Managing Diverticulosis and Diverticular Disease
Managing Diverticulosis and Diverticular Disease
The term 'diverticular disease' describes the symptoms linked to the anatomical–structural changes in the colon that harbour diverticula.
Clinical classification of DD is still currently based on the 1999 EAES (European Association for Endoscopic Surgery) criteria, which subdivided DD as symptomatic uncomplicated disease, recurrent symptomatic disease and complicated disease.
Symptomatic uncomplicated diverticular disease is characterised by nonspecific attacks of abdominal pain without evidence of an inflammatory process. This pain is typically colicky in nature, but can be constant, and is often relieved by passing flatus or having a bowel movement. Bloating and changes in bowel habits also can occur due to bacterial overgrowth, and constipation is more common than diarrhoea. Fullness or tenderness in the left lower quadrant, or occasionally a tender palpable loop of the sigmoid colon, is often discovered on physical examination.
Recurrent symptomatic disease is associated with the recurrence of the symptoms described above, and it may occur several times per year. As recently underlined, these symptoms may resemble irritable bowel syndrome (IBS). Moreover, it has been recently described that IBS occurs 4.7-fold more likely in patients after an episode of acute diverticulitis than controls. Several factors seem to explain persistence of symptom in those patients (significant attenuation in serotonin-transporter expression, increased neuropeptides expression in colonic mucosa, persistence of low-grade inflammation). Hence, in this way, it seems to be appropriate to speak of IBS-like symptoms rather than IBS in those patients.
On the contrary, it may be quite difficult to differentiate SUDD from IBS. Clinical and laboratory parameters may be useful. Cuomo et al. found recently that only a minority of DD patients (10%) fulfilled criteria for IBS diagnosis and that abdominal pain >24 h was more prevalent in SUDD than in IBS patients (P < 0.01). It was also demonstrated that, compared with IBS, DD patients had more episodes of pain lasting 24 h requiring medical attention (P < 0.01). More recently, we investigated 72 patients suffering from abdominal pain with diverticula identified on colonoscopy, of whom 42 were classified as having SUDD (abdominal pain for at least 24 consecutive hours in the left lower abdomen), and 30 were classified as having IBS-like symptoms fulfilling Rome III criteria. All patients underwent faecal calprotectin (FC) determination and it was found that FC levels were elevated in 64.3% of SUDD patients and in no patients in the IBS-like group (P < 0.0001). Moreover, the severity of the abdominal pain and the FC score correlated significantly in SUDD patients (P = 0.0015). FC is particularly useful in this setting, because raised FC may be detected in SUDD, acute diverticulitis and SCAD but not in IBS. Hence, the characteristic of abdominal pain (left lower quadrant pain lasting >24 h), and the detection of raised FC are very useful for achieving a correct differential diagnosis between IBS and DD in a patient with diverticulosis of the colon.
European Association for Endoscopic Surgery criteria classifies as 'complicated disease' all complications related to DD, ranging from haemorrhage to peritonitis and strictures. Acute diverticulitis (DD with signs and symptoms of diverticular inflammation) is included in complicated disease.
Regarding treatment, symptomatic uncomplicated and recurrent symptomatic forms of colonic DD generally require medical treatment. Uncomplicated diverticulitis is also generally treated medically, and complicated diverticulitis generally requires surgical treatment. This has been recently confirmed by Lamb et al., who found that urgent surgery, elective surgery and no surgery are required in 30%, 36% and 35% of uncomplicated diverticulitis patients, respectively.
The Clinical Picture of DD
The term 'diverticular disease' describes the symptoms linked to the anatomical–structural changes in the colon that harbour diverticula.
Clinical classification of DD is still currently based on the 1999 EAES (European Association for Endoscopic Surgery) criteria, which subdivided DD as symptomatic uncomplicated disease, recurrent symptomatic disease and complicated disease.
Symptomatic uncomplicated diverticular disease is characterised by nonspecific attacks of abdominal pain without evidence of an inflammatory process. This pain is typically colicky in nature, but can be constant, and is often relieved by passing flatus or having a bowel movement. Bloating and changes in bowel habits also can occur due to bacterial overgrowth, and constipation is more common than diarrhoea. Fullness or tenderness in the left lower quadrant, or occasionally a tender palpable loop of the sigmoid colon, is often discovered on physical examination.
Recurrent symptomatic disease is associated with the recurrence of the symptoms described above, and it may occur several times per year. As recently underlined, these symptoms may resemble irritable bowel syndrome (IBS). Moreover, it has been recently described that IBS occurs 4.7-fold more likely in patients after an episode of acute diverticulitis than controls. Several factors seem to explain persistence of symptom in those patients (significant attenuation in serotonin-transporter expression, increased neuropeptides expression in colonic mucosa, persistence of low-grade inflammation). Hence, in this way, it seems to be appropriate to speak of IBS-like symptoms rather than IBS in those patients.
On the contrary, it may be quite difficult to differentiate SUDD from IBS. Clinical and laboratory parameters may be useful. Cuomo et al. found recently that only a minority of DD patients (10%) fulfilled criteria for IBS diagnosis and that abdominal pain >24 h was more prevalent in SUDD than in IBS patients (P < 0.01). It was also demonstrated that, compared with IBS, DD patients had more episodes of pain lasting 24 h requiring medical attention (P < 0.01). More recently, we investigated 72 patients suffering from abdominal pain with diverticula identified on colonoscopy, of whom 42 were classified as having SUDD (abdominal pain for at least 24 consecutive hours in the left lower abdomen), and 30 were classified as having IBS-like symptoms fulfilling Rome III criteria. All patients underwent faecal calprotectin (FC) determination and it was found that FC levels were elevated in 64.3% of SUDD patients and in no patients in the IBS-like group (P < 0.0001). Moreover, the severity of the abdominal pain and the FC score correlated significantly in SUDD patients (P = 0.0015). FC is particularly useful in this setting, because raised FC may be detected in SUDD, acute diverticulitis and SCAD but not in IBS. Hence, the characteristic of abdominal pain (left lower quadrant pain lasting >24 h), and the detection of raised FC are very useful for achieving a correct differential diagnosis between IBS and DD in a patient with diverticulosis of the colon.
European Association for Endoscopic Surgery criteria classifies as 'complicated disease' all complications related to DD, ranging from haemorrhage to peritonitis and strictures. Acute diverticulitis (DD with signs and symptoms of diverticular inflammation) is included in complicated disease.
Regarding treatment, symptomatic uncomplicated and recurrent symptomatic forms of colonic DD generally require medical treatment. Uncomplicated diverticulitis is also generally treated medically, and complicated diverticulitis generally requires surgical treatment. This has been recently confirmed by Lamb et al., who found that urgent surgery, elective surgery and no surgery are required in 30%, 36% and 35% of uncomplicated diverticulitis patients, respectively.