Association between colonic polyps and diverticular disease

1. Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. Br Med J. 1971;2:450–454. [PMC free article] [PubMed] [Google Scholar]

2. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol. 1975;4:53–69. [PubMed] [Google Scholar]

3. Korzenik JR. Case closed? Diverticulitis: epidemiology and fiber. J Clin Gastroenterol. 2006;40:S112–S116. [PubMed] [Google Scholar]

4. Jemal A, Siegel R, Ward E, Murray T, Xu J, Smigal C, Thun MJ. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–130. [PubMed] [Google Scholar]

5. Giacosa A, Frascio F, Munizzi F. Epidemiology of colorectal polyps. Tech Coloproctol. 2004;8 Suppl 2:s243–s247. [PubMed] [Google Scholar]

6. Howe GR, Benito E, Castelleto R, Cornee J, Esteve J, Gallagher RP, Iscovich JM, Deng-ao J, Kaaks R, Kune GA. Dietary intake of fiber and decreased risk of cancers of the colon and rectum: evidence from the combined analysis of 13 case-control studies. J Natl Cancer Inst. 1992;84:1887–1896. [PubMed] [Google Scholar]

7. Aldoori WH, Giovannucci EL, Rockett HR, Sampson L, Rimm EB, Willett WC. A prospective study of dietary fiber types and symptomatic diverticular disease in men. J Nutr. 1998;128:714–719. [PubMed] [Google Scholar]

8. Painter NS, Burkitt DP. Diverticular disease of the colon, a 20th century problem. Clin Gastroenterol. 1975;4:3–21. [PubMed] [Google Scholar]

9. Glober GA, Kamiyama S, Nomura A, Shimada A, Abba BC. Bowel transit-time and stool weight in populations with different colon-cancer risks. Lancet. 1977;2:110–111. [PubMed] [Google Scholar]

10. Munakata A, Nakaji S, Takami H, Nakajima H, Iwane S, Tuchida S. Epidemiological evaluation of colonic diverticulosis and dietary fiber in Japan. Tohoku J Exp Med. 1993;171:145–151. [PubMed] [Google Scholar]

11. Stefansson T, Ekbom A, Sparen P, Pahlman L. Increased risk of left sided colon cancer in patients with diverticular disease. Gut. 1993;34:499–502. [PMC free article] [PubMed] [Google Scholar]

12. McCallum A, Eastwood MA, Smith AN, Fulton PM. Colonic diverticulosis in patients with colorectal cancer and in controls. Scand J Gastroenterol. 1988;23:284–286. [PubMed] [Google Scholar]

13. Morini S, de Angelis P, Manurita L, Colavolpe V. Association of colonic diverticula with adenomas and carcinomas. A colonoscopic experience. Dis Colon Rectum. 1988;31:793–796. [PubMed] [Google Scholar]

14. Soran A, Harlak A, Wilson JW, Nesbitt L, Lembersky BC, Wienad HS, O’Connell MJ. Diverticular disease in patients with colon cancer: subgroup analysis of national surgical adjuvant breast and bowel project protocol C-06. Clin Colorectal Cancer. 2006;6:140–145. [PubMed] [Google Scholar]

15. Vajrabukka T, Saksornchai K, Jimakorn P. Diverticular disease of the colon in a far-eastern community. Dis Colon Rectum. 1980;23:151–154. [PubMed] [Google Scholar]

16. Lee YS. Diverticular disease of the large bowel in Singapore. An autopsy survey. Dis Colon Rectum. 1986;29:330–335. [PubMed] [Google Scholar]

17. Nakaji S, Danjo K, Munakata A, Sugawara K, MacAuley D, Kernohan G, Baxter D. Comparison of etiology of right-sided diverticula in Japan with that of left-sided diverticula in the West. Int J Colorectal Dis. 2002;17:365–373. [PubMed] [Google Scholar]

18. Nakada I, Ubukata H, Goto Y, Watanabe Y, Sato S, Tabuchi T, Soma T, Umeda K. Diverticular disease of the colon at a regional general hospital in Japan. Dis Colon Rectum. 1995;38:755–759. [PubMed] [Google Scholar]

19. Chen SC, Wei TC, Wang SM, Hsu CY. Distributional pattern of diverticular disease of the colon in Taiwan. J Formos Med Assoc. 1993;92:662–664. [PubMed] [Google Scholar]

20. Fearnhead NS, Mortensen NJ. Clinical features and differential diagnosis of diverticular disease. Best Pract Res Clin Gastroenterol. 2002;16:577–593. [PubMed] [Google Scholar]

21. Petruzziello L, Iacopini F, Bulajic M, Shah S, Costamagna G. Review article: uncomplicated diverticular disease of the colon. Aliment Pharmacol Ther. 2006;23:1379–1391. [PubMed] [Google Scholar]

22. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut. 1969;10:336–344. [PMC free article] [PubMed] [Google Scholar]

23. Takano M, Yamada K, Sato K. An analysis of the development of colonic diverticulosis in the Japanese. Dis Colon Rectum. 2005;48:2111–2116. [PubMed] [Google Scholar]

24. Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK. Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital. Dis Colon Rectum. 2000;43:1383–1389. [PubMed] [Google Scholar]

25. Chia JG, Wilde CC, Ngoi SS, Goh PM, Ong CL. Trends of diverticular disease of the large bowel in a newly developed country. Dis Colon Rectum. 1991;34:498–501. [PubMed] [Google Scholar]

26. Chan CC, Lo KK, Chung EC, Lo SS, Hon TY. Colonic diverticulosis in Hong Kong: distribution pattern and clinical significance. Clin Radiol. 1998;53:842–844. [PubMed] [Google Scholar]

27. Levy N, Stermer E, Simon J. The changing epidemiology of diverticular disease in Israel. Dis Colon Rectum. 1985;28:416–418. [PubMed] [Google Scholar]

28. Morini S, Hassan C, Zullo A, De Francesco V, Festa V, Barberani F, Faleo D, Stroffolini T. Diverticular disease as a risk factor for sigmoid colon adenomas. Dig Liver Dis. 2002;34:635–639. [PubMed] [Google Scholar]

29. Kieff BJ, Eckert GJ, Imperiale TF. Is diverticulosis associated with colorectal neoplasia? A cross-sectional colonoscopic study. Am J Gastroenterol. 2004;99:2007–2011. [PubMed] [Google Scholar]

30. Choi CS, Choi SC, Seo GS, Cho EY, Cho HJ, Kim YS, Kim KH, Kim TH, Nah YH. [Association between diverticulosis and colonic Neoplasm in Koreans] Korean J Gastroenterol. 2007;49:364–368. [PubMed] [Google Scholar]

A 10-Year Retrospective Study in 13680 Patients

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AbstractBackgroundMethodsResultsDiscussionData AvailabilityConflicts of InterestReferencesCopyrightRelated Articles

Introduction. Shared by certain epidemiological and etiological characteristics, diverticulosis and colorectal cancer (CRC) as well as colonic polyps has long been linked. This association was studied in several heterogeneous studies but has reported inconsistent results. Clarifying the association is clinically relevant for endoscopist awareness and potential modification of screening and surveillance intervals for diverticulosis patients. Methods. In this retrospective single-center study, patients diagnosed with diverticulosis on colonoscopy over a 10-year period were included. Each diverticulosis patient was matched with 1 control by age, gender, setting (inpatient/outpatient), and procedure’s indication. CRC and polyp detection rates were recorded and compared between the groups before and after adjustment for bowel preparation quality and exam completion. CRC location was recorded and compared between groups. Results. A cohort of 13680 patients (6840 patients with diverticulosis and 6840 matched controls) was included. Diverticulosis was located mainly to the sigmoid and left colon (94.4%). The CRC diagnosis rate was lower in the diverticulosis group (2% vs. 4.5%, , , and ). Moreover, location of CRC was unrelated to diverticulosis location, as more CRCs in the diverticulosis group were located proximal to the splenic flexure as compared to the control group (42.5% vs 29.5%, respectively; ). Diverticulosis, however, was associated with an increased polyp detection rate compared to controls (30.5% vs. 25.5%; , , and ). Conclusion. We demonstrated that diverticulosis was not associated with an increased risk for CRC. A possible increased polyp detection rate, however, warrants further evaluation in large prospective studies.

1. Background

Diverticulosis is considered as one of the most common and burdensome GI disorders [1, 2]. The underlying pathological mechanisms resulting in diverticular formation of a colonic wall is still largely unknown. Diverticula develop at well-defined points of weakness in the circular muscle of colon and are likely to be the result of complex interactions between environmental and heritable factors including diet, increased age, and decreased colonic motility, among others [3, 4]. Typically, diverticulosis is identified incidentally at colonoscopy or imaging studies performed for various indications, and the majority of patients with diverticulosis remain asymptomatic throughout their lifetime [5].

Several observations hold that certain epidemiological and etiological characteristics are shared between colonic diverticulosis and colorectal cancer, suggesting a possible association between these two conditions. The prevalence of these conditions is markedly on the rise in the last decades, and they both are detected frequently in aged people as well as western population and industrialized countries [6–8]. Western diet, namely, low dietary fiber and high total fat, has been largely regarded to play a major role in the pathogenesis and was epidemiologically associated with an increased risk of both conditions [9–13].

The abovementioned connection is of great clinical relevance, as several reports demonstrated that patients with diverticular disease have a higher risk of harboring colonic cancer [14–16]. Above and beyond, one meta-analysis demonstrated that diverticular disease was associated as well with increased detection of colorectal adenomas [17].

However, data are still controversial and inconclusive as other recent studies failed to confirm this association [18–20]. Moreover, the vast majority of the studies inspecting a possible link between both conditions were limited by small patient numbers and did not account for multiple confounders that are known to affect CRC and polyp detection such as patients’ demographics, procedure’s indication, setting, quality of bowel preparation, and exam completion.

Taken together, unraveling the dilemma and clarifying the association between both conditions appear to be clinically relevant, as modifying screening or surveillance intervals for CRC and polyp follow-up may be warranted accordingly in patients with diverticular disease.

The present study is aimed at comparing the CRC diagnosis rate and location as well as polyp detection rate between patients with diverticular disease and a matched group without diverticulosis with adjustment for abovementioned confounders.

2. Methods and Settings

We conducted a retrospective, large cohort study, which examined consecutive patients who underwent colonoscopies over a 10-year period within the gastroenterology department at the Hillel Yaffe Medical Center, a university-affiliated hospital in Israel. All patients’ data were collected from our department’s electronic record system. We searched endoscopy reports to identify all patients with a diagnosis of diverticulosis to create a study group. For a control group, each patient from the study group was matched with 1 control patient by age, gender, setting (inpatient/outpatient), and procedure’s indication. Patients were excluded if they were less than 18 years, had prior diagnosis of colon cancer, or if full data set is missing. Endoscopy findings including cancer diagnosis and location as well as polyp detection were recorded in both groups. Diverticulosis location was documented as well in the diverticulosis group. Whenever an endoscopic diagnosis of colorectal cancer was encountered, histology reports were reviewed to confirm diagnosis.

We compared the rate of CRC and polyp diagnosis between both groups and use multivariable analysis to adjust for adequacy of bowel preparation (adequate/inadequate) and depth of examination (cecal intubation confirmed or not), in order to identify independent association of diverticulosis with CRC and polyp detection. CRC location was documented according to endoscopy reports, and we compared its location between both groups. Diverticulosis and CRC location was classified as proximal (proximal to splenic flexure) or distal (splenic flexure or distal). The local institutional Helsinki ethics board approved the study and granted exemption from informed consent in this retrospective study as patients were receiving standard care without relation to the study.

3. Statistical Analysis

This statistical analysis is dealing with cohort of “big data” (40128 patients), of them 6840 patients with diverticulosis (study group). We used the Propensity Score Matching in R program version 3. 3 to divide the total cohort to 1 : 1 ratio (study and control group). Descriptive statistics in terms of mean, SD, and percentiles were preformed to the whole parameters in the study. Differences between the two groups (diverticulosis diagnosed vs. matched group) in the quantitative parameters were demonstrated by -test. For the categorical parameters, we used fisher exact tests. Multivariate logistic regression model was used to determine the effect of the independent parameters associated with CRC. SPSS version 25 was also used for statistical analysis. was considered as significant.

4. Results

We included a large cohort of 40128 patients who underwent colonoscopy at our hospital. We searched endoscopy reports and identified 6840 patients (17%) with diverticulosis diagnosed during the study period. A matched group of 6840 control patients (at 1 : 1 ratio) was included for final analysis. Baseline characteristics of both groups were similar and are provided in Table 1. The overall mean age was years (range: 18-101), with a slight male predominance (52. 1%). The vast majority of the procedures (78.4%) were performed in the outpatient setting. Procedures’ indications did not differ significantly between groups. The most common indications for colonoscopy were abdominal pain and diarrhea (21.1%), rectal bleeding (14.2%), and anemia (13.2%).

The CRC diagnosis rate was lower in the diverticulosis group (2% vs. 4.5%; ) while the polyp detection rate was surprisingly higher (30.5% vs. 25.5%; ) as compared to the matched group (Table 2). Cecal intubation rate (92.8% vs. 84.1%; ), adequate bowel preparation rate (90.7% vs. 84.1%; ), and terminal ileum intubation rate (2.2% vs. 1.6%; and ; ) were significantly higher in the diverticulosis group (Table 2). Multivariate analysis (Table 3) to account for these variables revealed similar trends as diverticulosis patients were associated with less CRC diagnosis (, , and ) but increased polyp detection rate (, , and ).

Diverticulosis and CRC locations are demonstrated in Table 4. Diverticulosis was located mainly to the distal colon (94. 4%). Location of CRC was unrelated to diverticulosis location, as more CRCs in the diverticulosis group were located proximally compared to the control group (42.5% vs. 29.5%, respectively; ).

5. Discussion

The current study was designed to clarify several aspects of diverticulosis and its possible association with CRC and polyp diagnosis. This association has long been studied in observational, cross-sectional, and case-control studies and has reported inconsistent results. Moreover, small patient numbers and heterogeneous study design contributed to conflicting conclusions. In the current study, we included a large cohort over a 10-year period and performed group matching followed with multivariate analysis in order to account for as many confounders as possible that may have influenced results of preceding studies.

We found that diverticulosis patients were not associated with an increased rate of CRC diagnosis compared to a matched group (2% vs. 4.5%; , , ). Our findings confirm the findings from other recent studies that diverticulosis is not associated with increased CRC diagnosis. A nationwide case-control study found that diverticular disease does not increase the risk of colon cancer in the long term, and a history of diverticular disease does not affect colon cancer mortality [18]. Our findings are also in concordance with a study by Meurs-Szojda et al. on more than 4200 colonoscopies which demonstrated a negative correlation between colon cancer and diverticulosis [21].

Moreover, we provided detailed location of diverticulosis and colon cancer in our cohort. Similar to different reports in western population [6, 7, 9], diverticulosis was located predominantly to the distal colon as more than 94% of diverticula were located to sigmoid and descending colon. In this regard, not only we demonstrated that CRC was located into sigmoid and descending colon in less than 35% but also we showed that more CRCs in the diverticulosis group were located proximally compared to the control group (Table 3) (42.5% vs. 29.5%, respectively; ). Consistent findings were reported by Cooper et al. who showed that diverticulosis associated interval cancers were somewhat more likely to be in the proximal colon and less likely to be in the distal colon [15]. Taken together, these findings reinforce the conclusion that CRC and diverticulosis are unrelated.

One worth mentioning finding in this study, however, is the increased polyp detection rate in diverticulosis patients (30.5% vs. 25.5%; 2, , ). This observation is supported by several other studies reporting that patients with diverticulosis have a higher risk of colorectal polyps as compared to those without [22, 23]. One meta-analysis found a significant 1.67-fold increased odds of developing adenomas in patients with diverticulosis [17]. Unfortunately, we were unable to determine the location and histologic type of these polyps in the current study. However, given the lower CRC diagnosis rate in the diverticulosis patients, this may point out that the majority of the detected polyps were of low dysplastic progression potentials (diminutive/hyperplastic polyps), thus explaining the low CRC diagnosis albeit the high PDR. Nevertheless, this observation needs further validation by a large prospective cohort study.

Furthermore, we demonstrated that diverticulosis has no significant effect on the outcome of colonoscopy. Linked with suboptimal bowel preparation, it is thought that diverticulosis may cause technical difficulty to perform a complete colonoscopy as a result of a spastic colon and luminal narrowing [24–26]. However, we demonstrated the contrary as quality indicators such as the cecal intubation rate (92.8% vs. 84.1%; and ; ) and the adequate bowel preparation rate (90.7% vs. 84.1%; and ; ) as well as the terminal ileum intubation rate (2.2% vs. 1.6%; and ; ) which were even better in diverticulosis patients compared to those without. Similar findings were reported by Gohil et al. who found that diverticulosis did not adversely affect the cecal intubation rate, withdrawal times, or sedation requirements [27].

One of the strengths of the current study includes the large number of participants involved as well as the inclusion of multiple factors such as procedures’ settings and indications reflecting real daily practice. Our study has limits inherent in its retrospective nature. Besides, other possible factors that may have affected endoscopy findings such as withdrawal time and variable endoscopist experience could not be obtained and were not included.

In conclusion, diverticulosis apparently is not linked with an increased risk of CRC but is possibly associated with an increased polyp detection rate. Prospective studies to clarify these findings are warranted.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest

The authors certify that they have no affiliations with or involvement in any organization or entity with any financial or nonfinancial interest in the subject matter or materials discussed in this manuscript. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

1. N. J. Shaheen, R. A. Hansen, D. R. Morgan et al., “The burden of gastrointestinal and liver diseases, 2006,” The American Journal of Gastroenterology, vol. 101, no. 9, pp. 2128–2138, 2006.

   View at:

   Publisher Site | Google Scholar

2. J. E. Everhart and C. E. Ruhl, “Burden of digestive diseases in the United States part II: lower gastrointestinal diseases,” Gastroenterology, vol. 136, no. 3, pp. 741–754, 2009.

   View at:

   Publisher Site | Google Scholar

3. T. P. Bhucket and N. H. Stollman, “Diverticular disease of the colon,” in Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management, M. Feldman, L. S. Friedman, and L. J. Brandt, Eds., vol. 2, pp. 1–15, Elsevier, Philadelphia, 10th edition, 2014.

   View at:

   Google Scholar

4. A. Tursi, A. Papa, and S. Danese, “Review article: the pathophysiology and medical management of diverticulosis and diverticular disease of the colon,” Alimentary Pharmacology & Therapeutics, vol. 42, no. 6, pp. 664–684, 2015.

   View at:

   Publisher Site | Google Scholar

5. J. Hemming and M. Floch, “Features and management of colonic diverticular disease,” Current Gastroenterology Reports, vol. 12, no. 5, pp. 399–407, 2010.

   View at:

   Publisher Site | Google Scholar

6. J. Y. Kang, J. Hoare, A. Tinto et al., “Diverticular disease of the colon—on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000,” Alimentary Pharmacology & Therapeutics, vol. 17, no. 9, pp. 1189–1195, 2003.

   View at:

   Publisher Site | Google Scholar

7. D. A. Etzioni, T. M. Mack, R. W. Beart Jr., and A. M. Kaiser, “Diverticulitis in the United States: 1998-2005: changing patterns of disease and treatment,” Annals of Surgery, vol. 249, no. 2, pp. 210–217, 2009.

   View at:

   Publisher Site | Google Scholar

8. A. F. Peery, T. O. Keku, C. F. Martin et al., “Distribution and characteristics of colonic diverticula in a United States screening population,” Clinical Gastroenterology and Hepatology, vol. 14, no. 7, pp. 980–985.e1, 2016.

   View at:

   Publisher Site | Google Scholar

9. N. Painter and D. Burkitt, “Diverticular disease of the colon: a deficiency disease of Western civilization,” British Medical Journal, vol. 2, no. 5759, pp. 450–454, 1971.

   View at:

   Publisher Site | Google Scholar

10. J. S. Gear, A. Ware, P. Fursdon et al., “Symptomless diverticular disease and intake of dietary fibre,” The Lancet, vol. 1, no. 8115, pp. 511–514, 1979.

    View at:

    Publisher Site | Google Scholar

11. W. H. Aldoori, E. L. Giovannucci, E. B. Rimm, A. L. Wing, D. V. Trichopoulos, and W. C. Willett, “A prospective study of diet and the risk of symptomatic diverticular disease in men,” The American Journal of Clinical Nutrition, vol. 60, no. 5, pp. 757–764, 1994.

    View at:

    Publisher Site | Google Scholar

12. F. L. Crowe, P. N. Appleby, N. E. Allen, and T. J. Key, “Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians,” BMJ, vol. 343, no. 4, article d4131, 2011.

    View at:

    Publisher Site | Google Scholar

13. D. Aune, D. S. Chan, R. Lau et al., “Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies,” BMJ, vol. 343, no. 1, article d6617, 2011.

    View at:

    Publisher Site | Google Scholar

14. T. Stefánsson, A. Ekbom, P. Sparèn, and L. Påhlman, “Increased risk of left sided colon cancer in patients with diverticular disease,” Gut, vol. 34, no. 4, pp. 499–502, 1993.

    View at:

    Publisher Site | Google Scholar

15. G. S. Cooper, F. Xu, M. D. Schluchter, S. M. Koroukian, and J. S. Barnholtz Sloan, “Diverticulosis and the risk of interval colorectal cancer,” Digestive Diseases and Sciences, vol. 59, no. 11, pp. 2765–2772, 2014.

    View at:

    Publisher Site | Google Scholar

16. L. Q. Mortensen, J. Burcharth, K. Andresen, H. C. Pommergaard, and J. Rosenberg, “An 18-year nationwide cohort study on the association between diverticulitis and colon cancer,” Annals of Surgery, vol. 265, no. 5, pp. 954–959, 2017.

    View at:

    Publisher Site | Google Scholar

17. V. Jaruvongvanich, A. Sanguankeo, K. Wijarnpreecha, and S. Upala, “Risk of colorectal adenomas, advanced adenomas and cancer in patients with colonic diverticular disease: systematic review and meta-analysis,” Digestive Endoscopy, vol. 29, no. 1, pp. 73–82, 2017.

    View at:

    Publisher Site | Google Scholar

18. J. Granlund, T. Svensson, F. Granath et al., “Diverticular disease and the risk of colon cancer – a population-based case-control study,” Alimentary Pharmacology & Therapeutics, vol. 34, no. 6, pp. 675–681, 2011.

    View at:

    Publisher Site | Google Scholar

19. W. Y. Huang, C. C. Lin, Y. M. Jen et al., “Association between colonic diverticular disease and colorectal cancer: a nationwide population-based study,” Clinical Gastroenterology and Hepatology, vol. 12, no. 8, pp. 1288–1294, 2014.

    View at:

    Publisher Site | Google Scholar

20. S. Morini, A. Zullo, C. Hassan, S. Tomao, and S. M. Campo, “Diverticulosis and colorectal cancer: between lights and shadows,” Journal of Clinical Gastroenterology, vol. 42, no. 7, pp. 763–770, 2008.

    View at:

    Publisher Site | Google Scholar

21. M. M. Meurs-Szojda, “Diverticulosis and diverticulitis form no risk for polyps and colorectal neoplasia in 4,241 colonoscopies,” International Journal of Colorectal Disease, vol. 23, no. 10, pp. 979–984, 2008.

    View at:

    Publisher Site | Google Scholar

22. A. Muhammad, O. Lamendola, A. Daas, A. Kumar, and G. Vidyarthi, “Association between colonic diverticulosis and prevalence of colorectal polyps,” International Journal of Colorectal Disease, vol. 29, no. 8, pp. 947–951, 2014.

    View at:

    Publisher Site | Google Scholar

23. S. Morini, C. Hassan, A. Zullo et al., “Diverticular disease as a risk factor for sigmoid colon adenomas,” Digestive and Liver Disease, vol. 34, no. 9, pp. 635–639, 2002.

    View at:

    Publisher Site | Google Scholar

24. T. N. Witte and R. Enns, “The difficult colonoscopy,” Canadian Journal of Gastroenterology, vol. 21, no. 8, pp. 487–490, 2007.

    View at:

    Publisher Site | Google Scholar

25. J. C. Anderson, C. R. Messina, W. Cohn et al., “Factors predictive of difficult colonoscopy,” Gastrointestinal Endoscopy, vol. 54, no. 5, pp. 558–562, 2001.

    View at:

    Publisher Site | Google Scholar

26. B. P. Saunders, S. Halligan, C. Jobling et al., “Can barium enema indicate when colonoscopy will be difficult?” Clinical Radiology, vol. 50, no. 5, pp. 318–321, 1995.

    View at:

    Publisher Site | Google Scholar

27. V. B. Gohil, J. T. Patrie, V. M. Shami et al., “Colonic diverticulosis is associated with an increased adenoma detection rate in patients undergoing first-time screening colonoscopy,” Journal of Interventional Gastroenterology, vol. 2, no. 2, pp. 70–75, 2012 Apr-Jun.

    View at:

    Publisher Site | Google Scholar

Copyright

Copyright © 2019 Fadi Abu Baker et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Diverticula of the gastrointestinal tract Medical On Group Novosibirsk

Diverticulum (from Latin “road to the side”) is a hernia, a protrusion of the wall of a hollow organ. Diverticula can be either single or multiple. Diverticula are most commonly found in the digestive tract.

Also, the wall of the diverticulum may consist of the same layers as the wall of the organ, or be without a muscular layer. Accordingly, they are divided into true and pseudodiverticula.

Diverticula in the gastrointestinal tract can be located all over, causing various clinical manifestations and complications, depending on the level.

Esophageal diverticulum

Diverticula occur throughout the esophagus. Depending on the location, they are classified:
1. Pharynoesophageal
2. Pharyngoesophageal
3. Epibronchial (bifurcation, midesophageal)
4. Supraphrenic [1]

Depending on the causes of occurrence, they are divided:
1. Pulsion (due to disorders of peristalsis)
2. Traction (due to the occurrence of cicatricial changes during inflammation)

Causes of esophageal diverticulum may include:
1. Reflux esophagitis
2. Infectious lesion (tuberculosis, fungal infection)
3. Trauma
4. Inflammatory processes in nearby organs (mediastenitis) [2]

Symptoms depend on the location of the protrusion

Zenker’s diverticulum (in the region of the pharyngeal-esophageal junction) is most pronounced. Dysphagia develops (disturbance in the passage of food, nausea), bad breath appears, a change in the timbre of the voice. With the location of the diverticulum in the lower third of the esophagus, there may be pain in the heart, bronchospasm, shortness of breath.

Complications

Esophageal diverticula may be accompanied by mediastinitis (inflammation of the mediastinum), neck phlegmon, fistula formation and sepsis, mucosal erosion, and esophageal cancer.

Diagnosis

The main method of diagnosis is X-ray examination (examination in an X-ray machine after taking a contrast agent). An additional method is endoscopic esophagoscopy (inspection in the lumen with a probe with a video camera), which will allow you to examine the condition of the mucosa in the diverticulum, but it must be done very carefully, due to the danger of perforation.

Treatment

Diverticulum can only be cured surgically (by removing it).
With the danger of operations – severe concomitant diseases – conservative therapy is possible, consisting in a diet, taking anti-inflammatory drugs (enveloping the mucous membrane of the esophagus, lowering gastric secretion).

Modern medicine uses a laparoscopic technique for removing esophageal diverticula – thoracoscopy, when only a few small incisions are made on the body, and the removal itself takes place inside the chest cavity. This allows to reduce the period of rehabilitation of patients.

Diverticula of the large intestine

In the large intestine, diverticula are more common in the left part of the intestine (sigmoid colon).
Their occurrence is associated with a change in the elasticity of the intestinal wall, an increased content of refined food in the human diet and minimization of dietary fiber. With an increase in intraluminal pressure in the intestine, the mucosa prolapses through weak points (usually this is the place where the vessel exits in the intestinal wall). Diverticula are less common in vegetarians and more common in people with dysplasia (extensibility) of the connective tissue (especially diseases such as polycystic kidney disease, Marfan’s syndrome). [3]

Various conditions associated with colonic diverticula are distinguished.
A. Diverticulosis of the colon (that is, the presence of diverticula without clinical manifestations)
B. Clinically significant diverticulosis (presence of diverticula, no signs of inflammation or bleeding)
C. Diverticular disease (the presence of diverticula, as well as the presence of symptoms that may be associated with them – bleeding, inflammation) [4]

Symptoms

Diverticular disease of the large intestine manifests itself only with inflammation in the wall of the diverticulum. Clinically, this is bloating, pain in it, stool disorders, including diarrheal syndrome.[8]

Complications
With pronounced inflammation, bleeding occurs, due to the intimate location of the vessel in the wall of the diverticulum, intestinal bleeding is sometimes treated surgically.[7]

Paraintestinal infiltrate and sometimes abscess may occur. Perforation of the diverticulum results in fecal peritonitis. [9],10]

Diagnosis

The main diagnostic method of diverticular disease of the colon is fibrocolonoscopy – intraluminal examination of the intestine, as well as examination of the state of the mucosa in diverticula. Additionally, irrigoscopy can be used (examination on an X-ray machine, after the introduction of a contrast agent in an enema). Also, for the purpose of clarification, methods such as virtual fibrocolonoscopy are used (when the examination takes place in an MRI machine, and the computer program itself creates a picture of the intestine in the lumen).

Treatment
Surgical treatment of diverticular disease is used only for complications.
Patients in the presence of diverticula in the colon are prescribed a high-slag diet with the additional introduction of dietary fiber.

With individual characteristics and clinical manifestations in the form of pain, abdominal cramps, mesalazine preparations are used systematically, in courses.[11] A good effect is the use of probiotics, antispasmodics and prokinetics (drugs that reduce spasm in the intestine, regulating the synchronous work of the muscular wall of the intestine).

Prevention

Regular bowel movements and dietary intake minimizes the possibility of bowel diverticula. Conducted clinical studies have shown a decrease in the incidence of diverticular disease when they are taken. Fibers accelerate transit (movement of feces through the intestines), reduce constipation, thereby helping to reduce stress on the intestinal wall.

The most common dietary fiber:

• Cellulose is an unbranched glucose polymer containing up to 10 thousand monomers.
• Hemicellulose consists of pentose and hexose residues, which are associated with residues of arabinose, glucuronic acid and its methyl ester.
• Gum (gum) is a derivative of glucuronic and galacturonic acids, to which magnesium and calcium salts, arabinose, mannose, xylose are attached.
• Pectin – polymers of molecules of galacturonic and guluronic acids. Pectin substances are a group of macromolecular compounds that are part of the cell walls and the intermediate substance of higher plants
• Lignin is a non-carbohydrate substance. Minimum content in unripe fruits and vegetables.
• Alginates – salts of alginic acids, the main content in algae.
• Mucus – branched sulfated arabinoxylans.

Mucus is found in large quantities in oatmeal and pearl barley, rice. The seeds of psyllium (Plantago ovata) contain a lot of mucus and are used to produce psyllium. Psyllum does not irritate the intestinal wall, unlike coarse dietary fiber (bran), and can be used even for inflammation (diverticulitis) of the intestine. Together with metasalazine, it gives a good effect in the treatment of diverticular disease in exacerbation. [11,12]

Diverticula of the small intestine

The prevalence of diverticula of the small intestine of the world’s population is 0.5–2.3% [5].

Diverticula of the duodenum (DDC)

Diverticula of the duodenum are more often acquired, occur in people over 50 years of age. When inflammation causes pain in the right hypochondrium, radiating to the left shoulder blade.

Parafatheral diverticulum

This diverticulum is located in close proximity to the papilla of Vater in the duodenum, Wirsung’s duct. With inflammation and edema, it can cause obstructive jaundice, acute pancreatitis, cholangitis.

Diverticula of the jejunum and ileum.

Usually an incidental finding on x-ray, without clinical symptoms.

Meckel’s diverticulum

The first diverticulum was described in 1906. This is a local saccular protrusion of the ileum wall, formed due to incomplete fusion of the vitelline duct involved in the nutrition of the embryo, located 10-100 cm from the ileocecal node, ranging in size from 5 to 50 cm. Sometimes it contains cells of the gastric mucosa, as well as tissue pancreas (up to 50% of cases), which can cause bleeding and tumors [6].

Diagnostics

In diagnostics, great importance is attached to video capsule endoscopy, which makes it possible to clearly identify changes in the mucosa, including. Computed tomography may be the method of choice. Laparoscopy is also used for diagnosis, and often at the same time as its removal.

Complications

Diverticulitis, obstruction, perforation and bleeding – develop in 10-30% of cases. Mechanical intestinal obstruction can be caused by a foreign body, intussusception, stretched diverticula during the inflammatory process, adhesions, strictures resulting from past inflammations. With the progression of the inflammatory process, bleeding, obstruction, and perforation of the diverticulum are possible. In this case, peritonitis may develop.

Treatment

Treatment depends on clinical manifestations.

Bleeding. Bleeding can occur at any location of the diverticulum. The blood secreted by the blood is often maroon (due to the high location of the source of bleeding – the small intestine). For the diagnosis of intestinal bleeding, endoscopic methods (laparoscopy, video capsule endoscopy) and angiography (injection of a contrast agent into the blood and examination of the vessels supplying this section of the small intestine in an X-ray machine) are used. Treatment is often surgical (removal of the affected area of ​​the small intestine or an attempt to suture a blood vessel).

Intestinal obstruction. More often, this complication occurs in young children, with diverticulum volvulus. Intestinal obstruction can be caused by enteroliths (intestinal fecal stones), adhesions arising from inflammation of the diverticulum (diverticulitis). With this complication, surgical treatment is also performed (removal of the diverticulum and, possibly, resection of part of the intestine).

Diverticulitis. Often enteroliths (dense fecal stones) cause inflammatory changes in the diverticulum, cause infringement or stagnation in the vessels that feed the intestinal wall. In this case, treatment may be limited to antibiotic therapy, anti-inflammatory treatment, in the absence of effect and perforation of the diverticulum and the formation of an abscess, surgical treatment.

Abscess and peritonitis. With the progression of the inflammatory process in the diverticulum, an abscess develops, the perforation of which leads to peritonitis. Surgical treatment: a section of the intestine with an inflamed diverticulum is resected, followed by antibiotic therapy.

Obstructive jaundice and pancreatitis. These complications develop with inflammation of the parafatheral diverticulum. In this case, antibiotic therapy is prescribed, and in the absence of effect, surgical treatment.

Medical reference book of diseases: Diverticula of the esophagus.
1. Anokhina G.A. Diseases of the esophagus, stomach and intestines, Quorum – M., 2011.-166 p.
2. Commane D.M., Arasaradnam R.P., Mills S. et al. Diet, aging and genetic factors in the pathogenesis of diverticular disease. World J Gastroenterol 2009 May 28;15(20):2479-2488
3. Ivashkin V.T., Shelygin Yu.A., Achkasov S.I. and others. Recommendations of the Russian Gastroenterological Association and the Association of Coloproctologists of Russia for the diagnosis and treatment of adult patients with diverticular disease of the colon. RJGGT, 2016,1:65-80.
4. Singh Mohi R, Moudgil A, Kumar Bhatia S, Kaur T. Complicated Jeunal diverticulosis: Small bowel volvulus with obstruction. Iran J Med Sci. 2016;41(6):548-51.
5. Nain Rattan K, Singh J, Dalal P, Rattan A. Meckel diverticulum in children: Our 12-year experience- NCB1-NiH. Afr J Paediatr Surg. 2016;13(4):170-4.
6. Achkasov S.I. Surgical tactics in the rehabilitation treatment of complicated colonic diverticulosis. Candidate’s abstract. honey. Sciences – M., 1992. – 24 p.
7. Bolikhov K.V. Acute inflammatory complications of diverticular disease of the colon (clinic, diagnosis, treatment). Candidate’s abstract. honey. Sciences – M., 2006. – 30s.
8. Vorobyov G.I. Fundamentals of coloproctology M., 2006. 432 p. 4.
9. Moskalev A.I. Clinical and morphofunctional parallels in chronic complications of diverticular disease. Candidate’s abstract. honey. Sciences – M., 2007. – 29p.
10. Giffin J.M., Butcher H.R., Ackerman L.V. Surgical management of colonic diverticulitis. Arch Surg 1967;94:619–626.
11. Tutelyan V.A., Samsonov M.A. Dietology Handbook // M.: Medicine, 2002. – S. 542.
12. Tutelyan V.A., Sukhanov B.P., Gapparov M. et al. Nutrition in the struggle for survival –
nie // M.: Akademkniga, 2003, – S. 347.

What we do not know about the intestine. Intestinal diseases

We will discuss other bowel diseases: polyps, diverticula and congenital diseases. Find out where they come from and how they are treated.

This is part of the interactive lessons prepared by the Level One educational platform in collaboration
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Author of the lesson

Ksenia Benimetskaya

Candidate of Medical Sciences, practicing cardiologist, nutritionist. Senior Lecturer, Department of Internal Medicine, Novosibirsk State University

Familial adenomatous polyposis (FAP) 👩‍👩‍👦‍👦

🌋 This disease causes abnormal growths in the rectum and colon, as well as in other areas of the intestine. These growths are called polyps. Patients with familial adenomatous polyposis have hundreds or even thousands of polyps. They are not cancer, although they can turn into one.

🕳 With colonoscopy, you can see that the entire intestinal mucosa is lined with polyps. The risk of developing cancer in people with polyps is significantly higher than in healthy people. For example, colon cancer often develops as early as 40 years of age. If the number of polyps does not reach one hundred, then cancer usually develops later – usually about 50 years. It also increases the risk of cancer of the stomach, pancreas and even the brain.

👨‍👧‍👦 Familial adenomatous polyposis is a genetic disease that is often inherited. Some patients are the first of their kind to be diagnosed with FAP. This means that it was in their generation that the gene mutated. Usually, the first symptoms appear around the age of 20 – in adolescence and adolescence.

Various types of polyps. SAP is in the lower left corner.

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Diagnostics and treatment 👨‍⚕️

☝️ Symptoms of FAP include:

– stomach ache;

– spasms;

– constipation;

– diarrhea;

– weight loss;

– bloating;

– chronic fatigue.

❗️ If any of the family members have adenomatous polyposis, it is important to undergo regular examinations to make sure that it is not present or to diagnose it even before the first symptoms appear. As part of the examination, the doctor may recommend genetic testing not only to the patient himself, but also to some family members.

🔪 Depending on the symptoms, treatment may even include removal of the colon (colectomy), which is riddled with polyps. In most cases, it is still limited to the removal of polyps. This reduces the risk of developing cancer.

Surgical removal of a polyp.

Diverticulitis 💰

💣 This disease causes pain in the abdomen, fever and problems with bowel movements. Diverticula are small sacs in the wall of the large intestine. They make the intestine more voluminous. Many people have diverticula, but not all people suffer from health problems.

🌡 Diverticulitis is an inflammation of diverticula that occurs due to their damage or microperforations. It is usually diagnosed using contrast imaging, which allows you to view the diverticula in detail and assess their condition. Ultrasound is also used in the diagnosis.

🏥 Depending on the severity of symptoms, treatment may consist of a course of antibiotics and diet. In severe cases, hospitalization and droppers are necessary.

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