diverticular disease have been increasing in the younger population, probably a result of more sensitive diagnostic testing.

·         For reasons potentially attributable to diet, Western diverticulosis is typically left-sided, while diverticulosis in Asia is typically right-sided. Overall, diverticular disease has links to decreased fiber intake and obesity, though these associations are not particularly well defined.

·         The large majority of people with diverticular disease will NOT develop symptomatic disease, as only 20% of patients will ultimately develop diverticulitis.

What is the pathophysiology and clinical manifestations of diverticulitis?

·         Initially thought to be due to fecaliths obstructing diverticula, it is now generally accepted that micro-perforations in diverticula (leading to diverticulitis) is due to increased pressure within diverticula from food particles, which leads to inflammation.

·         Generally, such perforations are contained well by fat/mesentery and don’t lead to significant complications. Poorly contained perforations, or perforations with significant inflammation, can lead to abscesses, obstruction, free perforation with peritonitis, or fistulas. Such complications define “complicated diverticulitis,” which happens in about 25% of patients with diverticulitis at their initial episode.

·         The typical manifestation is left lower quadrant pain (70% of patients), that usually has been present for a few days prior to presentation (only 10-15% present with less than 24 hours of symptoms). Low-grade fever and leukocytosis are common as well. Nausea/vomiting, altered bowel habits, and urinary symptoms are other possible symptoms.

What is the management of uncomplicated vs. complicated disease? How does the article we talked about play into that decision…

·         Complicated diverticulitis generally requires surgical management, along with medical therapy. Abscesses, however, are a little more complicated. Most abscesses can be percutaneously drained, and surgery can be done electively. Additionally, sensitive imaging modalities are detecting smaller and smaller abscesses, which are not amenable to drainage, and may not even represent “complicated” cases. In one retrospective series of 22 patients, 60% patients with abscesses <3cm did NOT ultimately need surgical intervention.

·         Uncomplicated diverticulitis is treated with antibiotics covering gram negative and anaerobic organisms for a 10-14 day course, and bowel rest with slow advancement of diet. One-third of patients will have recurrent attacks, and risk factors for recurrent disease include retroperitoneal abscess, positive family history, and more than 5cm of colon involved in the initial episode.

·         Since recurrent attacks are associated with a higher rate of complications, surgical treatment is ultimately pursued in such cases. Operative management is generally curative, with new diverticula occurring in the remaining colon in 10% of patients.

·         Very interestingly, in a randomized study (attached) of cases of “uncomplicated diverticulitis,” patients were given antibiotics or no antibiotics, along with IV fluids (not blinded). Of those who didn’t receive antibiotics, 1.9% had complications, as compared to 1% of the control cohort (P > 0.05). There was also no difference between ultimate surgical management, hospital stay, or recurrent disease.

·         These are some very interesting findings, reinforcing that diverticulitis may have a more inflammatory, as opposed to infectious, pathogenesis. Nevertheless, the study was clearly flawed in several ways, mainly by a sample size that was not nearly large enough to detect a significant difference between the two cohorts, and a lost to follow up rate that exceeded the event rate.

Interesting stuff…A lot of GI this week…anyway enjoy the weekend and hope you learned something…KEEP READING!!

Acute Diverticulitis
Ferzoco et. al., NEJM 1999, Volume 338 (21): 1521 - 26

Chabok et. al., B J Surg 2012, Volume 99: 532-39
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