[Diverticular disease: treatment and management by general practitioners in Germany - high importance of probiotics in primary care]. / Divertikelkrankheit: Patientenmanagement in hausärztlichen Praxen in Deutschland : Hoher Stellenwert von Probiotika in der hausärztlichen Versorgung.

INTRODUCTION: The symptomatic uncomplicated diverticular disease (SUDD) is often difficult to treat and guidelines only provide few evidence-based treatment options. METHOD: For the German-wide survey, a questionnaire was sent to 13790 physicians. It contained questions concerning the status of medical care for patients with diverticula and queried their individual option in regards to current treatment options and challenges for the daily medical routine. RESULTS: In total, 526 questionnaires were sent back for analysis. The biggest challenge for doctors handling patients with chronic diverticular disease (SUDD) is to make the correct diagnosis (17%) and the distinction to the irritable bowel syndrome (22%). Despite the high abundance of SUDD pathology, only 6% of the medical practitioners feel themselves sufficiently informed about it. The support for general practitioners by medical specialists (gastroenterologists) is limited: In the case of a SUDD or a diverticulitis diagnosis, the physicians sometimes receive an acute therapy plan (27%), but rarely get recommendations for diverticulitis pre- and post-care (11% and 18%), or assisting information for patient education (4%). For primary prophylaxis for persons with asymptomatic diverticula, practitioners give nutrition (41%) and life style (37%) recommendations, as well as probiotics (18%). After an acute diverticulitis, 42% recommend life style and nutrition modifications and 26% the intake of probiotics. For the treatment of SUDD symptoms, they advise mostly life style and nutrition modifications (45%) and probiotics (30%). About 60% of the doctors are satisfied with the efficacy of probiotics. Another 15% stated that they have not yet used them to treat SUDD. The main reasons for it seem to be the lack of reimbursability for probiotics (31%), the poor adherence of patients to therapy (20%) due to the slow onset of positive effects, and the difficulty of finding an evidence-based probiotic (16%). CONCLUSION: In the daily medical routine the correct diagnosing of SUDD is a major challenge and supporting information by medical specialist is scarce. Physicians frequently choose life style and nutrition recommendations and the use of probiotics as treatment options. The majority of the general practitioners is thereby satisfied with the efficacy of probiotics for patients with chronic diverticular disease, even though the choice of an evidence-based probiotic is an obstacle.

Impact of anticoagulants on the clinical outcomes of colonic diverticular bleeding comparing warfarin and direct oral anticoagulants.

Recently, direct oral anticoagulants (DOACs) have been widely used as antithrombotic agents to replace warfarin, but their clinical impact in patients with gastrointestinal bleeding is unclear. We compared the effects of warfarin and DOACs on the outcomes of patients with colonic diverticular bleeding. The patients were divided into warfarin and DOAC groups. We compared the clinical outcomes and the effect of the DOAC dosing and examined any readmissions due to colonic diverticular bleeding within 1 year. A total of 95 events (warfarin group: n = 43 and DOAC group: n = 52) were included. Compared with the warfarin group, the DOAC group was significantly older, had a lower rate of concomitant antiplatelet agents, and a shorter hospital stay, but no significant differences were found in the other clinical outcomes. Thirty-seven patients (71.2%) in the DOAC group had appropriate dosing, whereas 15 patients (28.9%) had an inappropriate dose. The patients with overdose or contraindications had significantly lower minimum hemoglobin levels. In the univariate analysis, prior hospitalization for colonic diverticular bleeding was a significant predictor of readmission. Compared with warfarin, patients with colonic diverticular bleeding treated with DOACs were older and had shorter hospital stays, and the inappropriate use of DOACs may worsen outcomes.

Performance of a multicompounds nutraceutical formulation in patients with symptomatic uncomplicated diverticular disease.

BACKGROUND: Symptomatic uncomplicated diverticular disease (SUDD) is a recognized clinical condition characterized by abdominal pain and changes in bowel habits, attributed to diverticula but without macroscopic signs of diverticulitis. There is no consensus about the management of these patients. Enteroflegin®, an association of natural active ingredients, could be effective in the treatment of those patients. METHODS: We conducted a retrospective observational study to evaluate the performances of Enteroflegin® in patients with SUDD. Patients were treated with Enteroflegin® 2 cp/day for 10 days per month for 6 months. Primary endpoint was the clinical remission rate, defined as the absence of any symptoms; secondary endpoints were the impact of the treatment on reduction of symptoms, on fecal calprotectin (FC) expression, and the prevention of acute diverticulitis. RESULTS: Three hundred and fifty patients were retrospectively enrolled (183 males, median age 64 years, IQR 54-70). Enteroflegin® was effective in inducing remission in 9.34% and 17.64% of patients at 3 and 6 months respectively (P<0.001). Reduction of symptoms occurred in 92.3% and in 85.3% of patients at 3 and 6 months respectively (P<0.001), and symptoms' recurrence or worsening was recorded in only 1.71% of patients during the follow-up. FC expression dropped from 181.3 µg/g at baseline to 100.2 µg/g (P<0.001) and to 67.9 µg/g (P<0.001) at 3 and 6 months of follow-up respectively. No adverse event was recorded during the follow-up. Finally, acute diverticulitis occurred in just 2% of patients during the follow-up. CONCLUSIONS: Enteroflegin® seems to be an effective nutraceutical compound in obtaining remission and symptom relief in SUDD patients. Further randomized, placebo-controlled clinical trials are needed to confirm these preliminary data.

[Diverticula of the colon: Review of related entities]. / Kolondivertikel und Divertikulitis.

Diverticulosis, Diverticular Disease, and Diverticulitis, comprising different entities, pose increasing burdens for health care systems. The introduction of new scientific knowledge into daily clinical work is challenging for attending physicians. This review is related to case presentations and currently debated questions are discussed such as definitions: Which entities are meant by the term "Diverticular Disease", is "uncomplicated symptomatic Diverticular Disease"(SUDD) reality? To classify diverticula related diseases targeted diagnosis including imaging is necessary. The question is ultrasound or computed tomography, or the combination and in which order?Lastly, open questions of treatment have to be addressed: Outpatient care or hospitalisation, always antibiotics or only in defined situations, relapse prevention, indications to operate upon?The present review comes along with revised German guidelines, which will be published later this year on S3-level.

General practitioners' management of symptomatic uncomplicated diverticular disease of the colon by using rifaximin, a non-adsorbable antibiotic.

OBJECTIVE: Symptomatic uncomplicated diverticular disease of the colon (SUDD) is generally managed by gastroenterologists rather than General Practitioners (GPs). The aim of this study was to assess the efficacy of the treatment of SUDD with rifaximin, a non-absorbable antibiotic, in a primary care setting by GPs. PATIENTS AND METHODS: This retrospective, observational study investigated the use of rifaximin at a dose of 400 mg b.i.d. for 5, 7 or 10 days monthly, up to 3 months. The symptoms were reported by the patients using a visual analogic scale (VAS) of 0-10. RESULTS: 286 SUDD patients were enrolled (44.4% of men, average age 70.92±10.98). Respectively, 15 (5.2%) patients received the treatment for 5 days, 205 (71.7%) for 7 days and 66 (23.1%) for 10 days. After three months, a significant reduction of VAS score was observed in almost all symptoms assessed: 135 (47.2%) patients reported no abdominal pain (p<0.001) and 23 (8.1%) reported no symptom. Adverse events related to the treatment were recorded in 3 (1.04%) patients, all of them mild and not requiring interruption of the treatment. Acute diverticulitis occurred in 9 (3.1%) patients, but only 2 of them [0.7% (n=2)] underwent surgery due to complicated diverticulitis. Analysis within the different treatment groups (5, 7 and 10 days) shows that rifaximin treatment is effective in reducing the severity of symptoms in almost all groups except for the constipation in the 5-day group. CONCLUSIONS: Rifaximin can be effectively used by GPs in real-life for the management of SUDD.

Increased Faecalibacterium abundance is associated with clinical improvement in patients receiving rifaximin treatment.

Compositional and functional alterations of the gut microbiota are involved in the pathogenesis of several gastrointestinal diseases. Rifaximin is often used to induce disease remission due to its eubiotic effects on the gut microbiota. To investigate the correlation between changes in the gut microbiota composition and symptoms improvement in patients who present a clinical response to rifaximin treatment. Patients with ulcerative colitis (UC), Crohn's disease (CD), irritable bowel syndrome (IBS) and diverticular disease (DD) undergoing rifaximin treatment for clinical indication were enrolled in the study. Rifaximin was administered at the dose of 1,200 mg/day for 10 days. Faecal samples were collected at baseline and at the end of treatment; clinical improvement was assessed by Mayo score for UC, CD Activity Index (CDAI) for CD, IBS severity scoring system (IBS-SSS) for IBS and global symptomatic score (GSS) for DD. Twenty-five patients were included in the analysis and a clinical improvement was recorded for 10/25 (40%) of them. Microbial alpha diversity showed a slight increase in clinical responders (P=0.271), while it decreased in patients who did not improved (P=0.05). A significant post-treatment increase in Faecalibacterium abundance was observed in patients with a positive response (log2FC 1.959, P=0.042). Roseburia abundance decreased in both groups, whereas Ruminococcus decreased only in patients who clinically improved. Clinical improvement consequent to rifaximin treatment is associated with an increase in Faecalibacterium abundance. Achieving a positive shift in the gut microbiota composition seems a key event to obtain a clinical benefit from treatment.

The Effect of Carbazochrome Sodium Sulfonate in Patients with Colonic Diverticular Bleeding: Propensity Score Matching Analyses Using a Nationwide Inpatient Database.

Objective Carbazochrome sodium sulfonate (CSS) has been routinely used to treat bleeding; however, no study has examined the effect of CSS for gastrointestinal bleeding. Therefore, we aimed to investigate the effect of CSS for colonic diverticular bleeding. Methods We performed a nationwide observational study using the Japanese Diagnosis Procedure Combination inpatient database. We identified patients who were admitted for diverticular bleeding from July 2010 to March 2018. Patients who received CSS on the day of admission were defined as the CSS group, and those not receiving CSS were defined as the control group. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, total costs, and blood transfusion within 7 days of admission. Propensity score matching analyses were performed to compare outcomes between the two groups. Results A total of 59,965 patients met our eligibility criteria. Of these, 14,437 (24%) patients received CSS on the day of admission. One-to-one propensity score matching created 14,379 matched pairs. There was no significant difference in the in-hospital mortality between the CSS and control groups (0.6% vs. 0.5%, respectively; odds ratio: 0.96; 95% confidence interval: 0.72-1.29). The length of stay was longer in the CSS group than in the control group (11.4 vs. 11.0 days, respectively; difference: 0.44; 95% confidence interval: 0.14-0.73). There were no significant differences in the total costs or the proportion of patients receiving blood transfusion between the groups. Conclusions CSS may not reduce in-hospital mortality, length of stay, total costs, or the need for blood transfusion in patients with colonic diverticular bleeding.

Combined therapy: rifaximin-α and arabinogalactan with lactoferrin combination effectively prevents recurrences of symptomatic uncomplicated diverticular disease.

INTRODUCTION: Background: Diverticulosis is the most common finding in the GI tract. Nearly half of the people with diverticula experience symptomatic uncomplicated diverticular disease (SUDD). AIMS: The primary endpoints of our study were to assess the effectiveness of combined therapy with rifaximin-α and arabinogalactan-lactoferrin in symptom reduction and normalization of bowel movements. The secondary endpoints were an assessment of efficacy in SUDD recurrence prevention and patients' compliance to the combined therapy. METHODS: A retrospective observational survey study was performed in 2019 among physicians experienced in diverticular disease (DD) treatment in Poland. Patients with previous episodes of recurrences treated with combined therapy (cyclic rifaximin-α at least 400 mg b.i.d/7 days/every month and continuous arabinogalactan-lactoferrin supplementation 1 sachet daily) were assessed after 3 and 6 months regarding symptoms' resolution in the three-point scale. The patients' SUDD history, diagnostic methods, treatment, and results, as well as patients' compliance were evaluated. RESULTS: 281 patients met inclusion criteria, and were further evaluated (67.6% women, median age 65 years). After 6 months of combined treatment, there was a statistically significant reduction in the total severity score (median from 1.7 [max 3 points] to 0.26; P < 0.0001; sum from 8.5 [max 15 points] to 1.28; P < 0.0001) and improvement in each symptom score. Stool frequency statistically normalized in every group. As many as 31.7% had complete symptom resolution. Patients' compliance with the therapy was very good and good in 92.9% of cases. C onclusions and discussion: Combination therapy with cyclic rifaximin-α and continuous arabinogalactan combined with lactoferrin are effective in SUDD treatment in terms of symptom resolution, bowel movement normalization, prevention of recurrences with very good patient's compliance.

Role of dietary fibre in older adults with asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD): Systematic review and meta-analysis.

Dietary fibre and probiotics may play a role in the management of diverticular disease. This systematic review synthesises the evidence on the effects of dietary fibre modifications, with or without the use of probiotics, on the incidence in older adults of asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD), as well as on gastrointestinal function and symptoms. Five electronic databases were searched for studies through to December 2018. The body of evidence was appraised using the Cochrane Risk of Bias tool and GRADE. Nine studies were included, with mean sample ages ranging from 57 to 70 years, and three meta-analyses were performed. Only one study, with high risk of bias, measured the effect of dietary fibre on the incidence of diverticulitis. Dietary fibre supplementation improved stool weight (MD: 42 g/day, P < 0.00001; GRADE level of evidence: low), but had no significant effect on gastrointestinal symptoms (SMD: -0.13, P = 0.16; GRADE level of evidence: low) or stool transit time (MD: -3.70, P = 0.32 GRADE level of evidence: low). There was "very low" confidence for the body of evidence supporting symbiotics for AS or SUDD. A high dietary fibre intake, in line with dietary guidelines, may improve gastrointestinal function and is recommended in patients with AS or SUDD. Dietary fibre supplementation should be considered on an individualised basis to improve bowel function, while any recommendation on symbiotic supplements requires further well-designed research. Future studies should also measure the impact on the incidence of diverticulitis.

Fístula sigmoido-cervical secundaria a una enfermedad diverticular complicada / Sigmoido-cervical fistula due to diverticular disease

Resumen Introducción: Las fístulas secundarias a una enfermedad diverticular complicada son una indicación formal de cirugía electiva en el 4 a 23% de los casos. Caso Clínico: Se presenta el caso de una mujer de 52 años con antecedentes de una histerectomía subtotal por miomatosis uterina que consulta por cuadro de dolor abdominal en hipogastrio acompañado de fiebre de 4 días de evolución. La tomografía computada (TC) de abdomen y pelvis describe una diverticulitis complicada con absceso peridiverticular. Tratada con antibióticos con buena respuesta clínica consulta a los 3 meses en nuestro servicio por pérdida de material fecal por vagina. Nueva TC confirma la presencia de una colección perisigmoidea y engrosamiento de la pared vesical. La colonoscopía informa una estenosis franqueable a nivel de sigmoides y se constata salida de gases por vagina. La corrección quirúrgica electiva incluyó una sigmoidectomía abierta con traquelectomía en block, cierre de la cúpula vaginal y anastomosis colorrectal mecánica, con buena evolución posoperatoria, sin recidiva a los 12 meses de seguimiento. La fístula sigmoido-cervical es una complicación rarísima de la enfermedad diverticular complicada que puede ocurrir en pacientes sometidas a una histerectomía subtotal previa. Aunque el diagnóstico de la fístula es clínico, la colonoscopía y la TC permiten descartar otras etiologías. La resección radical del segmento afectado es el tratamiento estándar en pacientes aptos.

Introduction: Diverticular disease is complicated by fistulas in 4% to 23% of patients. Case Report: A woman 52 years-old previously operated on with parcial histerectomy was successfully treated with antibiotics due to diverticulitis complicated with an abscess. Three months later the patient presented with vaginal discharge of faeces. Computed tomography showed wall thickening of sigmoid colon and vesical wall. Colonoscopy exclude cancer and confirmed the exit of gas through vagina. En-bloc resection of the sigmoid colon with traquelectomy with primary anastomosis was performed. The postoperative course was good without recurrence after 12 months of follow up. Sigmoido-cervical fistula is a very rare benign fistula due to diverticular disease. Diagnosis is basically clinic, but tomography and colonoscopy are important to exclude other causes of fistulas. Radical surgery with primary anastomosis is the standard treatment.

Efficacy of combined prophylactic therapy (rifaximine alpha + prebiotic arabinogalactan with lactofferin) on GUT function in patients with diagnosed symptomatic uncomplicated diverticular disease.

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Italian nationwide survey of pharmacologic treatments in diverticular disease: Results from the REMAD registry.

Background: Although diverticular disease is a common condition, its effective treatment is challenging in clinical practice. Objective: The objective of this article is to assess pharmacological management in different clinical settings of diverticular disease and factors associated with treatment using the Italian registry Registro Malattia Diverticolare (REMAD). Methods: At study enrolment, patients were categorised into subgroups: diverticulosis, symptomatic uncomplicated diverticular disease and previous diverticulitis. We registered demographic, clinical and lifestyle factors, quality of life and the use of treatments for diverticular disease in the last year. Logistic regression analysis assessed the association between clinical factors and treatment consumption. Results: A total of 500 of the 1206 individuals included had had at least one treatment for diverticular disease in the last year: 23.6% (166/702) of patients with diverticulosis, 55.9% (165/295) of patients with symptomatic diverticular disease, and 80.9% (169/209) of patients with previous diverticulitis (p < 0.001). In multivariate analysis, the following factors were significantly associated with treatment use: female gender, family history of colonic diverticula, organic digestive comorbidity and impaired physical quality of life components. Conclusion: Individuals with diverticular disease take medications based on the different clinical settings of disease. We identified different features associated with treatment use in the distinct clinical entities of diverticular disease.ClinicalTrial.gov Identifier: NCT03325829.

Effects of Burdock tea on recurrence of colonic diverticulitis and diverticular bleeding: An open-labelled randomized clinical trial.

Colonic diverticular bleeding (CDB) and acute colonic diverticulitis (ACD) show high recurrence rates. The establishment of optimal strategies that prevent the recurrence of CDB and ACD is a major concern among gastroenterologists. This study aimed to assess the efficacy of burdock tea for preventing CDB and ACD recurrences. Newly diagnosed patients with CDB (n = 91) or ACD (n = 70) were randomly assigned into two groups. The experimental group received 1.5 g of burdock tea three times a day, whereas the control group did not receive any treatment. The median (interquartile range) of observation for recurrence of CDB or ACD was 22.0 (14.1) months and 30.3 (18.6), respectively. The burdock tea treatment showed significant preventive effects on recurrence of ACD. A lower ACD recurrence rate (5/47 [10.6%] vs. 14/44 [31.8%]) and longer recurrence-free duration was observed in the burdock tea group (59.3 months [95% CI: 54.0-64.7] vs. 45.1 months [95% CI: 37.1-53.0] by the Kaplan-Meier analysis; p = 0.012 by log rank test) than in the control group, although there was no significant preventive effects on the CDB recurrence. This randomized clinical trial demonstrated that daily intake of burdock tea could be an effective strategy for prevention of ACD recurrence, but not for CDB recurrence.

Budesonide MMX Is Effective in Patients Having Persistent Symptoms and Raised Fecal Calprotectin Following Treatments for Diverticular Disease.

BACKGROUND AND AIM: Although rifaximin and mesalazine seem to be effective in treating the majority of people suffering from diverticular disease (DD), some patients still experience symptoms following those treatments. The aim of this study was to assess the efficacy of budesonide MMXTM in managing symptoms and raised fecal calprotectin (FC) in patients with endoscopic diagnosis of DD and not responding to standard treatments. METHODS: We performed a post-hoc analysis of the patients enrolled in the DICA prospective study. All patients were at the first diagnosis of DD, scored according to DICA classification. We assessed abdominal pain, meteorism, constipation and diarrhea (scored from 0 to 10) and FC expression at baseline and after six months. Patients were treated with budesonide MMXTM for 4 weeks (9 mg/day for 2 weeks, followed by 9 mg every other day for further 2 weeks), followed by mesalazine 2.4 grams/day for further 5 months. RESULTS: We studied 24 patients (18 females and 6 males, median age 64, inter quartile range (IQR): 57.5- 73.5), previously treated with mesalazine and/or rifaximin (equally subdivided between DICA 2 and DICA 3). At 6-month follow-up, a significant reduction of all symptoms assessed was observed (abdominal pain and meteorism: p<0.001; constipation: p=0.007; diarrhea: p=0.009). Median (IQR) FC level was 244.5 (171.5- 322.0) µg/g at baseline and 51.0 (IQR: 35.5-61.5) µg/g (p< 0.001) after 6 months. No side effects were recorded. CONCLUSIONS: Treatment with budesonide MMXTM seems to be effective in obtaining symptoms' control and dropping of FC in patients with DD and not responding to standard treatments.

Hot Topics in Medical Treatment of Diverticular Disease: Evidence Pro and Cons.

Symptomatic Uncomplicated Diverticular Disease (SUDD) is the most common clinical form of Diverticular Disease (DD). The therapy should be aimed at reducing both the intensity and frequency of symptoms as well as preventing complications. The pharmacological treatments include fibers, not absorbable antibiotics (for example rifaximin), anti-inflammatory drugs (for example 5-amino-salycilic acid) and probiotics, alone or in combination with other drugs. Although some of these treatments seem to be effective in treating SUDD, but their efficacy in preventing complications of the disease is still uncertain. It has been hypothesized that microbial imbalance associated with bacterial overgrowth of the colon, may be the key to the development of diverticular disease (DD). Therefore, drugs that can manipulate gut microbiota such as probiotics or rifaximine are considered as a potential key therapy. Rifaximine is able to modulate the intestinal ecosystem, restoring eubiosis. Traditionally, DD of the colon is thought to be related to low grade of inflammation. By analogy with other inflammatory bowel diseases mesalazine has been studied also in DD. There are several evidences that may support the use of mesalazine in the SUDD. Unfortunately, mesalazine cannot be used to prevent diverticulitis because of the paucity of high-quality studies. Currently, mesalazine has a limited place for the management of SUDD. In SUDD probiotics have been proven as an effective therapy in reducing abdominal symptoms, but unfortunately there has been limited number of relevant studies regarding efficacy of this therapy.

Long-term efficacy of rifaximin to manage the symptomatic uncomplicated diverticular disease of the colon.

Although rifaximin is currently advised in managing symptomatic uncomplicated diverticular disease (SUDD) of the colon, no long-term data are available. This retrospective study assessed the outcome of a large cohort of patients with SUDD, treated with rifaximin, during an 8-year follow-up. The study group (group A) included 346 patients with SUDD (median age 64 years, IQR 58-69, 62.4% females), treated with rifaximin 800 mg/d for 7 days every month. The control group (group B) included 470 patients with SUDD (median age 65 years, IQR 59-74 years, 60.8% females), taking any other treatment on demand. Two symptoms (left lower abdominal pain and bloating) were assessed by a visual analog scale (VAS), graded from 0=no symptom to 10=the most severe symptom. Daily bowel movements were also reported. Median (IQR) VAS score for pain was 6 (5-7) in group A and 6 (6-7) in group B at baseline (p=0.109); at 8-year follow-up it was 3 (3-4) and 6 (5-7), respectively (p<0.000). Both bloating and daily bowel movements were significantly reduced in group A. Acute diverticulitis occurred in 9 (2.6%) patients in group A and in 21 (4.5%) patients in group B (p=0.155). Surgery occurred in 4 (1.2%) patients in group A and 9 (1.9%) in group B (p=0.432). Disease-related mortality occurred in no patient in group A and 2 (0.4%) patients in group B (p=0.239). No side effects were recorded during the entire study period. Rifaximin is effective to relieve symptoms and reduce the risk of disease-related complications in patients with SUDD.

Mesalazine for People with Diverticular Disease: A Systematic Review of Randomized Controlled Trials.

Background: Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms. Aim: We systematically reviewed current evidence on benefits and harms of mesalazine versus all other treatments in people with diverticular disease. Methods: We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov for studies published to July 2018. We estimated risk ratios (RR) for dichotomous outcomes (disease remission/recurrence, acute diverticulitis in symptomatic uncomplicated diverticular disease, need for surgery/hospitalization, all-cause/disease-related mortality, adverse events), mean differences (MD) or standardized MD (SMD) for continuous outcomes (quality of life, symptoms score, time to recurrence/remission), and their 95% confidence intervals (CI) using random-effects models. We quantified heterogeneity by Chi2 and I2 tests. We performed subgroup analyses by disease subtype, comparator, follow-up duration, mesalazine dose, and mode of administration. Results: We identified 13 randomized trials (n=3028 participants). There was a higher likelihood of disease remission with mesalazine than controls in acute uncomplicated diverticulitis (1 trial, 81 participants, RR=2.67, 95%CI=1.05-6.79), but not in symptomatic uncomplicated diverticular disease (1 trial, 123 participants, RR=1.04, 95%CI=0.81-1.34). There was a lower likelihood of disease recurrence with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 216 participants, RR=0.52, 95%CI=0.28-0.97), but not in acute uncomplicated diverticulitis (7 trials, 2196 participants, RR=0.90, 95%CI=0.61-1.33). There was no difference in the likelihood of developing acute diverticulitis in symptomatic uncomplicated diverticular disease between the two groups (3 trials, 484 participants, RR=0.26, 95%CI=0.06-1.20). There was a higher global symptoms score reduction with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 326 participants, SMD=-1.01, 95%CI=-1.51,-0.52) and acute uncomplicated diverticulitis (2 trials, 153 participants, SMD=-0.56, 95%CI=-0.88,-0.24). Conclusions: Mesalazine may reduce recurrences in symptomatic uncomplicated diverticular disease. There is uncertainty on the effect of mesalazine in achieving diverticular disease remission. Mesalazine may not prevent acute diverticulitis in symptomatic uncomplicated diverticular disease.

New concepts on intestinal microbiota and the role of the non-absorbable antibiotics with special reference to rifaximin in digestive diseases.

Digestive diseases are a broad range of chronic disorders that substantially and negatively impact the patients' quality of life. Here, we review our current understanding on the pathophysiology of hepatic encephalopathy, irritable bowel syndrome, and diverticular disease, with a special focus on the gut microbiota composition associated with these disorders. Furthermore, we review the current clinical practice for their therapeutic treatments, including probiotics, diet change, non-adsorbable disaccharides, and antibiotics. We highlight that broad-spectrum non-adsorbable antibiotics, such as rifaximin, are quite effective and safe for the treatment of all essayed digestive diseases.

Diagnosis of symptomatic uncomplicated diverticular disease and the role of Rifaximin in management.

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.

Hinchey I and II diverticular abscesses: long-term outcome of conservative treatment.

BACKGROUND: The management of diverticular disease and its complications are an increasing burden to the health system. The natural history of conservatively managed diverticular abscesses (Hinchey I and II) is poorly described and it remains open to debate whether subsequent sigmoid resection is indicated after conservative management. This observational study compares outcomes of patients treated with conservative management (antibiotics +/- percutaneous drainage) and surgery. METHODS: All patients admitted at Christchurch Hospital with diverticulitis between 1 January 1998 and 31 December 2009 were recorded in a database. A retrospective analysis of patients with an abscess due to complicated diverticulitis was undertaken. Initial management, recurrence and subsequent surgery were recorded. The patients were followed until 1 January 2014. RESULTS: Of 1044 patients with diverticulitis, 107 with diverticular abscess were included in this analysis. The median age was 66 ± 16 and 60 were male. All patients had sigmoid diverticulitis and were diagnosed with a computed tomography. The median abscess size was 4.2 ± 2.1 cm. During median follow-up of 110 months, the overall recurrence rate was 20% (21/107). Recurrence varied according to initial treatment; namely antibiotics (30%), percutaneous drainage plus antibiotics (27%) and surgery (5%) (P = 0.004). The median time to recurrence was 4 ± 11.7 months, and most recurrences were treated conservatively; four patients underwent delayed surgery. CONCLUSION: Recurrence after diverticular abscess is higher after initial conservative treatment (antibiotics +/- percutaneous drainage) compared with surgery, however, patients with recurrent disease can be treated conservatively with similar good outcomes and few patients required further surgery.