Diverticulosis

Andreas Stefan MDPortland Gastroenterology Center

Maine Medical CenterMarch 21, 2015

Overview

Epidemiology

Pathophysiology

Diverticulitis

Bleeding

Segmental Colitis Associated with Diverticulosis (SCAD)

Symptomatic Uncomplicated Diverticular Disease (SUDD)

EpidemiologyAge – In the United States

1/3 by age 60

2/3 by age 85

Male/female incidence the same

Diet – low fiber, high meat and sugar

Uncommon in Southeast Asia and Africa

Very common in Australia, US, Europe and Canada

Immigration studies (Africans moving to Sweden)

First report of surgery for diverticular disease by Mayo 1907

Why does diverticulosis

develop?

Pathogenesis of Diverticulosis

Exaggerated segmental contractions

Laplace’s law P = kT/R (sigmoid colon is narrowest portion of colon)

Patients with diverticular disease demonstrate higher pressures in colon than controls

Old theory speculated that local trauma by stool contents that may injure the wall of colon – e.g. seeds, nuts etc . . .

Typical diverticulum is in fact a pseudodiverticulum since not all layers are contained (no muscularis propria)

Segmental Contraction

Etiology of Diverticulosis

Diverticulitis

Colonic Anatomy

Risk of Diverticulitis

Clinical Presentation

SymptomsFever and/or chills 50% time

Left lower quadrant or lower abdominal pain

Change in bowel habits

Urinary symptoms including dysuria or pneumaturia (no hx diverticulitis in many)

Presence of localized or generalized peritonitis (micro/macroperforation)

R sided disease can mimic appendicitis

Diagnosis

Labs frequently show elevated WBC

Role of colonoscopy limited

CT scan valuable

Typically looking for 2 of 3 elements to establish diagnosis: symptoms, labs, and or CT

DiagnosisComputed Tomography (CT)

CT Scan with contrast – diagnostic test of choice with sensitivity of 94% and specifity 81% in pts with classic symptoms

Reliably shows the segment of bowel and the extent of disease

Identifies abscess and fistula formation

Reveals involvement of adjacent organs such as the small bowel, bladder and abdominal wall

Can be used to guide percutaneous drainage

Can be used to classify severity of diverticulitis

CT classification or grading

Modified Hinchey Staging – Originally based on clinical findings at surgery

Stage 0: LLQ pain, elevated WBC, fever, no confirmation by imaging or surgery

Stage Ia: Confined pericolic inflammation or phlegmon

Stage Ib: Confined pericolic abscess

Stage II: Pelvic, distant intraabdominal or retro-peritoneal abscess

Stage III: Generalized purulent peritonitis

Stage IV: Generalized feculent peritonitis

Stage 0 Often seen by PCP,

GI or ER

Generally treated with oral antibiotics

Cipro/Flagyl, Bactrim

Augmentin, Avelox

Low residue diet initially

High fiber diet once symptoms resolve

Stage Ia

Follow up of Stage 0 and Ia

Careful history regarding prior attacks including number, frequency, severity, and comorbidities including immunosuppression

Interval colonoscopy to rule out malignancy

High fiber diet

<25% will have second attack

Risk of third attack >50% after second attack

Resection for patients with multiple attacks

Stage Ib or II

Percutaneous drainage if possible

Transrectal drainage of pelvic abscess

IV antibiotic

Close clinical observation

Stage Ib or IIComplicated DiverticulitisClose follow up to assure resolution of symptoms and monitor for recurrence

Interval colonoscopy to rule out malignancy

Segmental resection with primary anastomosis 4-6 weeks after episode

Risk of recurrence if managed conservatively secondary to complications of diverticulitis (abscess, stricture or fistula)

MN study 42% pts not undergoing resection developed recurrent problems over 7 years (comorbidities)

Gaertner WB Dis Col Rectum 2013

Stage III and IVComplicated Diverticulitis

Can be difficult to distinguish on CT Scan or clinically

Generalized or Localized Peritonitis

Sepsis

Fever

Elevated WBC

Stage III and IVComplicated Diverticulitis

Usually require emergent operative intervention

Hartman’s Procedure (1921) Colostomy with closure of distal bowel

Primary anastomosis with diverting loop ileostomy in select cases

Laparoscopic lavage with drainage and interval sigmoid colectomy

Stage III and IVComplicated Diverticulitis

Stage III or IVComplicated DiverticulitisRequires a second operation to restore intestinal continuity

High percentage of patients never have them reversed (25-70%)

Morbidity associated with stomasChange in body image

Difficulty with stomal pouching

Peristomal hernia

Stomal retraction

Stomal prolapse

Indications for Elective Resection

After two episodes one should seriously consider elective resection

Immunosuppression

Ib and above disease

Fistula

Stricture

Colonic FistulasComplicated Diverticulitis

Colo-cutaneous fistulaMay be a consequence of percutaneous drainage of pericolic abscess

Colo-vesicular fistula50% of patients will not remember having diverticulitis

Men > Women

Pneumaturia, fecaluria, frequent UTI’s

Colo-vaginal fistulaGenerally seen in post hysterectomy female

Sigmoid adhesions to the pelvis

Colonic FistulaComplicated Diverticulitis

Rarely a cause for emergent surgery

Patient often improves with fistula formation

IV antibiotics

Await decrease in inflammation

Colonic StrictureComplicated Diverticulitis

Usually due to adhesion formation or as a result of recurrent inflammation and scarring

Often difficult to distinguish from Crohn’s disease or carcinoma on imaging

May be asymptomatic and identified at the time of colonoscopy

Diagnosis may be accomplished with barium enema or CT with retrograde contrast

If diagnostic uncertainty then surgical resection is recommended

Colonic Stricture

Can we eat Seeds, Nuts and Popcorn?

Can we eat Seeds, Nuts and Popcorn?

Recommendation to avoid seeds, nuts and popcorn was a result of the theory from the 1960’s (direct trauma, obstruction) – no data

Current epidemiologic data supports the intraluminal pressure model of diverticulosis

However, the avoidance of seeds, nuts and popcorn persists

Can we eat Seeds, Nuts and Popcorn?

Health Professionals Follow-up Study

Cohort of US men (51,529) followed prospectively from 1986 – 2004

Follow diet, life style and medical history with biennially questionaire

90% mean followup

Primary endpoints diverticulitis and diverticular bleeding

Strate et al, JAMA 2008

Can we eat Seeds, Nuts and Popcorn?

801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding

Looked at nut, corn and popcorn consumption and diverticulitis and diverticular bleeding

Found nut, corn and popcorn consumption did not increase the risk of diverticulitis or diverticular complications

Inverse associations between nut and popcorn consumption and the risk of diverticulitis in patient’s who consumed them >2x/week

Strate et al, JAMA 2008

Can we eat Seeds, Nuts and Popcorn?

Yes!

Diverticular bleeding

Bleeding Colonic Diverticulum

Clipping of Bleeding Diverticulum

Diverticular Bleeding

5-15% with diverticulosis will develop bleeding

Usually painless and not a/w diverticulitis 50% bleeding proximal to splenic flexure Stops spontaneously majority of time Risk of second bleed 20%, third bleed 50% Bursts of larger bleeding (not small

frequent)

Therapeutic Colonoscopy

Jensen et al NEJM 2000

10 of 48 patients (21%) presenting with diverticular hemorrhage had bleeding site identified

Treated with injection and/or cautery

No rebleeds at median f/u 30 months

Colonoscopy within 12 hours of admit

Findings May Not Be Generalizable

High rate of bleeding site identification, other studies 5-15%

Endoscopic treatment riskier given tissue thickness

Bit of an outlier in terms of rebleed (other studies show rates as high as 38%)

Segmental Colitis Associated with Diverticulosis (SCAD)

Segmental Colitis Associated with Diverticulosis

Segmental Colitis Associated with Diverticulosis

May be asymptomatic or have hematochezia and abdominal pain – rectum spared

Average age onset 62

Dx made endoscopically and histologically

Interdiverticular mucosa inflamed without involvement of diverticular orifices (oppose diverticulitis or IBD)

Histologically ranges from modest inflammation to prolapse to chronic inflammation with crypt abscesses and distorted crypt architecture

SCAD

Natural history incompletely understood

Histologically resembles IBD, infx and ischemic colitis

One study 10% went on to Crohns over 6 year f/u

Treatment with 5 ASA, antibiotics, probiotics, even infliximab

Elevated TNF alpha

Terminology

Symptomatic Uncomplicated Diverticular Disease (SUDD)

Commonly LLQ pain often worse after eating and better with defecation of passage of flatus

Overlap with IBS and question late consequence

Diverticulosis may not be just an intermittent condition

Surgical resection series at Mayo: 47 pt with 12 month f/u on 68%. Resolution of symptoms 77% and 88% pain free (76% of specs with acute/chronic inflammation)

Medical Treatment Options for Recurrent

Diverticulitis, SCAD and SUDD

Mesalamine

Rifaximin

Probiotics

Fiber

TreatmentMesalamine

Given evidence of chronic inflammation in patients with diverticular disease

Trepsi et el: 400 bid mesalamine x 8 wks after acute attack: 15% vs 46% relapse after 4 years vs placebo

Tursi et al: continuous mesalamine 1.6g/day better than 10d/month: 78 vs 56% symptom free (SUDD)

Systematic review 818 pts with uncomplicated diverticulitis or SUDD found mesalamine better at relief of symptoms

Studies with limitations including lack of adequate control groups and open label design

More recently PREVENT 1 and 2 and DIVA trials performed

TreatmentMesalamine

(for prevention of recurrent diverticulitis)

PREVENT 1 and 2 trials

584 pts with resolved diverticulitis 1.2, 2.4 or 4.8 g mesalamine daily for 2 years

No difference in recurrent attacks

DIVA trial (MC, PC, DB) mesalamine better symptom response compared with placebo (probiotic no additional benefit) in pts with CT documented diverticulitis but no change in recurrent diverticulitis

TreatmentRifaximin

Tursi et al: 218 pts recurrent diverticulitis randomized to rifaximin 400 bid 7 days per month and mesalamine 800 mg bid: combination better than placebo at symptoms relief 86 vs 49% and preventing recurrence 3 vs 18%.

Meta-analysis: 64% vs 35% pts treated with rifaximin and fiber vs fiber alone were symptom free at 1 year follow up. NNT 3 for rifaximin vs placebo to achieve symptom relief

TreatmentProbiotics

Small uncontrolled studies

DIVA (looked at preventing recurrence diverticulitis) study without benefit

Fiber

Probably protective

0.58 RR in Health Professionals Study (n= 51,000) between highest quintile vs. lowest quintile of fiber intake

> 30g fiber a day likely necessary (apple = 4 g; www.wehealny.org)

Low fiber initially after an attack then high (although no clear evidence this prevents future attacks)

Some patients with stricturing may not tolerate a high fiber diet

Conclusions

Common but most don’t go on to complications such as bleeding or diverticulitis

OK to eat seeds/nuts and popcorn

May not just be an acute disease – consider SCAD and SUDD

New treatment regimens may be effective at preventing recurrent attacks and/or reducing symptoms