Diverticular Disease Emerging evidence in a common condition Determinants of treatment

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Bruce Hodge
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1 FALK SYMPOSIUM 148, Munich th June 2005 Diverticular Disease Emerging evidence in a common condition Determinants of treatment NATURAL COURSE OF THE DISEASE Marios Z Panos Euroclinic of Athens

2 WHY CONSIDER IT? Better understanding appropriate interventions Arrest progression Prevent complications Better quality of life Reduce drain on resources

3 EPIDEMIOLOGY Diverticular disease - a disease of industrialised countries - Europeans: Left colon affected = 95% - Asians : Right colon affected = 76% Prevalence is difficult to estimate - most are asymptomatic Data from: - barium enema series - necropsy series - colonoscopy

4 EPIDEMIOLOGY PREVALENCE OF DIVERTICULAR DISEASE Country Preval.. (%) n Year England Scotland 23 USA Reference Manousos Method A 1967 Manousos Eastwood BE 1985 Burkitt BE Thailand Vajrabukka China Guo-Zong Japan Kubo Ghana Archmpong Kenya Calder Nigeria Jhekwaba BE C BE BE BE A References: Manousos O BMJ 1967, Eastwood M Gut 1977, Burkitt DP Lancet 1985, Vajrabukka T Dis Col Rect 1980, Guo-Zong P 1984 Ch Med J, Kubo A 1983 Jap J M, Archmpong EQ 1978 Ann RCSEng,, Calder JF 1979 BMJ, JhekwabaFN JRCS Ed

5 EPIDEMIOLOGY contd. Prevalence rises with age Age(yr (yr) Prevalence Study <40 2-5% Painter >50 30 % Parks >60 35% Manousos >70 50% Painter >85 66% Parks References: Parks TG 1975 Clin Gastroenterol, Manousos O 1967 BMJ, Painter NS & Burkitt DP 1971 BMJ.

6 EPIDEMIOLOGY contd. Prevalence rises with Westernisation Population Japanese Japanese Country Year Prevalence Japan % Study Sato % Sato Japanese Hawaii % Stemmerman Right sided colonic disease remains predominant (76%) References: Sato E 1976 Cancer, Stemmerman GN 1973 Cancer

7 EPIDEMIOLOGY contd. Influence of fibre intake Prevalence of asymptomatic DD in over 45s Vegetarians v Volunteers Barium follow-through examination Fibre/d DD men DD women Veget.. 42g 2% 0% Volun.. 21g 31% 21% Reference : Gear JS et al Lancet 1979;i:511-4

8 EPIDEMIOLOGY contd. Influence of fibre intake USA Health Professionals Follow-Up Study men 40-75yr, 4yr f.u new cases Diverticular Disease RR Insol.. Fibre 0.63 Cellulose 0.52 CI 0.63 ( ) 0.91) 0.52 ( ) 0.75) No increased risk with smoking, caffeine, alcohol Reference : Aldoori WH et al J Nutrition 1998;128:714-9

9 OVERVIEW DIVERTICULOSIS 25% SYMPTOMATIC 75% ASYMPTOMATIC 25% Haemorrhage 75% Diverticulitis 1/3 Massive 75% Uncomplicated 25% Complicated 1/3 asymptomatic 1/3 non-specific sy s 1/3 recurrent/complicated diverticulitis Ref. Fearnhead N & Mortensen N Best Prac Res Clin Gastr 2002;16:4:577-93

10 COMPLICATIONS ACUTE DIVERTICULITIS Short duration of symptoms Previous attacks in only 8% Response to medical Rx 75% Recurrence 2% p.a. or 33% long term Recurrence after 2 nd attack = 90% surgery after 2 nd attack Ref. Farmakis N et al Br J Surg 1994;81:733-5 Sarin S & Boulos PB Ann RCS Eng 1994;76:

11 COMPLICATIONS ACUTE DIVERTICULITIS ABSCESS/PERFORATION Hinchey s classification of perf.. in acute diverticulitis Stage I - pericolic/mesenteric abscess medical Rx Stage II - walled off pelvic/retroperitoneal abscess Stage III - generalised purulent peritonitis Stage IV - generalised faecal peritonitis (6-35% mortality) Overall mortality % Surgical mortality 12-17% 17% Post surg symptoms 3-15% 3 Ref. Hinchey EJ et al Adv in Surg 1978;12: Sarin S & Boulos PB Ann RCS Eng 1994;76:

12 COMPLICATIONS contd. DIVERTICULITIS RISK OF PERFORATION - SPECIAL SITUATIONS Immune State Incidence Mortality Suppressed 43% 39% Competent 14% 2% Immunosuppressed = unlikely to respond to medical Rx early surgery recommended Ref. Tyau ES et al. Arch Surg 1991;126:855-9 Perkins JD et al Am J Surg 1984;148:745-8

13 COMPLICATIONS contd. DIVERTICULAR HAEMORRHAGE - 40% of all cases lower g.i. Hge - UK incidence 4/ pop. Risk of bleeding % patients with diverticulosis bleed - Risk factors - increasing age - R sided disease (46%) - NSAIDs RR 2.24, paracetamol RR 1.81 Ref. Aldoori WH et al Arch Fam Med 1998;7: McGuire HH Ann Surg 1994;220:653-6

14 COMPLICATIONS DIVERTICULAR HAEMORRHAGE contd. Bleeding outcome - 1/3 cases bleeding is massive - 40% continue to bleed / rebleed 7% surgery (mortality 2.2%) - After 1 bleed recur. risk at 4 yrs : 25% - After 2 bleeds recur. risk : 50% Ref. Aldoori WH et al Arch Fam Med 1998;7: McGuire HH Ann Surg 1994;220:653-6

15 COMPLICATIONS contd. DIVERTICULAR FISTULA bowel neoplasm, Crohn s OBSTRUCTION bowel neoplasm, extrinsic compresion, Crohn s DIVERTICULAR STRICTURE bowel neoplasm, extrinsic compresion, Crohn s, post-radiotherapy, ischaemic colitis

16 COMPLICATIONS contd. DIVERTICULAR FISTULAE overall incidence 2% Phlegmon or abscess ruptures into adjacent organ colovesical 65%, colovaginal 25%, rest 10% bowel neoplasm, extrinsic neoplasm, Crohn s

17 COMPLICATIONS contd. OBSTRUCTION Small bowel 70% - inflam.. mass, paral. ileus Large bowel 30% - - inflam., oedema, fibrosis bowel neoplasm, extrinsic compresion, Crohn s

18 COMPLICATIONS contd. DIVERTICULAR STRICTURE Fibrosis due to recurrent attacks Oedema and hypertrophy superimposed bowel neoplasm, extrinsic compresion, Crohn s, post-radiotherapy, ischaemic colitis

19 Diverticular Disease Emerging evidence in a common condition DETERMINANTS OF TREATMENT NATURAL COURSE OF THE DISEASE Diverticulosis is common in Western societies and its frequency rises with age Understanding the natural course of the disease may help identify appropriate points of preventive or therapeutic intervention.

DIVERTICULOSIS MEDICAL AND SURGICAL MANAGEMENT. Simon Radley Consultant Surgeon March 2013

DIVERTICULOSIS MEDICAL AND SURGICAL MANAGEMENT Simon Radley Consultant Surgeon March 2013 Definitions Diverticulosis: presence of diverticulae Diverticular disease: diverticulae associated with symptoms