Prevalence and Distribution of the Colonic Diverticulosis. Review of 417 Cases from Lower Silesia in Poland

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1 Colonic diverticulosis prevalence Prevalence and Distribution of the Colonic Diverticulosis. Review of 417 Cases from Lower Silesia in Poland Katarzyna Blachut 1, Leszek Paradowski 1, Jerzy Garcarek 2 1) Department of Gastroenterology and Hepatology. 2) Department of Radiology, Wroclaw Medical University, Wroclaw, Poland Abstract Background. The prevalence of ic diverticulosis increases with age and is the most common pathology of the large bowel in the elderly. Studies of the frequency of diverticulosis are performed in necroptic, radiological and endoscopic surveys. Aim. The assessment of the prevalence and distribution of ic diverticulosis evaluated with barium enemas. Material and methods. 1,912 consecutive barium enemas examinations, performed between were reviewed. The patients were 1,228 females and 684 males (mean age 55.4 yrs). Results. Diverticula were observed in 21.7 percent (417) of the patients (279 females /mean age 64.1/ and 138 males /mean age 64.5 yrs). The prevalence of diverticulosis among females was 22.7 per cent and among males 20.2 per cent. The frequency of diverticulosis in patients aged years was 5.3 per cent, years 8.7 per cent, years 19.4 per cent, years 29.6 per cent, years 40.2 per cent, and in those aged over 80 years it was 57.9 percent. Conclusions. Diverticular disease of the is a significant problem in elderly patients, both females and males. The most common occurrence is in the sigmoid and descending. Key words Colonic diverticulosis - large bowel contrast examinationepidemiology Rezumat Premize. Prevalenþa diverticulozei ice creºte cu vârsta, fiind cea mai comunã patologie a ului la vârstnici. Romanian Journal of Gastroenterology December 2004 Vol.13 No.4, Address for correspondence: Dr.Katarzyna Blachut Dept. of Gastroenterology and Hepatology Wroclaw Medical University Poniatowskiego Street Wroclaw, Poland Studiile privind frecvenþa diverticulozei au fost efectuate în serii necroptice, radiologice ºi endoscopice. Scop. Evaluarea prevalenþei ºi distribuþiei diverticulozei ice investigatã prin clismã baritatã. Material ºi metodã. Au fost revãzute 1912 clisme baritate consecutive efectuate în perioada Pacienþii au fost 1228 femei ºi 684 bãrbaþi (vârsta medie 55,4 ani). Rezultate. Diverticulii au fost observaþi la 21,7% (417) dintre pacienþi: 279 femei, vârsta medie 64,1 ani, ºi 138 bãrbaþi, vârsta medie 64,5 ani. Prevalenþa diverticulozei la femei a fost de 22,7% ºi la bãrbaþi 20,2%. Frecvenþa la pacienþii în vârstã de ani a fost de 5,3%, la ani 8,7%, la ani 19,4%, la ani 29,6%, la ani 40,2%, iar la cei peste 80 de ani a fost 57,9%. Concluzii. Diverticuloza ului reprezintã o problemã semnificativã la vârstnici, atât femei cât ºi bãrbaþi. Localizarea cea mai frecventã este în sigmoid ºi ul descendent. Introduction Acquired ic diverticula are pseudodiverticula within the intestinal wall consisting of mucosa and submucosa. Prevalence of diverticulosis increases with age and it is the most common pathology of the large bowel in the elderly. Studies regarding the frequency of diverticulosis are performed in necroptic, radiological and endoscopic surveys. Results of such studies have shown that marked geographic and temporal variations in disease epidemiology exist. Diverticulosis occurs more often in Western Europe, the USA, Australia and Asian countries adopting western life style compared to other Asian countries and Africa. The data from Eastern and Middle Europe are limited, and this was the major reason for our study. Material and methods 1,912 consecutive barium enemas performed during were reviewed for the presence of diverticula. Frequency and anatomic distribution of diverticulosis, and

2 282 Blachut et al the relationship between prevalence and gender and age were studied. The study group consisted of 1,228 females and 684 males (mean age 55.4±14.5 years, ranges 17-97). Results Diverticulosis of the was detected in 417 (21.8%) patients (mean age 64.2 ± 10.6, ranges years). There were no patients younger than 30 years in the studied group (Fig.1) % of the women and 20.29% of the men presented diverticulosis. Table I Prevalence of ic diverticulosis according to gender and age Age Total Females Males (years) n=417 n=279 n= % (7) 1.9% (1) % (23) 7.5% (10) % (58) 21.6% (29) % (87) 29.7% (46) = % (104) 37.7% (52) The distribution of the diverticula in the is shown in Table II. Table II Distribution of the diverticula in the Location Total Females Males % (n) % (n) % (n) entire 14.6 (61) 14.7 ( (20) sigmoid 84.7 (353) 86 (240) 81.9 (113) descen- 54 (225) 52.7 (147) 56.5 (78) ding splenic 19.9 (83) 19.7 (55) 20.4 (28) flexure transverse 20.5 (85) 21.5 (60) 18.1 (25) hepatic 17.5 (73) 18.6 (52) 15.2 (21) flexure ascending 17.5 (73) 16.5 (46) 19.6 (27) caecum 16.5 (69) 17.6 (49) 14.5 (20) Fig.1 Prevalence of ic diverticulosis according to age. Discussion Etiopathogenesis of the ic diverticulosis still remains unclear. Currently most authors agree that it is multifactorial disease comprising: environmental factors, structural and motility disorders (1). The first studies on the etiology of diverticulosis have been based on the geographic variation in the disease prevalence. D.P. Burkitt suggested the significance of a low-fiber diet in the development of diverticulosis and cancer with a rare occurrence among African communities (2). Painter and Burkitt described ic diverticulosis as a deficiency disease of Western civilization (3). Lin et al. in a study performed in Taiwan concluded that -sided diverticulosis was associated with more frequent meat consumption. They did not find a similar relation between diverticulosis and fruit/vegetable intake or fiber supplementation (4). Manousos et al in an epidemiological study in Greece found out that a higher risk of diverticulosis was associated with a significant larger and frequent meat consumption (to a lesser extent milk and dairy products) and less frequently with vegetable and brown bread (to a lesser extent fruit and potatoes) intake (5). The prevalence of diverticulosis has been increasing worldwide simultaneously with increasing Westernization of the diet (6). Authors of the epidemiological studies performed in different time periods and different world regions have agreed that: - there is a predominance of -sided diverticulosis in Western countries; - there is a predominance of - sided diverticulosis in Asian communities; - the frequency of diverticulosis increases with age; - the frequency of diverticulosis increased during the twentieth century. The anatomic pattern of ic diverticulosis has a significant clinical meaning. Localization of diverticula influences type of complications and their evolution. In Western countries in patients with diverticulosis complicated by inflammation the main symptom is abdominal pain in the lower quadrant. In Asian countries, where there is a predominance of -sided

3 Colonic diverticulosis prevalence 283 Table III Geographic prevalence of diverticulosis Author (Reference) Country Method No.patients in the study Rate % Predominant site in the Eide et al. (25) Loffeld et al. (27) Paspatis et al.(26) Hughes (28) Chan et al. (21) Lee et al. (14) Chia et al. (15) Sugihara et al. (17) Miura et al. (18) Miura et al. (19) Calder (23) B³achut et al.(present study) Norway Holand Greece Australia Hongkong Singapore Singapore Kenya Poland Endoscopic * (men), 43(women) (men), 15.5(women) 28.3(men), 19.1(women not known not known * barium enema diverticulosis, patients with diverticulitis suffer from pain in the lower quadrant. Markham and Li reported that in the group of 35 patients with sided diverticulitis the preoperative diagnosis in 34 cases was appendicitis (7). Keidar et al estimated the frequency of preoperative diagnosis of appendicitis in patients with caecal diverticulitis was 77% (8). Other authors also emphasized the problems encountered in the differential diagnosis of -sided diverticulitis concluding that this may be associated more often with surgical interventions. Therefore, the preoperative diagnosis of -sided diverticulitis deserves serious consideration (9,10). The source of diverticula bleeding in most cases are -sided diverticula even in communities with a predominance of -sided diverticulosis (11). A recently recognized entity is diverticular colitis occurring in patients with sigmoid diverticulosis (12,13). Epidemiological studies were performed and the prevalence of ic diverticulosis in different world regions is shown in Table III. Lee et al detected diverticulosis in 19 per cent of 1,000 autopsy examinations in Singapore, more often in males than females aged under 60 years (14). Chia et al reported a similar frequency of diverticulosis (20%) in the barium enemas performed over a 18 month period ( ) in a Singapore hospital. Patients with -sided location were younger than patients with -sided diverticulosis by approximately 10 years. The incidence of diverticulosis increased with age and was similar among males and females. The results of these studies showed almost an equal prevalence rate of diverticulosis compared to Western countries. Authors suggest that the frequency is influenced by dietary and other environmental factors and the location depends on genetic factors. This observation was confirmed by an increase in the diverticulosis prevalence in Asian countries adopting a Western life style with a remaining anatomic pattern specific for Asia (15,16). The ese authors found diverticulosis in 13.3 per cent of 1839 barium enemas performed in in Tokyo (17). Miura et al studied 7,543 barium enemas done in between and Diverticulosis affected 22.2 percent of males 15.5 percent of females. The was the most frequent location (18). Miura et al. reviewed almost 14, 000 barium enemas performed in a Tokyo hospital between 1982 and 1997 to ascertain trends of diverticular disease epidemiology in. Diverticulosis was observed in 23.8 per cent of males and 19.1 per cent of females. The incidence of -sided and bilateral diverticulosis increased during the studied period. The prevalence of solitary diverticula (1 or 2) of the increased during this period among males and females. Surprisingly, the prevalence of multiple diverticula (3 or more) increased only in males. The number of diverticula cases did not change with time and with aging. The authors concluded that the prevalence of diverticulosis in has increased (19). Coode et al in an autopsy study in Hong Kong detected diverticula in 5 per cent of cases, most of them located in the caecum. However, the authors showed some limitations of the study resulting from the fact, that most of the citizens of Hong Kong came from China (20). Chan et al recognized diverticula in 25.1 percent of 858 barium enemas in Hong Kong. Diverticulosis affected men and women with similar frequency. In about 50 per cent of the patients, diverticula were limited to the -side of the and in 1/3 of cases bilateral type of disease were recognized (21). Lin et al reviewed 3,105 of screening oscopies performed in Chinese patients. Right-sided diverticula were found in 4.3 per cent of cases and -sided in 1.7% of cases (4). Calder ascertained frequency of diverticulosis in barium enemas in Kenya. Diverticula were seen in 6.6 per cent of cases (22). African authors suggest that probably the widely accepted belief that diverticulosis is a rarity among Africans, is a result of difficult access to diagnostic procedures and short life expectancy. In barium enemas in Kampala, Uganda, diverticulosis affected most often the sigmoid and descending. In Accra in Ghana the bilateral type of the disease was the most common (23,24). In Norway, Eide et al reviewed 280 necropsies for the presence of diverticulosis. Diverticula were seen in 25 per

4 284 cent of males and 43 per cent of females. They also showed an increase in frequency with age (25). A study of a series of 502 autopsy examinations in Crete revealed the prevalence of diverticulosis of 22.9 per cent. Authors also confirmed an increase of diverticulosis frequency with age (26). Loffeld et al studied 9086 oscopies performed during 8.5 years. Diverticulosis was revealed in 27 per cent of patients and its frequency has increased with age (27). Hughes et al evidenced diverticulosis in 43 per cent of 200 necropsies. In 99 per cent of cases the sigmoid was affected (28) (Table III). In a recently published article, the frequency of ic diverticular disease was compared in British patients of Indian-subcontinent Asian origin with other ethnic groups. The authors studied the oscopies done in a London hospital. Diverticulosis was recognized in 4 per cent of Indian subcontinent Asian males and 6 per cent females compared with 22 males and 23 percent of females of other ethnic groups. Patients of Indian subcontinent Asian origin were younger comparing to other ethnic groups but the difference in the frequency of diverticulosis persisted even when age was taken into account (29). Prevalence of diverticulosis revealed in our study is comparable with that of similar studies performed in European countries and Asian communities who have adopted a Western life style. As in other studies, Blachut et al diverticulosis affected men and women with the same frequency. Prevalence of diverticulosis increased with age as was reported in earlier observations. With the increase in the life expectancy in Poland ( years for males and years for females compared to the year years for males and years for females), diverticular disease, being especially a disease of the elderly, is becoming a problem of important clinical value. In the studied group, the most commonly encountered was the -sided diverticulosis, which is specific for non Asian communities. In 69 per cent of patients the disease was limited to the sigmoid and/or descending. In our study, we did not analyze the indications for examination. We concluded that diverticulosis is a significant problem in elderly patients, because of the high prevalence rate in this age group. This fact is one of the features of diverticulosis, which is of clinical importance. The other one is the risk of complications associated with diverticulosis, which can occur even in asymptomatic patients, and which can be serious and usually require hospitalization or even surgical interventions. 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