Epidemiology of diverticulosis and diverticular disease. Alfredo Papa U.O.C. Medicina Interna e Gastroenterologia, C.I. Columbus

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1 Epidemiology of diverticulosis and diverticular disease Alfredo Papa U.O.C. Medicina Interna e Gastroenterologia, C.I. Columbus

2 Summary Burden of disease on health care resources (outpatients visits, admissions, costs, mortality) Prevalence of diverticulosis Risk of developing diverticular disease (and its complicances) in subjects with diverticulosis Risk factors for diverticulosis and for diverticular disease (including diverticulitis): environmental and genetic factors 2

3 Burden of diverticular disease outpatients -Data obtained from the 2010 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey - 8 th most frequent outpatient gastrointestinal diagnosis: 2.7 million clinic visits Peery AF e t al., Gastro

4 Burden of diverticular disease inpatients -Inpatients gastrointestinal, liver and pancreatic discharge diagnoses from the 2012 Nationwide Inpatients Sample (NIS) -The 2012 NIS includes all discharge data from 4378 hospitals located in 44 states (in US) -Diverticulitis without hemorrhage admissions are more than 200,000 with an aggregate cost of 2,2 billions of USD - Diverticular hemorrhage (included in gastrointestinal hemorrhage diagnosis) have an adjunctive burden of admissions and costs Peery AF e t al., Gastro

5 Burden of diverticular disease- Mortality Peery AF e t al., Gastro

6 Burden of diverticular disease- Europe Delvaux M. AP&T

7 Paterson HM et al, Colorectal Disease Percentage change in DD, digestive diseases and all hospital admissions in Scotland, Data obtained from the Scottish Morbidity Records -The study cohort included all patients with a hospital admission and a primary diagnosis of diverticular disease (DD) -90,990 admissions for DD from 2000 to Average annual increase per year of 4.5% -DD is an increasing burden on health service resources, particularly in younger age groups.

8 Paterson HM et al, Colorectal Disease Standardised mortality ratio (SMR) among patients having a first admission for DD -Data obtained from the Scottish Morbidity Records -The study cohort included all patients with a hospital admission and a primary diagnosis of diverticular disease (DD) -90,990 admissions for DD from 2000 to Average annual increase per year of 4.5% -DD is an increasing burden on health service resources, particularly in younger age groups.

9 Worldwide prevalence of diverticulosis Reichert M et al., UEG Journal 2015 and Tanase I et al., Chirurgia

10 -Retrospective study using administrative and clinical data from Veterans Affairs Greater Los Angeles Healthcare System pts with baseline diverticulosis. -11 yrs follow-up period: 95 pts developed diverticultis (4.3%, 6 per 1000 patient-year). - Each additional decade of age at the time of diagnosis reduced the risk for diverticulitis by 24%: younger patients have a higher risk of diverticulitis. Shahedi K et al, CGH

11 -1514 patients with endoscopy-confirmed asymptomatic diverticulosis (Tokyo area) - End-point: bleeding event - Median follow-up time: 46 months -Bleeding events occurred in 35 patients -Median time-to-event interval was 50 months -Overall incidence was 0.46 per 1000 patient-year - Age 70 and bilateral diverticulosis were significant risk factors for bleeding Nikura R et al, AP&T

12 Diverticulosis and diverticular disease- risk factors Diverticulosis Diverticulitis Diverticular bleeding and other complications Aging Obesity Aspirin and NSAID Alcohol Smoking Red meat Fibre intake (protective) Vegetarian diet (protective) Vitamin D (protective) Aspirin and NSAID Alcohol Obesity Smoking Aspirin and NSAID Alcohol Obesity Smoking Vitamin D (protective) 12

13 Risk of diverticular disease by intake of meat and fibre -47,033 men and women living in England and Scotland Of whom (33%) vegetarian -Assessment of the intake of dietary fibre cases of diverticular disease during a 11-years period of mean follow-up Crowe FL et al., BMJ

14 Risk of diverticular disease by diet group -47,033 men and women living in England and Scotland Of whom (33%) vegetarian -Assessment of the intake of dietary fibre cases of diverticular disease during a 11-years period of mean follow-up Crowe FL et al., BMJ

15 - Cross-sectional study of 2104 partecipants who underwent to colonoscopy - Assessment of diet and physical activity -High intake of fiber did not reduce the prevalence of diverticulosis. - Constipation was not a risk factor for diverticulosis. Peery AF et al., Gastro

16 Aspirin and NSAID use and risk of diverticulitis and bleeding -47,210 men of the Health Professionals follow-up Study (HPFS) cohort (age at inclusion in 1986) were included. -Assessment of NSAID and aspirin use biennially. -Identification of men with diverticulitis and diverticular bleeding cases of diverticulitis and 256 of diverticular bleeding during a 22-years period of follow-up Strate LL et al., Gastro

17 -Partners Healthcare System: 9116 patiens with uncomplicated diverticulosis and 922 who developed diverticulitis that required hospitalization. -Measurement of 25-OH-D. -Patients with UD had significantly higher mean pre-diagnostic 25-OH-D than patients with diverticulitis. -Significant trend protective for diverticulitis risk according to quintiles of serum vitamin D. Maguire LH et al., CGH

18 - 226,522 non elective diverticulitis admissions in the Nationwide Inpatients Sample and linked hospital locations to UV data. -Compared to high UV area, low UV areas had a higher rate of diverticulitis, diverticular abscess and colectomy. - Seasonal variation with a lower rate of diverticulitis in the winter months compared to summer, particularly in areas with the greatest UV fluctuations. -Because UV exposure largely determines vitamin D status, these findings support a role for vitamin D in the pathogenesis of diverticulitis. Maguire LH et al., JAMA Surg

19 Genetic factors Contribution of environmental and genetic factors to the development of DD in twins 19

20 Conclusions Diverticular disease is a serious burden for health care systems. Mortality for complicated diverticular disease (particularly in case of emergency surgery) is still considerable. Risk of developing diverticulitis (and its complications) in subjects with diverticulosis is low. Risk factors for diverticulosis and for diverticular disease (including diverticulitis) are not yet completely elucidated. Thus, well-designed, large, epidemiological studies are needed to address the lack of data! 20

21 .thank you for your attention! 21