Morphological and functional features of the colonic mucus barrier in patients with symptomatic uncomplicated diverticular disease and acute uncomplicated diverticulitis.

OBJECTIVE: Aim: The purpose was to identify the morphological and functional features of the colonic mucus barrier in patients with symptomatic uncomplicated diverticular disease and acute uncomplicated diverticulitis. PATIENTS AND METHODS: Materials and Methods: In the research, three groups were formed. Group 1 included fragments of the mucous membrane of the large intestine, which were collected from 12 people during autopsies. The results of autopsies and histological examination of the material did not reveal any gastrointestinal pathology. Group 2 included biopsies of the mucous membrane of the large intestine from the area of the diverticulum of 34 patients with symptomatic uncomplicated diverticular disease. Group 3 included biopsies of the mucous membrane of the large intestine of 26 patients with acute uncomplicated diverticulitis. Histological (hematoxylin and eosin staining), histochemical (PAS reaction) and immunohistochemical (mouse monoclonal antibodies to Mucin 2 (MUC2) and Mucin 4 (MUC4)) staining methods were used. A morphometric study was also carried out. RESULTS: Results: In patients with diverticular disease, the authors identified disturbances in the morphofunctional state of the mucus barrier of the colon, the structure and function of goblet cells contained in its mucous membrane, characterized by a decrease in the thickness of the mucus layer covering the surface of the mucous membrane; a decrease in the size and number of goblet cells with a decrease in their mucus-producing ability; a change in the mucin profile, characterized by a violation of the content of MUC2 and MUC4. These changes were greatest in patients with acute uncomplicated diverticulitis compared with patients with symptomatic uncomplicated diverticular disease. CONCLUSION: Conclusions: The identified disturbances in the morphofunctional state of the mucus barrier of the colon, structural and functional changes in goblet cells may be one of the mechanisms for the development of acute uncomplicated diverticulitis and symptomatic uncomplicated diverticular disease.

Systematic Review and Meta-analysis on Colorectal Cancer Findings on Colonic Evaluation After CT-Confirmed Acute Diverticulitis.

BACKGROUND: CT findings of acute diverticulitis can overlap with features of malignancy, and current guidelines recommend colonic evaluation after acute diverticulitis. However, the benefits of routine colonic evaluation have been questioned. OBJECTIVE: We review 30 studies, composed of 29,348 subjects, to evaluate the role of routine colonic evaluation after CT-proven acute diverticulitis. DATA SOURCES: Medline, EMBASE, and the Cochrane Library were searched for articles published up to July 2018 to identify all relevant articles. STUDY SELECTION: A combination of both Medical Subject Headings and non-Medical Subject Headings key terms using Boolean operators were used on Medline, including colonic neoplasms, colorectal cancer, colon cancer, colonic cancer, colonoscopy, and diverticulitis. Any randomized or nonrandomized, English-language article that specifically analyzed incidence of colorectal cancer after performing colonoscopy in patients with previous diverticulitis was included. MAIN OUTCOME MEASURES: The desired outcome was to evaluate for incidence of colonic malignancy in cases of acute colonic diverticulitis. Subgroup analyses for incidence of malignancy in uncomplicated and complicated diverticulitis, and Asian population studies were also performed. RESULTS: Findings of colonic malignancy occurred in 1.67% (95% CI, 1.24-2.14) of patients with CT-diagnosed diverticulitis. The risk of malignancy in cases with uncomplicated diverticulitis was 1.22% (95% CI, 0.63-1.97) as compared with 6.14% (95% CI, 3.20-9.82) in cases with complicated diverticulitis, with a relative risk of 5.033 (95% CI, 3.194-7.930; p < 0.001). LIMITATIONS: Significant variability in design and methodology of the individual studies contributed to the heterogeneity of this study, but these were addressed by using the random-effects model analysis. CONCLUSIONS: Colonic evaluation is worth considering for patients with diverticulitis because of the small but serious risk of underlying malignancy. The risk of malignancy is higher for patients of advanced age and with complicated diverticulitis.

A curious case of colitis.

Segmental colitis associated with diverticulosis (SCAD) is a rare variant of chronic colitis that is limited to segments of the left colon that harbor diverticula. Histologically, SCAD is known to mimic chronic idiopathic inflammatory bowel disease. Patients usually present with hematochezia and cramping abdominal pain; SCAD often resolves spontaneously without treatment, or completely after a limited course of therapy. Due to the histologic overlap with ulcerative colitis and occasional Crohn colitis, the implications of an inaccurate diagnosis are significant.

Novel swine model of colonic diverticulosis.

The pathophysiology of colonic diverticulosis has not been completely understood. The development of appropriate animal models is essential to study diverticular disease. To date, no large animal models are available for this disease condition. The objective of this study was to develop a swine model by damaging the colon wall, combined with or without a low-fiber diet to mimic the pathogenesis of diverticulosis. To create a weakness on the colon wall, collagenase was applied in vivo to degrade the collagen in the colon wall. Three groups of Yucatan minipigs were included. Group 1 (n = 12) underwent collagenase injection (CI) with a low-fiber diet for 6 mo, group 2 (n = 8) underwent CI alone with a standard swine diet for 6 mo, and group 3 (n = 12) received a low-fiber diet alone for 6 mo. We found that diverticulosis occurred in 91.7% (11 of 12) of pigs in the CI + diet group and 100% (8 of 8) in CI-alone group. Moreover, around 30-75% of colon CI spots for each pig developed diverticular lesions. Diet alone for 6 mo did not induce diverticulosis. The endoscopic and histological examinations revealed the formation of multiple wide-mouthed diverticular lesions along the descending colon. Our results provide convincing evidence of the high efficacy of the reduced colon wall strength caused by CI in the development of a swine model of diverticulosis. Low-fiber diet consumption for 6 mo had no influence on the generation time or incidence rate of diverticulosis. In this model, digestion of the collagen in the colonic wall is sufficient to cause diverticulosis. NEW & NOTEWORTHY Effective large animal models of diverticulosis are currently lacking for the study of diverticular disease. This study marks the first time that a swine model of diverticulosis was developed by damaging colon wall structure, combined with or without a low-fiber diet. We found that a defect of colon wall could result in colon diverticular lesions within 6 mo in swine. This animal model mimicking the pathological process of diverticulosis is of great clinical value.

Pericolic or paracolic? The right word in the right place for acute diverticulitis.

KEY POINT: • The term "pericolic" is wrongly used to describe an abscess adjacent to the colon in patients with acute diverticulitis. We explain why the proper term is the word "paracolic."

Bowel wall thickening: inquire or not inquire? Our guidelines.

INTRODUCTION: Bowel wall thickening is not an uncommon finding among patient undergoing abdomen CT scan. It may be caused by neoplastic, inflammatory, infectious or ischaemic conditions but also be a normal variant. Although specific radiologic patterns may direct to a precise diagnosis, occasionally misidentification may occur. Thus, in the absence of guidelines, further and not always needed diagnostic procedures (colonoscopy, esophagogastroduodenoscopy or capsule endoscopy) are performed. PATIENTS AND METHODS: We conducted a retrospective study on data collected from May 2016 to June 2017. We selected 40 adult patients, admitted in Emergency Department with "abdominal pain" and undergone an abdomen CT scan, in which bowel wall abnormalities were founded. RESULTS: 75% patients were found to have a benign condition vs 25% a malignant condition. In the stomach group, 50% were found to have a neoplasm, whilst 33.3% presented an aspecific pattern and 16.7% had an inflammatory disease. In the small bowel cluster, 33.3% patients had an ischaemic disease, 33.3% an aspecific pattern, 22.2% an inflammatory disease and 11.1% was diagnosed with cancer. In the colon group, 36% had an inflammatory disease, 24% a colon cancer, 24% an aspecific pattern and 16% an ischaemic condition. CONCLUSIONS: We recommend to perform a further endoscopic procedure to all patients with gastric or colonic wall abnormalities on CT scan, on the basis of growing rate of cancer and IBD. Capsule endoscopy should be taken into account in patients with severe symptoms and after a previous negative endoscopic examination.

Role of visceral fat in colonic inflammation: from Crohn's disease to diverticulitis.

PURPOSE OF REVIEW: The composition of activated adipose tissue with adipocytes secreting a broad spectrum of immune-modulatory adipokines next to adipose tissue-derived stromal cells and professional immune effector cells in the visceral fat creates a complex network of inflammatory processes shaping local immune responses in the adjacent inflamed intestinal mucosa. RECENT FINDINGS: In Crohn's disease a particular phenomenon called 'creeping fat' can be observed. Here the hyperplastic mesenteric fat tissue not only grows around inflamed small intestinal segments but also furthermore affects the regulation of the mucosal immune system. Diverticular disease is highly prevalent in the western world but the knowledge about its immunopathology remains incomplete. Interestingly, adipose tissue also frequently covers the basolateral site of inflamed diverticula, hence locally reflecting the phenomenon seen in Crohn's disease. SUMMARY: This review aims to summarize the current knowledge in which measures this intraabdominal fat participates in the regulation of intestinal inflammation with a particular focus on differences and possible parallels in Crohn's disease and diverticulitis. The available data allow for suggesting that each inflamed diverticula mechanistically reflects Crohn's disease on a miniature scale.

A Markov Decision Model to Guide Treatment of Recurrent Colonic Diverticulitis.

BACKGROUND & AIMS: Although colonic diverticulitis is a common disorder, there is no clear treatment strategy for patients with recurrent episodes of diverticulitis. We investigated whether colonic resection or conservative or medical treatments have the greatest effects on quality-adjusted life-years (QALYs). METHODS: A Markov model simulating patients with 2 episodes of non-surgically treated diverticulitis was used to simulate all relevant outcomes of each treatment strategy. A 1-year cycle length with 10-year follow-up period was used to allow for chance of recurrent diverticulitis. Primary outcome was QALYs gained from each strategy. Factors considered were morbidity, mortality, chance of colostomy formation, risk of recurrence, and persistence of abdominal pain. The probabilities of clinical events were determined by using the best available published data. RESULTS: A strategy in which colonic resection was performed after 2 episodes of diverticulitis was associated with the lowest quality-adjusted survival (a gain of 8.66 QALYs) and highest chance of stoma formation (1.1%) but the lowest chance of a mild (3.5%) or severe (1.1%) recurrence. The strategies of colonic resection or conservative or medical treatment after the third episode of diverticulitis were comparable in terms of quality-adjusted survival, providing 8.78, 8.76, and 8.74 QALYs, respectively. Probabilistic sensitivity analysis did not change these results. Persistent abdominal complaints were lowest in the medical treatment strategy. CONCLUSIONS: Elective surgery after 2 episodes of diverticulitis should be questioned in terms of QALYs. After the third episode of diverticulitis, surgical or conservative or medical treatments provide similar QALYs, but rates of abdominal symptoms are lower with the medical treatment strategy. This Markov decision model has limitations when the individual patient and physician face a complex decision weighing early and long-term risks and benefits of elective surgery or conservative management.

Do Appendicitis and Diverticulitis Share a Common Pathological Link?

OBJECTIVE: The aim of this study was to determine whether there is an association between appendicitis and diverticulitis. DESIGN: This study is a retrospective cohort analysis. SETTING: This study was conducted in a subspecialty practice at a tertiary care facility. PATIENTS: We examined the rate of appendectomy among 4 cohorts of patients: 1) patients with incidentally identified diverticulosis on screening colonoscopy, 2) inpatients with medically treated diverticulitis, 3) patients who underwent left-sided colectomy for diverticulitis, and 4) patients who underwent colectomy for left-sided colorectal cancer. INTERVENTIONS: There were no interventions. MAIN OUTCOME MEASURES: The primary outcome measured was the appendectomy rate. RESULTS: We studied a total of 928 patients in this study. There were no differences in the patient characteristics of smoking status, nonsteroidal use, or history of irritable bowel syndrome across the 4 study groups. Patients with surgically treated diverticulitis had significantly more episodes of diverticulitis (2.8 ± 1.9) than the medically treated group (1.4 ± 0.8) (p < 0.0001). The rate of appendectomy was 8.2% for the diverticulosis control group, 13.5% in the cancer group, 23.5% in the medically treated diverticulitis group, and 24.5% in the surgically treated diverticulitis group (p < 0.0001). After adjusting for demographics and other clinical risk factors, patients with diverticulitis had 2.8 times higher odds of previous appendectomy (p < 0.001) than the control groups. LIMITATIONS: The retrospective study design is associated with selection, documentation, and recall bias. CONCLUSIONS: Our data reveal significantly higher appendectomy rates in patients with a diagnosis of diverticulitis, medically or surgically managed, in comparison with patients with incidentally identified diverticulosis. Therefore, we propose that appendicitis and diverticulitis share similar risk factors and potentially a common pathological link.

The relation between quality of life and histopathology in diverticulitis; can we predict specimen-related outcome?

PURPOSE: An important factor in the decision to perform laparoscopic sigmoid resection for patient suffering from recurrent and ongoing diverticulitis is quality of life (QoL). It is unknown whether quality of life relates to the severity of diverticulitis as seen in the resected colonic segment. The aim of this study is to analyze histopathological findings of patients suffering from recurrent or ongoing diverticulitis and their QoL before and after surgery in order to improve patient outcome prediction. METHODS: A cohort of consecutive patients with diverticulitis between January 2010 and April 2014 was analyzed. All patients were scheduled for surgery and had at least three episodes of diverticulitis or more within the last 2 years or experienced ongoing complaints for at least 3 months or more and confirmation by a radiologist. We compared QoL questionnaires, to known histopathological entities. RESULTS: For this study, 54 consecutive patients were included, 15 (27.8%) men and 39 (72.2%) women. A marked difference in quality of life before and after surgery for patients having a more severe histopathological entity was not found (p = 0.83). However, a clinically relevant higher VAS score 6 months after surgery was shown in patients with peritonitis. Furthermore, these patients had more fibrosis in the histopathological samples. CONCLUSION: In conclusion, even though a relation between the different pathological entities and QoL could not be determined, patients with diverticulitis and concomitant microscopic peritonitis had significantly more fibrosis and suffered from a higher VAS scores 6 months after surgery.

Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis: a comparative cohort study.

BACKGROUND: Current guidelines recommend routine follow-up colonoscopy after acute diverticulitis to confirm the diagnosis and exclude malignancy. Its value, however, has recently been questioned because of contradictory study results. Our objective was to compare the colonoscopic detection rate of advanced colonic neoplasia (ACN), comprising colorectal cancer (CRC) and advanced adenoma (AA), in patients after a CT-proven primary episode of uncomplicated acute diverticulitis with average risk participants in a primary colonoscopy CRC screening program. METHODS: A retrospective comparison was performed of prospectively collected data from cohorts derived from two multicenter randomized clinical trials executed in the Netherlands between 2009 and 2013. 401 uncomplicated diverticulitis patients and 1,426 CRC screening participants underwent colonic evaluation by colonoscopy. Main outcome was the diagnostic yield for ACN, calculated as number of diverticulitis patients and screening participants with ACN relative to their totals, with differences expressed as odds ratios (OR). The histopathology outcome of removed lesions during colonoscopy was used as definitive diagnosis. RESULTS: AA detection was similar [5.5 vs. 8.7%; OR 0.62 (95% CI 0.38-1.01); P = 0.053]. CRC was detected in 1.2% (5/401) of diverticulitis patients versus 0.6% (9/1,426) of screening participants [OR 1.30 (95% CI 0.39-4.36); P = 0.673]. ACN was diagnosed in 6.7% (27/401) of diverticulitis patients versus 9.1% (130/1,426) of screening participants [OR 0.71 (95% CI 0.45-1.11); P = 0.134]. ORs were adjusted for age, family history of CRC, smoking, BMI, and cecal intubation rate. CONCLUSIONS: ACN detection does not differ significantly between patients with recent uncomplicated diverticulitis and average risk screening participants. Routine follow-up colonoscopy after primary CT-proven uncomplicated left-sided acute diverticulitis can be omitted; these patients can participate in CRC screening programs. Follow-up colonoscopy may be beneficial when targeted at high-risk patients, but such an approach first needs prospective evaluation.

Statement of the section internal medicine of the DEGUM - ultrasound obtains pole position for clinical imaging in acute diverticulitis.

This paper reviews and interprets the role of ultrasonography in view of the recently published Guideline on diverticular disease of the Consensus conference of the German Societies of Gastroenterology (DGVS) and Visceral Surgery (DGAV) implying a new classification of diverticular disease (CDD). Qualified US is not only equipotent to qualified CT and frequently effectual for diagnosis but considers relevant legislation for radiation exposure protection. Unsurpassed resolution allows detailed resolution thereby allowing to differentiate and stratify the relevant types of diverticular disease. Subsequently, US is considered the first choice of imaging in diverticular disease. Vice versa, CT has definite indications in unclear / discrepant situations ­ or insufficient US-performance.

Expression of basic fibroblastic growth factor, syndecan 1 and tumour necrosis factor α in resected acute colonic diverticulitis.

AIM: Inflammation and fibrosis are present in both colonic diverticulitis and Crohn's disease (CD). The molecular pattern of basic fibroblastic growth factor (bFGF) and syndecan 1 (SD1) expression is altered in stenosing CD, but their expression in resected complicated colonic diverticulitis (ACD) is unknown. METHOD: The expression of bFGF, SD1 and tumour necrosis factor α (TNF-α) in 20 patients after resection of ACD was compared with 15 patients having a resection for CD. Analysis was conducted using real-time reverse transcriptase polymerase chain reaction in biopsy samples. RESULTS: Lymphocytic and neutrophil inflammation scores were similar in both groups (P = 0.771 and P = 0.562). TNF-α and bFGF expression was significantly higher in ACD than in CD (P < 0.0001 and P = 0.009). SD1 expression was similar in both groups (P = 0.841). CONCLUSION: TNF-α and bFGF are significantly overexpressed in ACD with respect to CD, whilst SD1 levels do not differ. The findings confirm that inflammation and its association with altered molecular patterns of mucosal healing may play an important role in the phenotype of the diseases.

Quality of coroner's post-mortems in a UK hospital.

PURPOSE: The aim of this paper was, principally, to look at the coroner's post-mortem report quality regarding adult medical patients admitted to an English hospital; and to compare results with Royal College of Pathologists guidelines. DESIGN/METHODOLOGY/APPROACH: Hospital clinical notes of adult medical patients dying in 2011 and who were referred to the coroner's office to determine the cause of death were scrutinised. Their clinical care was also reviewed. FINDINGS: There needs to be a comprehensive approach to coroner's post-mortems such as routinely taking histological and microbiological specimens. Acute adult medical patient care needs to improve. RESEARCH LIMITATIONS/IMPLICATIONS: Steps should be taken to ensure that comprehensive coroner's post-mortems are performed throughout the UK, including with routine histological and microbiological specimens examination. Additionally, closer collaboration between clinicians and pathologists needs to occur to improve emergency adult medical patient clinical care. ORIGINALITY/VALUE: The study highlights inadequacies in coroner's pathology services.

Is early colonoscopy beneficial in patients with CT-diagnosed diverticulitis?

OBJECTIVE: The purpose of this study was to establish CT criteria as an indication for colonoscopy in patients with acute diverticulitis. MATERIALS AND METHODS: The study was composed of patients diagnosed with acute diverticulitis on contrast-enhanced CT (CECT) from January 2000 to December 2004. Patients without subsequent colonoscopy were excluded. Findings on CT were correlated with patient outcomes over follow-up. Sensitivity, specificity, and predictive values of the imaging parameters for prediction of colon cancer were calculated. Outcomes were also compared between men and women. RESULTS: Of 1034 patients with a CT diagnosis of diverticulitis, 402 (235 women and 167 men; mean age, 63.3 years) had available endoscopic colonic evaluation after CECT. The mean follow-up was 5.3 years. Seventy-eight patients had polyps (71% adenomatous) and nine patients (2.2%) were diagnosed with colon cancer (seven women, two men). The odds ratio for diagnosis of colon cancer was 23.35 in patients with mesenteric or retroperitoneal lymphnodes, 4.67 for abscess, and 24.43 in patients with obstruction and localized mass reported on CT. A significant correlation was found between the location of diverticulitis and cancer (p < 0.001). The diagnosis of cancer was made within 6 months from the date of CECT in eight patients. The odds of cancer were 2.5 times higher in women. CONCLUSION: On the basis of the significant correlation of complicated diverticulitis or presence of lymph nodes with new diagnoses of colon cancer, we recommend early colonoscopy in patients with wall thickness more than 6 mm, abscess, obstruction, or lymph nodes seen on CECT.

Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis.

BACKGROUND: This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis. OBJECTIVE: This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis. METHODS: A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes. RESULTS: Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001). CONCLUSIONS: Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.