Enfermedad diverticular de colon no complicada sintomática: revisión sistemática del diagnóstico y tratamiento / Management of symptomatic uncomplicated diverticular colon disease: A systematic review of diagnosis and treatment

La enfermedad diverticular de colon (EDC) no complicada sintomática (EDCNCS) es una patología con elevada prevalencia en nuestro medio que afecta de manera importante la calidad de vida de los pacientes que la padecen. Los cambios recientes en la comprensión de la historia natural de esta enfermedad y los avances tecnológicos y farmacológicos han incrementado sustancialmente las opciones disponibles tanto para su diagnóstico como para el tratamiento. Sin embargo, el consenso que existe en cuanto al uso de estas opciones es pobre y en algunas ocasiones carente de evidencia científica. El objetivo de esta revisión sistemática es esclarecer la evidencia científica existente y fundamentar la utilización de las diferentes opciones diagnósticas y terapéuticas en la EDCNCS, comparando las ventajas y desventajas entre estas, para sugerir finalmente un algoritmo diagnóstico-terapéutico para esta patología y al mismo tiempo proponer nuevas preguntas de investigación.(AU)

Symptomatic uncomplicated diverticular colon disease (SUDCD) is a highly prevalent disease in our setting, which significantly affects the quality of life of patients. Recent changes in understanding the natural history of this disease and technological and pharmacological advances have increased the available options for both diagnosis and treatment. However, consensus regarding the use of these options is scarce and sometimes lacks scientific evidence. The objective of this systematic review is to clarify the existing scientific evidence and analyse the use of the different diagnostic and therapeutic options for SUDCD, comparing their advantages and disadvantages, to finally suggest a diagnostic-therapeutic algorithm for this pathology and, at the same time, propose new research questions.(AU)

Major duodenal diverticular bleeding / Hemorragia de divertículo duodenal

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Colonic diverticulosis and the metabolic syndrome: an association?

Background and objectives: Colonic diverticulosis (CD) is related to advanced age and a lack of dietary fiber. Recently, several studies have shown that metabolic syndrome (MS) is also implicated in the etiopathogenesis of CD. This study aimed to assess the association between MS, obesity and CD. Methods: This was a prospective study of a one-year duration. The MS was defined according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III). Demographic data, risk factors for MS and endoscopic findings of patients who underwent a total colonoscopy in the department were collected. Obesity was defined as a body mass index ≥ 30 kg/m2. Informed consent was obtained. The local Ethics Committee and National Data Protection Committee approved the study. Statistical analysis was performed with SPSS 21 and statistical significance was defined as p < 0.05. Results: The study included 203 patients, 95 males with a mean age of 65.5 years. CD was diagnosed in 30.5% of patients. Univariate analysis showed that age, hypertension, increased waist circumference and hyperlipidemia were associated with colonic diverticulosis. There was no association with gender, obesity or type 2 diabetes mellitus. Multivariate analysis showed that age and a greater waist circumference increased the risk of diverticulosis. Ageadjusted analysis showed that MS was associated with diverticulosis. The prevalence of adenoma in patients with CD was similar to that in patients without CD. Conclusion: In this series, MS was significantly associated with CD. The identification of risk groups is important since diverticulosis can have serious and potentially fatal complications. To our knowledge, this is the first Southern European prospective study evaluating the association between MS and CD (AU)

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Plan de cuidados a paciente con enfermedad diverticular complicada / Care plan for patients with complicated diverticular disease

Se presenta el caso de un varón de 48 años, con diagnóstico de enfermedad diverticular complicada, que presenta sangrado recurrente posterior a la cirugía. La valoración enfermera se realiza teniendo como marco la Teoría del Autocuidado de Dorothea Orem. Se identificaron los factores condicionantes básicos y los requisitos de autocuidado universales del desarrollo y de desviación a la salud. Se utilizó el modelo de Análisis de Resultados del Estado Actual (AREA) y la taxonomía de la North American Nursing Diagnosis Association (NANDA), elaborándose un plan de cuidados considerando los resultados esperados y las intervenciones de Enfermería propuestas también en la Nursing Interventions Classification (NIC) y la Nursing Outcomes Classification (NOC). La aplicación del modelo AREA para el razonamiento clínico de Enfermería ayuda a priorizar los requisitos de autocuidado alterados del paciente, lo que permite identificar el diagnóstico enfermero principal, los diagnósticos secundarios y los diagnósticos de riesgo y, de esta forma, planificar los cuidados específicos para brindar una atención de salud integral (AU)

We hereby present the case of a 48-year-old male patient, with diagnosis of complicated diverticular disease, presenting recurrent postsurgical bleeding. Nursing evaluation was conducted within the setting of the Dorothea Orem's Self-Care Theory. Basic determining factors were identified, as well as universal self-care requirements for development and health deviation. The study used the model from the Analysis of Current Status Outcomes (ACSO), and the taxonomy by the North American Nursing Diagnosis Association (NANDA); the care plan was prepared considering the expected outcomes and the nursing interventions also put forward by the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC). The application of the ACSO model for the clinical rationale of Nursing allows to prioritize the altered self-care requirements of the patient, which facilitates the identification of the primary Nursing diagnosis, secondary diagnoses and risk diagnoses, and therefore, to plan the specific care in order to offer comprehensive patient care (AU)

Hepatitis aguda medicamentosa / Drug-induced acute hepatitis

Presentamos el caso de una mujer de 75 años que presenta hepatitis aguda tras recibir tratamiento prolongado con nitrofurantoína, como profilaxis de infecciones urinarias recurrentes. Los fármacos son una importante causa de hepatotoxicidad; más de 900 fármacos, toxinas y plantas han sido implicados como causa del daño hepático. Los clínicos deben vigilar y detectar precozmente para evitar cuadros severos de toxicidad hepática (AU)

We report the case of a 75-year-old female with acute hepatitis after a long-term treatment with nitrofurantoin as prophylaxis for recurrent urinary tract infections. Drugs are an important cause of hepatotoxicity; over 900 drugs, toxins, and herbs have been reported to cause liver damage. Physicians must be vigilant and identify drug-related liver damage early to avoid severe liver toxicity (AU)

Enfermedad diverticular complicada: toma de posición sobre tratamiento ambulatorio, intervención de Hartmann, lavado-drenaje peritoneal y cirugía laparoscópica. Documento de consenso de la Asociación Española de Coloproctología y Sección de Coloproctología de la Asociación Española de Cirujanos / Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

Desde la Asociación Española de Coloproctología (AECP) y la Sección de Coloproctología de la Asociación Española de Cirujanos (AEC), se propone un documento de consenso sobre la enfermedad diverticular complicada que pueda ser de utilidad en la toma de decisiones. En él se expone, principalmente, la actualidad en el tratamiento ambulatorio, la intervención de Hartmann, el lavado laparoscópico peritoneal, así como el papel del abordaje laparoscópico en la resección colónica (AU)

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed (AU)

Colonic diverticular bleeding. Have we identified the risk factors for massive bleeding yet?

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Risk factors for severity and recurrence of colonic diverticular bleeding

Background: Colonic diverticular bleeding is the most common cause of lower gastrointestinal bleeding. Risk factors related to severity and repeated bleeding episodes are not completely clearly defined. Objective: To characterize a Portuguese population hospitalized due to colonic diverticular bleeding and to identify the clinical predictors related to bleeding severity and rebleeding. Methods: Retrospective analysis of all hospitalized patients diagnosed with colonic diverticular bleeding from January 2008 to December 2013 at our institution. The main outcomes evaluated were bleeding severity, defined as any transfusion support requirements and/or signs of hemodynamic shock, and 1-year recurrence rate. Results: Seventy-four patients were included, with a mean age of 75.7 ± 9.5 years; the majority were male (62.2%). Thirty-six patients (48.6%) met the criteria for severe bleeding; four independent risk factors for severe diverticular bleeding were identified: low hemoglobin level at admission (≤ 11 g/dL; OR 18.8), older age (≥ 75 years; OR 4.7), bilateral diverticular location (OR 14.2) and chronic kidney disease (OR 5.6). The 1-year recurrence rate was 12.9%. We did not identify any independent risk factor for bleeding recurrence in this population. Conclusion: In this series, nearly half of the patients hospitalized with diverticular bleeding presented with severe bleeding. Patients with low hemoglobin levels, older age, bilateral diverticular location and chronic kidney disease had a significantly increased risk for severe diverticular bleeding. In addition, a small number of patients rebled within the first year after the index episode, although we could not identify independent risk factors associated with the recurrence of diverticular bleeding (AU)

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Diagnóstico y tratamiento de la enfermedad diverticular del colon derecho: revisión de conjunto / Diagnosis and management of right colonic diverticular disease: A review

El objetivo de esta revisión es definir las características clínico-patológicas y aclarar el tratamiento de la enfermedad diverticular del colon derecho. Es poco frecuente en Europa, Estados Unidos y Australia, y más común en Asia. Durante los últimos años, su incidencia ha aumentado en Occidente, con diferentes distribuciones entre poblaciones. Muchos estudios han mostrado que es difícil diferenciar antes de la cirugía los síntomas de presentación de esta enfermedad de los de la apendicitis, ya que los síntomas y signos son similares, por lo que no es infrecuente encontrarse con un diagnóstico incorrecto. Con estudios de diagnóstico por la imagen exactos es posible establecer un diagnóstico preoperatorio preciso a fin de evaluar una estrategia de tratamiento adecuada. Actualmente, el tratamiento de esta enfermedad no está bien definido, no se han propuesto recomendaciones claras y no se sabe si también se pueden aplicar las recomendaciones para la enfermedad diverticular del colon izquierdo. Varios autores han señalado que el tratamiento conservador es el mejor enfoque, incluso en caso de reincidencia, y que la cirugía solo estaría indicada en determinados casos

The aim of this narrative review is to define the clinical-pathological characteristics and to clarify the management of right colonic diverticular disease. It is rare in Europe, USA and Australia and more common in Asia. In the recent years its incidence has increased in the West, with various distributions among populations. Many studies have reported that it is difficult to differentiate the presenting symptoms of this disease from those of appendicitis before surgery, because the signs and symptoms are similar, so misdiagnosis is not infrequent. With accurate imaging studies it is possible to reach a precise preoperative diagnosis, in order to assess an accurate treatment strategy. Currently the management of this disease is not well defined, no clear guidelines have been proposed and it is not known whether the guidelines for left colonic diverticular disease can also be applied for it. Several authors have stated that conservative management is the best approach, even in case of recurrence, and surgery should be indicated in selected cases

Colonic diverticular disease. Treatment and prevention / Enfermedad diverticular cólica. Tratamiento y prevención

Diverticular disease represents the most common disease affecting the colon in the Western world. Most cases remain asymptomatic, but some others will have symptoms or develop complications. The aims of treatment in symptomatic uncomplicated diverticular disease are to prevent complications and reduce the frequency and intensity of symptoms. Fibre, probiotics, mesalazine, rifaximin and their combinations seem to be usually an effective therapy. In the uncomplicated diverticulitis, outpatient management is considered the optimal approach in the majority of patients, and oral antibiotics remain the mainstay of treatment. Admission to hospital and intravenous antibiotic are recommended only when the patient is unable to intake food orally, affected by severe comorbidity or does not improve. However, inpatient management and intravenous antibiotics are necessary in complicated diverticulitis. The role of surgery is also changing. Most diverticulitis-associated abscesses can be treated with antibiotics and/or percutaneous drainage and emergency surgery is considered only in patients with acute peritonitis. Finally, patient related factors, and not the number of recurrences, play the most important role in selecting recipients of elective surgery to avoid recurrences

La enfermedad diverticular es la enfermedad cólica más frecuente en el mundo Occidental. La mayoría de los pacientes permanecerán asintomáticos a lo largo de su vida, pero un porcentaje no despreciable presentarán síntomas o desarrollarán complicaciones. El objetivo del tratamiento en la enfermedad diverticular no complicada sintomática es prevenir las complicaciones y reducir la frecuencia e intensidad de los síntomas. La fibra, los probióticos, la mesalazina, la rifaximina y sus combinaciones parecen ser terapias eficaces. En la diverticulitis no complicada, el manejo extrahospitalario se considera actualmente el manejo óptimo, siendo los antibióticos administrados por vía oral la piedra angular del tratamiento. El ingreso hospitalario solo será necesario en pacientes con intolerancia oral, comorbilidad grave o ausencia de mejoría. Sin embargo, el manejo intrahospitalario es preciso en las diverticulitis complicadas. La mayoría de los abscesos podrán ser tratados con antibióticos y/o drenaje percutáneo, reservando la cirugía urgente para pacientes con peritonitis aguda. La indicación de cirugía electiva para prevención de recurrencias debe ser indidualizada y no basarse únicamente en el número de episodios previos de diverticulitis

Otro gran imitador..., con desenlace fatal / Another great wannabe..., with fatal outcome

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Nuevas tendencias en el manejo de la diverticulitis y la enfermedad diverticular del colon / New trends in the management of diverticulitis and colonic diverticular disease

La enfermedad diverticular del colon es una entidad crónica con una variada sintomatología abdominal que puede cursar con episodios recurrentes de diverticulitis aguda. Debido a su estrecha relación con la edad, su prevalencia ha aumentado de forma muy significativa en los países de occidente en las últimas décadas, incrementando sobremanera los gastos derivados de su tratamiento. Recientemente, varios trabajos han aportado evidencia a una serie de medidas que podrían mejorar los resultados al tiempo que disminuir los gastos asociados a este proceso. El objetivo de la presente revisión es exponer una visión, basada en la mayor evidencia disponible, de las nuevas tendencias en el manejo de la diverticulitis aguda y enfermedad diverticular del colon

Colonic diverticular disease is a chronic disorder presenting with a variety of abdominal symptoms and recurrent episodes of acute diverticulitis. It is close linked to age so its prevalence has risen notably during the last decades in western countries, increasing costs related to medical attention. Recently, several works have provided evidence to a series of measures that could improve the outcomes as well as reduce expenses associated to this process. The aim of the present review is to expose a view of the new trends in the management of diverticulitis and colonic diverticular disease, based on the highest clinical evidence available

Hemorragia diverticular de colon: colonoscopia urgente sin preparación y tratamiento endoscópico con hemoclips y adrenalina / Colonic diverticular bleeding: urgent colonoscopy without purging and endoscopic treatment with epinephrine and hemoclips

La enfermedad diverticular en la causa más frecuente de hemorragia digestiva baja. En la mayoría de las ocasiones el sangrado cesa sin ninguna intervención, pero en un 10-20 % de los casos es necesario tratar la hemorragia. Se han descrito varias modalidades de tratamiento endoscópico tras preparar el colon. Presentamos cinco casos de hemorragia diverticular severa tratados con inyección de adrenalina y hemoclips. Todas las colonoscopias se realizaron de urgencia y sin preparación del colon, con correcta visualización del punto de sangrado. Los pacientes evolucionaron favorablemente evitando otros procedimientos agresivos como una arteriografía o cirugía (AU)

Diverticular disease is the most frequent cause of lower gastrointestinal bleeding. Most of the times, bleeding stops without any intervention but in 10-20 % of the cases it is necessary to treat the hemorrhage. Several modalities of endoscopic treatment have been described after purging the colon. We present five cases of severe diverticular bleeding treated with injection of epinephrine and hemoclips. All the colonoscopies were performed without purging of the colon in an emergency setting, with correct visualization of the point of bleeding. Patients recovered well avoiding other aggressive procedures such as angiography or surgery (AU)

Medición de la absorción de los ácidos biliares en el diagnóstico inicial de la diarrea crónica / Measurement of 75Se-SeHCAT abdominal retention in the initial diagnosis of Bile Acid Absorption (BAM)

Objetivo. Evaluar la utilidad de la prueba del 75SeHCAT en el diagnóstico precoz del síndrome diarreico (SD). Se evaluaron prospectivamente 37 pacientes con SD de un mes de evolución. Método. Se midió la retención abdominal (RA) de 75SeHCAT 4 y 7 días post-administración de 0,01 mCi de 75SeHCAT antes del tratamiento y a los tres meses en los pacientes con estudio basal positivo. La prueba se consideró positiva si la RA era: < 25% el 4.° y < 10% el 7.° días. Los pacientes fueron visitados a los tres meses. Según la respuesta se distinguió: a) respuesta completa: normalización del ritmo deposicional; b) respuesta parcial, disminución de la frecuencia/consistencia, y c) no respuesta. Resultados. Grupo A: la RA fue normal en 21 pacientes. El diagnóstico fue: 6 divertículos colónicos, 8 síndrome de intestino irritable, 1 colitis linfocitaria, 1 síndrome post-gastroenteritis, 1 enfermedad celíaca, 1 estenosis de cardias y 4 continuan en estudio. Grupo B: la RA disminuyó en 16 pacientes; todos mostraron una RA baja a los 7 días y solo uno a los 4 días. Tras la administración de resina de colestiramina, 8 (50%) presentaron respuesta parcial y 8 (50%) respuesta completa. A los tres meses, la RA había aumentado en tres pacientes al 4.° día y en 9 al 7.° día. Conclusión. La medición de la RA de 75Se-SEHCAT permite el diagnóstico precoz de la malabsorción de sales biliares en el 43% de pacientes con SD. La medición a los 7 días parece más precisa que la de los 4 días(AU)

Aim. To evaluate the usefulness of the 75SeHCAT abdominal retention (AR) measurement in the early diagnosis of diarrhea syndrome (DS). Methods. Thirty-seven patients with diarrhea syndrome within the first month of evolution were prospectively evaluated. The 75Se-SeHCAT abdominal retention was measured 4 and 7 days post-administration of 0.01 mCi of 75SeHCAT. The test was performed prior to treatment and at 3 months when the baseline study was positive. The test was considered positive if the RA was <25% at 4th and <10% on the 7th day. The patients were visited at 3 months. Depending on the response, 3 groups were established: a) complete response: normalization of stool frequency, b) partial response, decrease of frequency or c) no response. Results. Group A: The AR of 75Se-SEHCAT was normal in 21 patients. Six were diagnosed of colonic diverticulosis, 8 of irritable bowel syndrome, 1 of lymphocytic colitis, 1 of post-gastroenteritis syndrome, 1 of celiac disease and 1 of stenosis of the cardia. Four are still under study. Group B: The AR of 75Se-SEHCAT decreased in 16 patients. All showed abnormal AR at day 7 and all but 1 at day 4. Following administration of cholestyramine resin, 8 (50%) presented partial response and 8 (50%) complete response. At 3 months, AR had increased at day 4 and 9 at day 7. Conclusion. The measurement of 75SEHCAT abdominal retention allows the early diagnosis of bile acid malabsorption in 43% of the patients with DS. Measurement at 7 days seems more accurate than that at 4 days(AU)

Hemorragia digestiva baja grave de origen diverticular / Severe lower gastrointestinal tract bleeding due to diverticulosis

Introducción. La diverticulosis supone la causa más frecuente de hemorragia digestiva baja (HDB) en pacientes adultos de países occidentales. Los objetivos son analizar: 1) el manejo diagnóstico-terapéutico de los pacientes con HDB severa de origen diverticular; 2) valorar la morbimortalidad asociada; 3) analizar la necesidad de cirugía, y 4) valorar los índices de recidiva de la hemorragia tras el alta hospitalaria. Material y métodos. Se revisan retrospectivamente 42 pacientes con HDB grave de origen diverticular. Fueron considerados los siguientes casos: pacientes con rectorragias que requirieron la transfusión de al menos tres concentrados de hematíes y aquéllos pacientes que presentaron un descenso del hematocrito igual o mayor a 10 puntos. Como grupo control se utilizaron 133 HDB graves en pacientes donde las etiologías no eran la enfermedad diverticular colónica. Resultados. Todos los pacientes se estabilizaron con medidas conservadoras excepto uno que precisó cirugía urgente. Se realizó colonoscopia a 39 pacientes siendo lo más frecuente hallar signos recientes de hemorragia con independencia del momento de su realización precoz o tardía. En un caso se realizó tratamiento endoscópico mediante electrocoagulación con láser de Argón. El índice de recidiva de hemorragia tras el alta hospitalaria fue del 31% de los pacientes (n=13), precisando 7 de ellos (16%) reingreso hospitalario. Conclusión. La HDB grave de origen diverticular cede en la mayoría de los casos con tratamiento conservador aunque con un alto porcentaje de recidiva de la hemorragia. La realización de endoscopia precoz no es tan importante como en el resto de causas de HDB grave (AU)

Introduction. Diverticulosis is the most frequent cause of lower gastrointestinal (GI) bleeding in adults in western countries. The aims of the present study were to analyze: 1) the diagnostic and therapeutic management of patients with severe lower GI bleeding due to diverticulosis; 2) associated morbidity and mortality; 3) the need for surgery, and 4) bleeding recurrence rates after hospital discharge. Material and methods. Were retrospectively reviewed 42 patients with severe lower GI bleeding due to diverticulosis. Patients with rectorrhagia requiring transfusion of at least three packed red blood cell units and those with a decrease in hematocrit of 10 points or more were included. As a control group, we used 133 patients with severe lower GI hemorrhage due to causes other than colonic diverticular disease. Results. All patients were stabilized with conservative measures except one who required emergency surgery. Colonoscopy was performed in 39 patients and the most frequent finding consisted of recent signs of bleeding independently of whether colonoscopy was performed early or was delayed. Endoscopic treatment with Argon laser electrocoagulation was performed in one patient. Bleeding recurrence after hospital discharge occurred in 13 patients (31%); of these, seven (16%) required hospital readmission. Conclusion. Severe lower GI bleeding due to diverticulosis can usually be resolved with conservative treatment although the percentage of bleeding recurrence is high. Early endoscopy is not as important as in the remaining causes of severe lower GI bleeding (AU)

Imagen radiológica del carbonato de lantano / No disponible

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