Enfermedad diverticular: nuevas perspectivas en el tratamiento dieto-terapéutico / Diverticular disease: new perspectives in diet-therapeutic treatment

La enfermedad diverticular corresponde a una condición habitual en el territorio occidental, siendo el hallazgo más frecuente en población de zonas urbanizadas. Respecto a su origen, se ha planteado la influencia de factores ambientales y genéticos, incluyendo en su etiología una inadecuada ingesta de fibra dietética, disbiosis de la microbiota intestinal y niveles alterados de vitamina D. A su vez, la enfermedad diverticular sintomática no complicada (EDNC) corresponde a un tipo de diverticulosis crónica cuyas características asemejan al síndrome de intestino irritable, lo que resalta la importancia en la comprensión de esta condición. Recientemente, se ha discutido la forma en que se aborda la enfermedad diverticular y en el siguiente escrito se expondrá evidencia sobre la patogénesis y su actual manejo.

Diverticular disease corresponds to a habitual condition in the western territory, being frequently found among the population of urban areas. Regarding its origin, the influence of environmental and genetic factors, including the etiology of dietary fiber intake, intestinal microbiota dysbiosis and altered levels of vitamin D have been recognized. Symptomatic uncomplicated diverticular disease corresponds to a type of chronic diverticulosis whose characteristics resemble irritable bowel syndrome, highlighting the importance of understanding this condition. Recently, the treatment of the disease has been discussed and the following review presents evidence on pathogenesis and its management.

Evidence for Dietary Fibre Modification in the Recovery and Prevention of Reoccurrence of Acute, Uncomplicated Diverticulitis: A Systematic Literature Review.

In practice, nutrition recommendations vary widely for inpatient and discharge management of acute, uncomplicated diverticulitis. This systematic review aims to review the evidence and develop recommendations for dietary fibre modifications, either alone or alongside probiotics or antibiotics, versus any comparator in adults in any setting with or recently recovered from acute, uncomplicated diverticulitis. Intervention and observational studies in any language were located using four databases until March 2017. The Cochrane Risk of Bias tool and GRADE were used to evaluate the overall quality of the evidence and to develop recommendations. Eight studies were included. There was "very low" quality evidence for comparing a liberalised and restricted fibre diet for inpatient management to improve hospital length of stay, recovery, gastrointestinal symptoms and reoccurrence. There was "very low" quality of evidence for using a high dietary fibre diet as opposed to a standard or low dietary fibre diet following resolution of an acute episode, to improve reoccurrence and gastrointestinal symptoms. The results of this systematic review and GRADE assessment conditionally recommend the use of liberalised diets as opposed to dietary restrictions for adults with acute, uncomplicated diverticulitis. It also strongly recommends a high dietary fibre diet aligning with dietary guidelines, with or without dietary fibre supplementation, after the acute episode has resolved.

An unrestricted diet for uncomplicated diverticulitis is safe: results of a prospective diverticulitis diet study.

AIM: The optimal diet for uncomplicated diverticulitis is unclear. Guidelines refrain from recommendation due to lack of objective information. The aim of the study was to determine whether an unrestricted diet during a first acute episode of uncomplicated diverticulitis is safe. METHOD: A prospective cohort study was performed of patients diagnosed with diverticulitis for the first time between 2012 and 2014. Requirements for inclusion were radiologically proven modified Hinchey Ia/b diverticulitis, American Society of Anesthesiologists class I-III and the ability to tolerate an unrestricted diet. Exclusion criteria were the use of antibiotics and suspicion of inflammatory bowel disease or malignancy. All included patients were advised to take an unrestricted diet. The primary outcome parameter was morbidity. Secondary outcome measures were the development of recurrence and ongoing symptoms. RESULTS: There were 86 patients including 37 (43.0%) men. All patients were confirmed to have taken an unrestricted diet. There were nine adverse events in seven patients. These consisted of readmission for pain (five), recurrent diverticulitis (one) and surgery (three) for ongoing symptoms (two) and Hinchey Stage III (one). Seventeen (19.8%) patients experienced continuing symptoms 6 months after the initial episode and 4 (4.7%) experienced recurrent diverticulitis. CONCLUSION: The incidence of complications among patients taking an unrestricted diet during an initial acute uncomplicated episode of diverticulitis was in line with that reported in the literature.

Dietary restrictions for acute diverticulitis: evidence-based or expert opinion?

PURPOSE: Diet restrictions are usually advised as part of the conservative treatment for the acute phase of a diverticulitis episode. To date, the rationale behind diet restrictions has never been thoroughly studied. This study aims to investigate which factors influence the choice of dietary restriction at presentation. Additionally, the effect of dietary restrictions on hospitalization duration is investigated. METHODS: All patients hospitalized for Hinchey 0, Ia, or Ib diverticulitis between January 2010 and June 2011 were included. Patients were categorized according to the diet imposed by the treating physician at presentation and included nil per os, clear liquid, liquid diet, and solid foods. The relation between Hinchey classification, C-reactive protein, leucocyte count and temperature at presentation and diet choice was examined. Subsequently, the relation between diet restriction and number of days hospitalized was studied. RESULTS: Of the 256 patients included in the study 65 received nil per os, 89 clear liquid, 75 liquid diet, and 27 solid foods at presentation. Solely high temperature appeared to be related to a more restrictive diet choice at presentation. Patients who received liquid diet (HR 1.66 CI 1.19-2.33) or solid foods (HR 2.39 CI 1.52-3.78) were more likely to be discharged compared to patient who received clear liquid diet (HR 1.26 CI 1.52-3.78) or nils per os (reference group). This relation remained statistically significant after correction for disease severity, treatment and complications. CONCLUSION: Physicians appeared to prefer a more restrictive diet with increasing temperature at presentation. Notably, dietary restrictions prolong hospital stay.

Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis.

BACKGROUND: In most cases of diverticulitis, inflammation is mild, and the only treatment required is a clear liquid diet and antibiotics. Until recently, patients were given this treatment as inpatients with the consequent expenditure of resources. The aim of this study was to assess the safety and efficacy of an outpatient treatment protocol with oral antibiotics in selected patients with uncomplicated acute diverticulitis in comparison with inpatient intravenous treatment. METHODS: We conducted a prospective non-randomized study between January 2007 and December 2009. We included all patients diagnosed with uncomplicated acute diverticulitis, at the Emergency Department of the University General Hospital of Elche. We compared the efficacy, safety and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics. Seventy-six patients were included in the study. Forty-four of them underwent intravenous treatment with Metronidazole 500 mg/8 h + Ciprofloxacin 400 mg/12 h (hospital treatment group) and 32 took oral antibiotics Metronidazole 500 mg/8 h and Ciprofloxacin 500 mg/12 h (outpatient group). RESULTS: Outpatient treatment is viable in almost 95 % of those patients suffering from uncomplicated acute diverticulitis. Treatment was effective in resolving inflammation, and there were no complications in the majority of cases (94 %). Only 2 patients (6 %) required admission after outpatient treatment. The results further reflect complications and relapse rates similar to those of patients admitted to hospital and treated with intravenous antibiotics. There are no significant statistical differences (p = 0.86) between inpatients and outpatients. It is possible to save approximately 1,600 € per patient with outpatient treatment (p < 0.05). CONCLUSIONS: Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources.

Diverticulosis y consumo de nueces, maíz y palomitas de maíz "pochoclo" / Diverticular disease and nuts, corn, popcorn consumption

A partir del caso de un paciente con diverticulosis oligosintomática, se plantea la utilidad de la restricción del consumo de nueces y semillas con el objetivo de prevenir complicaciones de la enfermedad diverticular. Se plantea la pregunta con el formato PICO, y se describe la mejor evidencia obtenida -una única investigación observacional en forma de un prolijo estudio de cohortes en la que el consumo de dichos alimentos no mostró asociación con la incidencia de enfermedad diverticular complicada, salvo un efecto preventivo de las palomitas de maiz- concluyéndose que la indicación de restringir el consumo de estos alimentos no estaría indicada.

Diverticulosis y consumo de nueces, maíz y palomitas de maíz "pochoclo" / Diverticular disease and nuts, corn, popcorn consumption

A partir del caso de un paciente con diverticulosis oligosintomática, se plantea la utilidad de la restricción del consumo de nueces y semillas con el objetivo de prevenir complicaciones de la enfermedad diverticular. Se plantea la pregunta con el formato PICO, y se describe la mejor evidencia obtenida -una única investigación observacional en forma de un prolijo estudio de cohortes en la que el consumo de dichos alimentos no mostró asociación con la incidencia de enfermedad diverticular complicada, salvo un efecto preventivo de las palomitas de maiz- concluyéndose que la indicación de restringir el consumo de estos alimentos no estaría indicada.(AU)

[Safety and efficiency of ambulatory treatment of acute diverticulitis]. / Eficiencia y seguridad del tratamiento ambulatorio de la diverticulitis aguda.

INTRODUCTION: The treatment of acute diverticulitis is currently being modified, showing a tendency to limit surgical treatment and favor conservative management. OBJECTIVE: To analyze the safety and efficiency of ambulatory treatment of acute diverticulitis in a selected group of patients. METHODS: We performed a prospective study of domiciliary oral antibiotic therapy for acute diverticulitis in a cohort of patients in the Emergency Surgery Section of our hospital. Seventy-four patients (44 men and 30 women) were included between 2000 and 2006. Patients with Hinchey stage 1 diverticulitis and those with Hinchey stage 2 diverticulitis and abscesses of less than 3cm, who were clinically and biochemically stable, were selected. The patients were treated with oral ciprofloxacin and metronidazole for 7-10 days. Follow-up was performed in the outpatients unit with clinical evaluation at 10 days and an imaging test at 1 month. RESULTS: The mean age of the patients was 55 years. The most frequent clinical presentation was spontaneous abdominal pain associated with leukocytosis. The mean duration of treatment was 8.8 days. Four patients (5.4%) required subsequent hospital admission for intravenous antibiotic administration and 70 (94.6%) completed treatment without complications. During follow-up, two cases of colonic adenocarcinoma and six cases of polyposis were diagnosed. Only 13 patients underwent elective surgery. CONCLUSIONS: In most of the patients studied, ambulatory conservative management was safe and effective in the treatment of uncomplicated acute diverticulitis. Moreover, this approach reduces length of hospital stay and lowers costs.

[Applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis]. / Aplicabilidad, seguridad y eficacia de un protocolo de tratamiento ambulatorio de la diverticulitis aguda no complicada.

INTRODUCTION: The aim of this study was to evaluate the applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis. PATIENTS AND METHODS: All patients diagnosed with uncomplicated acute diverticulitis based on abdominal computed tomography findings during a 2-year period were prospectively included. Patients with vomiting, severe comorbidities, or without an appropriate family environment were excluded. Ambulatory treatment consisted of oral antibiotics for 1 week (amoxicillin-clavulanic 1 g t.i.d. or ciprofloxacin 500 mg b.i.d. plus metronidazole 500 mg t.i.d. in patients with penicillin allergy). A clear liquid diet for the first 2 days and pain control with oral acetaminophen 1 g t.i.d. were also recommended. RESULTS: Fifty-three patients were diagnosed with uncomplicated acute diverticulitis and 13 patients were excluded. Therefore, ambulatory treatment was initiated in 40 patients. Only two patients (5%) required admission after outpatient therapy was started due to vomiting and persistent abdominal pain, respectively. In both patients, the inflammatory process was successfully resolved by intravenous antibiotic treatment. In the remaining 38 patients (95%), ambulatory treatment was completed without complications. CONCLUSIONS: Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable in most patients with tolerance to oral intake and with an appropriate family environment.

Dietary fiber.

Dietary fiber is plant-derived material that is resistant to digestion by human alimentary enzymes. Fiber may be divided into two broad chemical classes: 1) non-alpha-glucan polysaccharides (cellulose, hemicelluloses, and pectins) and 2) lignins. Dietary fiber behaves within the gastrointestinal tract as a polymer matrix with variable physicochemical properties including susceptibility to bacterial fermentation, water-holding capacity, cation-exchange, and adsorptive functions. These properties determine physiological actions of fiber and are dependent on the physical and chemical composition of the fiber. Fiber undergoes compositional changes as a consequence of bacterial enzymatic action in the colon. Dietary fiber is of clinical significance in certain disorders of colonic function and in glucose and lipid metabolism. Dietary fiber increases stool bulk by acting as a vehicle for fecal water and by increasing fecal bacterial volume. Use of fiber in the treatment of constipation and uncomplicated diverticular disease is well established. By increasing stool bulk, fiber also reduces the fecal concentration of bile acids and other substances. Certain types of fiber decrease the rate of glucose absorption and attenuate postprandial rises in blood glucose and insulin. Plasma cholesterol levels are reduced by mucilaginous forms of fiber. This effect appears to be mediated in part by an increase in fecal acidic sterol excretion.