[Ultrasound diagnosis of chronic paracolic inflammatory mass in diverticular disease]. / Ul'trazvukovaya diagnostika khronicheskogo parakolicheskogo infil'trata pri divertikulyarnoi bolezni obodochnoi kishki.

OBJECTIVE: To evaluate the feasibility of ultrasound in diagnosis of chronic paracolic inflammatory mass in patients with diverticular disease. MATERIAL AND METHODS: We analyzed ultrasonic findings in 216 patients with chronic inflammatory complications of colonic diverticular disease. Chronic paracolic inflammatory mass as the most common and significant chronic complication of diverticular disease was analyzed in 116 patients. Ultrasonic findings were compared with specimen assessment, intraoperative data, irrigoscopy, colonoscopy, endoscopic ultrasound and computed tomography data. RESULTS: Sensitivity of ultrasound for diagnosis of chronic paracolic inflammatory mass was 76,7%, specificity - 100%, overall accuracy - 87,5%. CT and endoscopic ultrasound were the most informative among different diagnostic tools (sensitivity 79,6% and 77,8%, respectively). CONCLUSION: Ultrasonic examination and computed tomography are the most valuable methods for diagnosis of chronic paracolic inflammatory mass in patients with diverticular disease. Ultrasound is a first-line method for diagnosis and follow-up of complicated diverticular disease due to its availability, safety and unnecessary special preparation of patients.

[Epidemiological investigation of colonic diverticulosis detected by computed tomography colonography].

Among 586 patients who underwent computed tomography colonography (CTC) from May 2012 to September 2017, 333 were diagnosed with colonic diverticulosis. The incidence of colonic diverticulosis increases with age. Despite a high frequency of ascending colonic diverticulosis, multiple diverticulosis (>10 in a colonic segment) were the most frequent in the sigmoid colon. In previous studies, the frequency of detection of colonic diverticulosis by CTC was higher than that by colonoscopy and barium enema. In addition, using CTC, the detection rate of colonic diverticulosis has been recently increasing, suggesting that CTC is the most sensitive procedure for detecting colonic diverticulosis.

Therapeutic impact of colon capsule endoscopy with PillCam™ COLON 2 after incomplete standard colonoscopy: a Spanish multicenter study.

INTRODUCTION: Colon capsule endoscopy (CCE) is an alternative approach for the examination of the colon in patients who refuse colonoscopy or after incomplete colonoscopy (IC). We conducted a study to determine the frequency of complete colonoscopy after IC, the diagnostic yield of CCE, the therapeutic impact of lesions found in CCE, the level of colon cleanliness and the safety of the procedure. METHODS: We performed a prospective, multicenter study involving ten Spanish hospitals. Consecutive outpatients aged ≥ 18 years with previous IC were invited to participate. The latest version of the CCE device, PillCam™ COLON 2 (CCE-2), was administered to all patients according to the protocol. RESULTS: The study population comprised 96 patients. The most frequent cause of IC was the inability to move past a loop using standard maneuvers (75/96 patients, 78%). Complete visualization of the colon was obtained with CCE-2 in 69 patients (71.9%). Of the 27 patients in whom the CCE-2 did not reach the hemorrhoidal plexus, it passed the colonic segment explored with the previous colonoscopy in 20 cases; therefore, it could be inferred that a combined approach (CCE-2 plus colonoscopy) enabled complete visualization of the colonic mucosa in 92.7% of patients. CCE-2 revealed new lesions in 58 patients (60.4%). Polyps were the most frequent finding (41 patients; 42.7% of the total number of patients). In 43 of the 58 patients (44.8% of the total number of patients), the new lesions observed led to modification of therapy, which included a new colonoscopy for polyp resection or surgery in patients with colonic neoplasm. CONCLUSIONS: CCE-2 is a suitable diagnostic procedure that can lead to more frequent diagnosis of significant colonic lesions after IC.

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.

Intestinal Ultrasonography in the Diagnosis and Management of Colonic Diverticular Disease.

Diverticula of the colon and their symptomatic manifestations, including acute diverticulitis (AD), are frequent complaints and the cause of an increasing burden of ambulatory visits, diagnostic procedures, and hospital admissions. Endoscopic and radiologic diagnostic procedures have a well-known role in the diagnosis and management of the disease, but recently intestinal ultrasonography has been proposed as a complementary tool in the diagnosis and follow-up of diverticular disease. This review shows the main sonographic features of diverticula and discusses the potential role of ultrasound in suggesting the presence of symptomatic uncomplicated diverticular disease of the colon. Moreover, the sonographic features of AD, diagnostic accuracy, advantages, and limitations of the technique will be discussed. We place special emphasis on the present role of intestinal ultrasonography in patients with suspected AD. Owing to its high sensitivity and high positive predictive value in assessing AD, intestinal ultrasound is currently suggested by some European national consensus guidelines as the first-line examination in this setting. In fact, to minimize false-negative findings and avoid unnecessary radiation exposure in patients with suspected AD, intestinal ultrasound might be used as the first-line examination in a sequential diagnostic strategy, followed by computed tomography only in the case of negative or inconclusive findings.

Diverticular Disease of the Colon: News From Imaging.

Different scenarios embrace computed tomography imaging and diverticula, including asymptomatic (diverticulosis) and symptomatic patients (acute diverticulitis, follow-up of acute diverticulitis, chronic diverticulitis). If the role of computed tomography is validated and widely supported by evidence in case of acute diverticulitis, this is not the case of patients in their follow-up for acute diverticulitis or with symptoms related to diverticula, but without acute inflammation. In these settings, computed tomography colonography is gaining consensus as the preferred radiologic test.

The alterations of the sigmoid-rectal junction in diverticular disease of the colon revealed by MR-defecography.

PURPOSE: The sigmoidorectal junction (SRJ) has been defined as an anatomical sphincter with particular physiological behavior that regulates sigmoid and rectum evacuation. Its function in clinical conditions, such as diverticular disease has been advocated. The aim of our study is to identify the SRJ and to compare the morphometric and dynamic features of the SRJ between patients with diverticular disease and healthy subjects using MR-defecography. METHODS: Sixteen individuals, eight with uncomplicated diverticular disease and eight healthy subjects, were studied using MR-defecography to identify the SRJ and to compare the morphometric and dynamic features observed. RESULTS: In each subject studied, MR-defecography was able to identify the SRJ. This resulted in the identification of a discrete anatomical entity with a mean length of 31.23 mm, located in front of the first sacral vertebra (S1) and at a mean distance of 15.55 cm from the anal verge, with a mean wall thickness of 4.45 mm, significantly different from the sigmoid and rectal parietal thickness. The SRJ wall was significantly thicker in patients with diverticular disease than the controls (P = 0.005), showing a unique shape and behavior in dynamic sequences. CONCLUSION: Our findings support the hypothesis that SRJ plays a critical role in patients with symptomatic diverticular disease; further investigation may clarify whether specific SRJ analysis, such as MR-defecography, would predict inflammatory complications of this diffuse and heterogenic disease.

Diverticular disease of the colon does not increase risk of repeat C. difficile infection.

BACKGROUND: Studies have suggested that colonic diverticulosis might increase the likelihood of repeat Clostridium difficile infection (CDI). Our study was designed to compare rates of repeat infection in patients with and without colon diverticula. METHODS: Patients who had a positive C. difficile toxin assay and colonoscopic evidence of diverticulosis were classified as CDI and diverticulosis (CDI-D), whereas those with a positive toxin assay but no such colonoscopic evidence were classified as CDI and no diverticulosis (CDI-ND). Various clinical and epidemiologic factors were recorded for each patient. Primary outcomes were "relapse" (repeat CDI within 3 mo of initial infection) and "recurrent" infection (repeat CDI≥3 mo after initial infection). Secondary outcomes 30 days after diagnosis were mortality, intensive care unit transfer, and continuous hospitalization. RESULTS: A total of 128 patients were classified as CDI-D, whereas 137 had CDI-ND. There were no significant differences between CDI-D and CDI-ND when comparing frequencies of repeat infection and its subclassifications, relapse or recurrence. There were, however, statistical associations seen between diverticulosis of the ascending colon and increased recurrence rates [hazard ratio (HR): 1.4±0.38, P<0.05] and decreased rates of relapse in diverticular disease of the descending (HR: 0.40±0.46, P<0.05), and sigmoid colon (HR: 0.39±0.49, P<0.05). The ascending colon association is limited by a small patient population. There were no significant differences in any of the 30-day outcomes including intensive care unit requirement, hospitalization stay, or mortality. CONCLUSIONS: Patients with diverticular disease of the colon are not at increased risk of repeat CDI.

[Colonic diverticulosis: natural history and therapeutic indications]. / Diverticulose colique: histoire naturelle et indications thérapeutiques.

Colonic diverticulosis defined by the presence of mucosal hernia passing through the colic muscularis is symptomatic due to complications in 10-20% of cases. It affects less than 10% of patients before 40 years old and reaches 80% at 80 years old. Primary prevention is a diet of 25g of dietary fiber per day. We are witnessing a decrease of the number of the resections during the last ten years. The diagnosis requires CT proofs. The most serious complications are often inaugural, and severity of acute accesses decreases then. Emergency cares are often minimally invasive therapies as imaging guided and laparoscopic drainage. Resection is reserved for peritonitis, chronic stenosis, fistula, or persistent diseases despite medical management, in patients with more than 3 outbreaks and patients with specific medical risk or immunocompromised.

Asymptomatic diverticulosis identified by computed tomography is not a risk factor for enteric peritonitis.

BACKGROUND: Colonic diverticulitis is an important cause of polymicrobial peritonitis, which requires surgical treatment and cessation of peritoneal dialysis (PD). The aim of this study was to examine whether plain abdominal computed tomography (CT) is useful for evaluating colonic diverticulosis in chronic kidney disease (CKD) patients and to explore whether colonic diverticulosis is a risk factor for enteric peritonitis. METHODS: The subjects consisted of 137 consecutive CKD patients (Stage 4 or 5) who were candidates for PD from February 2005 to November 2009. Abdominal CT without contrast media was performed in all PD candidates. RESULTS: Diverticula of the colon were detected by plain CT in 57 cases (41.6%). The number of diverticula tended to increase with age. The most common site of involvement of diverticulosis was the ascending colon. In patients treated with PD, the incidence of peritonitis was higher in patients with diverticulosis than in those without diverticulosis (P = 0.004). However, only one episode of enteric peritonitis was observed among patients with diverticulosis. The presence of diverticulosis did not affect cumulative or technical survival. PD was not selected in four cases due to a high frequency of diverticula with episodes of abdominal pain. Two cases developed severe diverticulitis with peritonitis and underwent resection of the colon. CONCLUSIONS: Our study suggests that plain CT examination is useful for detecting diverticulosis in CKD patients. Silent diverticulosis is not a risk factor for enteric diverticulosis-related peritonitis. PD may be contraindicated in cases having frequent diverticulosis with episodes of lower abdominal pain.

Association between colorectal cancer and colonic diverticulosis: case-control study based on computed tomographic colonography.

BACKGROUND: The association between colorectal cancer (CRC) and diverticulosis is uncertain, and there is little data reported in Asia. This study examined the association of both diseases based on the computed tomographic colonography (CTC). METHODS: This study was designed as a case-control study. Korean subjects undergoing CTC between April 2002 to April 2008 in Samsung Medical Center were eligible. Patients with histologically proven colorectal cancer (case group) and asymptomatic age and gender matched controls (control group) were analyzed retrospectively. RESULTS: A total of 604 subjects were enrolled in this study (Case group N = 302, Control group N = 302). The case group was 54.6% male and the median age was 56.9 years old. Among them 24.5% of CRC patients had diverticulosis compared to 29.5% of controls (P = 0.169). The distribution of diverticulosis between the two groups was similar. Subset analysis revealed no difference in the location of diverticulosis in patients with right colon cancer and left colon cancer (P = 0.781). CONCLUSIONS: This study indicates that CRC is not associated with diverticulosis.

Role of virtual colonoscopy following incomplete optical colonoscopy: our experience.

AIM: To evaluate the role of Computed Tomography Colonography (CTC) in patients who failed an Optical Colonoscopy (OC). PATIENTS AND METHODS: Sixtyeight patients (48 female, 20 male; mean age 60,4 years) with a previous incomplete OC underwent CTC. RESULTS: A complete CTC examination was achieved in all 68 patients. We classified the detected polyps in relation to the diameter in small (<5mm), medium (from 5 to 10mm) and large (>10mm). In 19 patients (27,9%) any pathological finding was observed. In 11 patients (16,2%) one or more polyps not detected with the previous OC have been found.Only in one case the number of detected polyps corresponded to the OC findings. In 18 (26,4%) patients a diverticular disease was observed, and in 15 of them it was diagnosed by the previous OC (26,5%). In 8 patients (11,8%) the diverticular disease was associated to the presence of polyps. In 12 patients (17,6%) colonic stenosis or masses have been observed. CONCLUSIONS: CTC was performed in all patients with a previous incomplete OC, obtaining a complete and accurate visualization of the colon whithout any patient's discomfort.

Recent trends in the prevalence and distribution of colonic diverticula in Japan evaluated using computed tomography colonography.

BACKGROUND: Computed tomography colonography (CTC) may be superior to colonoscopy and barium enema for detecting diverticula. However, few studies have used CTC to diagnose diverticula. AIM: To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC. METHODS: This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial, which included 1181 participants from 14 hospitals in Japan. We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex. The relationship between the diverticula and the length of the large intestine was also analyzed. RESULTS: Diverticulosis was present in 48.1% of the participants. The prevalence of diverticulosis was higher in the older participants (P < 0.001 for trend). The diverticula seen in younger participants were predominantly located in the right-sided colon. Older participants had a higher frequency of bilateral type (located in the right- and left-sided colon) diverticulosis (P < 0.001 for trend). The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula (P < 0.001). CONCLUSION: The prevalence of colonic diverticulosis in Japan is higher than that previously reported. The prevalence was higher, and the distribution tended to be bilateral in older participants.

[CT colonography: pathologic findings and pitfalls]. / CT-Kolonographie: Pathologische Befunde und Pitfalls.

Thin-section multidetector-row computed tomographic (MDCT) colonography is a powerful tool for detection and classification of colonic lesions. It is based on a helical thin-section (0.75-2 mm) CT dataset of the cleansed and air-distended colon. 2D and 3D projections are prepared and used for image interpretation. Evaluation of CT colonography datasets requires correct perception and interpretation of colonic lesions and filling defects. Various criteria are needed for correct interpretation of filling defects and differentiation between genuine lesions and artifacts. Such defects are characterized by their morphology, their structure, the absorption of contrast medium and their mobility. Knowledge of the morphologic and attenuation characteristics of common colonic lesions and of artifacts is essential for the correct interpretation of a filling defect. This review article summarizes the main imaging features of polyps, diverticula, lipomas, and carcinomas and also of common pseudolesions of the colon.

Development and usefulness of the new endoscopic classification: DICA.

Colonic Diverticulosis is one of the most common anatomical findings during colonoscopy. This condition has 60% incidence in the population over 60 years old. About 20% of patients will develop Diverticular Disease, and 5% of them will evolve into Diverticulitis. Until the last years there weren't any approaches for the endoscopic classification of this pathology. In 2013, in Florence, the first endoscopic classification was developed: DICA (Diverticular Inflammation and Complication Assessment). The aim of this article is to focus on the process of the development and the validation of the classification by the pool of gastroenterology experts, and, as well, its usefulness during the clinical practice.

A critical appraisal of advances in the diagnosis of diverticular disease.

INTRODUCTION: Diverticulosis of the colon is a common condition, and about one-fourth of those people develop symptoms, which is called 'diverticular disease' (DD). Since there are still some concerns about the diagnosis of DD, the aim of this review was to analyze current and evolving advances in its diagnosis. Area covered: Analysis of clinical, radiology, laboratory, and endoscopic tools to pose a correct diagnosis of DD was performed according to current PubMed literature. Expert commentary: A combination of clinical characteristic of the abdominal pain and fecal calprotectin expression may help to differentiate between symptomatic uncomplicated diverticular disease and irritable bowel syndrome. Abdominal computerized tomography (CT) scan is still the gold standard in diagnosing acute diverticulitis and its complications. CT-colonography may be useful as a predicting tool on the outcome of the disease. Diverticular Inflammation and Complications Assessment (DICA) endoscopic classification shows a significant relationship between severity of DICA score inflammatory indexes, as well as with severity of abdominal pain. Moreover, it seems to be predictive of the outcome of the disease in terms of acute diverticulitis occurrence/recurrence and surgery occurrence. Finally, preliminary data found intestinal microbiota analysis is a promising tool in diagnosing and monitoring this disease.

Colonic diverticulosis in an infant: A clue to total colonic Hirschsprung disease.

Total colonic aganglionosis is a rare phenotype of Hirschsprung disease (HD). While the diagnosis is generally established within the neonatal period there are reports of delayed presentation. In this case, we describe a 9-month old girl with no previous medical or surgical history who presented with a small bowel obstruction. A contrast enema performed as part of the work up demonstrated right sided colonic diverticula with no other anatomical abnormalities. Surgical intervention was required to manage the obstruction and colonic biopsies were consistent with HD. This case highlights the association of the unusual finding of colonic diverticula with total colonic HD in infants.

Indocyanine green fluorescence angiography: a new ERAS item.

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case-control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.