Hits and Myths of Diverticulosis. JR Gray Gastoenterology UBC

Transcription

1 Hits and Myths of Diverticulosis JR Gray Gastoenterology UBC

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Disclosures None pertinent to this presentation Except I have diverticulosis myself

4 Diverticulosis New Questions Etiology and terminology Risks for diverticulosis Role of diet Need for antibiotics Risks for colon cancer

5 Traditional Dogma Diverticulosis results from low fiber diet Lifetime risk of diverticulitis is 10-25% Diverticulitis is an infection requiring antibiotics Elective resection advised after second attack Elective resection after first attack in the young

6 Colonoscopy Findings With Age Am J Gastro 2012; 107: 1486

7 Prevalence of Diverticulosis by Age Gastro 2012; 142: 266

8 Increasing Incidence of Diverticulitis Am J Gastro 2015; 110: 1589

9 Role of CT Imaging in Increasing Diagnosis of Diverticulitis Am J Gastro 2015; 110: 1589

10 Burden of GI Disease in USA 2009 Rank for GI Diagnosis % Change from 2000 Hospital Days 1 Acute Pancreatitis ,409,000 2 Cholecystitis ,000 3 Diverticulitis ,099,000 4 Appendicitis , Diverticular hemmorhage ,000 Gastro 2012; 143: 1179

11 Terminology Diverticulosis Diverticular Disease Asymptomatic Diverticulosis Diverticulitis Symptomatic Uncomplicated Diverticular Disease (SUDD) Acute Diverticulitis Chronic Diverticulitis Am J Gastro 2012; 107: 1486

12 Terminology Diverticulosis Diverticular Disease Asymptomatic Diverticulosis Diverticulitis Symptomatic Uncomplicated Diverticular Disease (SUDD) Acute Diverticulitis Chronic Diverticulitis Complicated Abscess Obstruction Fistula Sepsis Uncomplicated Chronic Recurrent Diverticulitis Segmental Colitis Associated With Diverticulosis (SCAD) Am J Gastro 2012; 107: 1486

13 SCAD Segmental Colitis associated with Diverticulosis?Spectrum of IBD Inflammatory markers present

14 Old Views on Pathogenesis Fiber Deficiency Hypothesis (Painter s Hypothesis) Low fiber diet Small volume stool increasing colon pressure Herniation thru colon wall Diverticulosis Plug of hard stool or seed in diverticulum causing local trauma and microperforation BMJ 1971; 2: 450

15 New Views on Pathogenesis of Diverticulosis and Diverticulitis Genetic predisposition Weakening of colonic wall Environmental influences Diet Microbiome Ageing Elastosis Fecolith impaction Micro perforation Environmental influences Diverticulosis Neural degeneration Altered receptor sensitivity Muscle thickening Diverticulitis Chronic symptoms Pain, diarrhea, constipation Post inflammatory hypersensitivity After APT 2014; 39: 359

16 Diet and Diverticular Disease Role of diet in developing diverticulosis Role of diet in developing diverticulitis Role of diet in preventing recurrence Role of other lifestyle factors

17 Increased Risk of Diverticulosis with Increasing Fiber Intake (A post colonoscopy diet survey) Increasing Fiber 1 st quartile p ( ) 1.14 ( ) 1.30 ( ) Peery. Gastro 2012; 142: 266

18 Increasing Risk of Diverticulosis with Increasing Stool Frequency < 7 BM/ week 7 BM/ week 8-14 BM/ week > 15 BM/ week ( ) 1.59 ( ) 1.70 ( ) P<.001 Peery. Gastro 2012; 142: 266

19 Constipation Not associated With Diverticulosis Clin Gastro Hep 2013; 11: 1622

20 Diet and Risk of Diverticular Disease (Prospective 11 yr F/U of 47,000 people) Diet Cases of diverticular disease Adjusted Relative Risk Meat Eater P=0.001 No meat, some fish ( ) Vegetarian ( ) Vegan ( ) Crowe. BMJ 2011; 343: d4131

21 Increasing Risk of Diverticulitis With Unprocessed Red Meat Gut doi: /gutjnl

22 Reduced Risk of Diverticular Disease with Increasing Fiber Intake Increasing Fiber 1 st quintile th quintile ( ) 0.76 ( ) 0.72 ( ) 0.59 ( ) Crowe. BMJ 2011; 343: d4131

23 Nuts, Corn and Popcorn in Diverticulitis Health Professional Follow-up Study n= 47,228 for 18 yrs Number of Servings <1 / mon 1-3 / mon 1 / wk > 2 /wk p Nuts ( ) 1.10 ( ) 0.77 ( ).006 Corn ( ) 0.95 ( ) 1.0 ( ) 0.64 Popcorn ( ) 0.88 ( ) 0.71 ( ).004 Strate. JAMA 2008: 300: 907

24 Lifestyle Risks for Diverticular Disease Smoking Relative Risk BMI Relative Risk Never 1.00 p<.001 Former 1.31 ( ) Light 1.34 ( ) Heavy 1.86 ( ) < ( ) P< ( ) ( ) > ( ) Education Relative Risk Some Secondary 1.00 P=.001 Higher Secondary 0.72 ( ) University degree 0.78 ( ) Crowe. BMJ 2011; 343: d4131

25 Heritability of Diverticular Disease 53% of suscepitibility to diverticular disease results from genetic factors Sibling Dizygotic Twin Monozygoyic Twin Gastro 2013; 144: 736

26 Risk of Diverticulitis and Medications NSAIDs Aspirin Steroids Ca Channel Blockers Colorectal Dis 2013; 16: o189

27 Risk of Acute Diverticulitis after Incidental Finding of Diverticulosis Diverticulitis 4.3% Definite Diverticulitis 1% N = 2222 Shahedi. Clin Gastro Hep 2013; 11: 1609

28 Management of Acute Diverticulitis Traditional Acute presentation Antibiotics Surgery Chronic recurrent Surgery

29 No Need for Antibiotics in Acute Uncomplicated Diverticulitis? Chabok. Br J Surg 2012; 99: 532 Cochrane 2012; 11: CD DIABOLO study. Abstract, UEGW Oct, 2014

30 No Difference at One Year Follow-up With or Without Antibiotics for Uncomplicated Diverticulitis Brit J Surg 2012; 99: 532

31 Antibiotics Provided No Difference in Pain in Uncomplicated Diverticulitis Br J Surg 2017; 104: 52

32 Antibiotics Provided No Difference in Time to Recovery in Uncomplicated Diverticulitis Br J Surg 2017; 104: 52

33 When should elective surgery be offered

34 Likelihood of Surgery by Age and Number of Admissions Arch Surg 2005; 140: 681

35 Diverticulitis in Young vs Elderly Need for Urgent Surgery Risk of Diverticulitis Recurrence Scand J Gastro 2013; 48: 643

36 No Difference in Surgical Outcome for Young or Old with Diverticulitis J Gastro Surg 2011; 15: 667

37 Surgical Management Acute Sepsis, peritonitis Elective No longer after second attack Not age related Lower threshold for surgery if immunosuppressed, steroids, malnutrition Case by case Surgery for Diverticulitis in the 21 st Century. JAMA Surgery 2014; 149: 292

38 Outcome After Surgery Persistent Symptoms after Successful Surgery 25% in 33 month follow-up of 124 pts Painful constipation or diarrhea Distension Cramps Dis Col Rect 2008; 51: 1044

39 Outcome After Diverticulitis Recurrence Old dogma 7-62% Am J Gastro 1999; 94: 3110 New studies 13% over 9 yrs Arch Surg 2005; 140: % over 16 yrs Arch Surg 2005; 140: % more than 2 episodes Br J Surg 2010; 97; 952

40 Risk of Recurrent Diverticulitis After Initial Episode of Diverticulitis Dis Col & Rect 2011; 54: 283

41 Risk of Complicated Diverticulitis After Initial Episode of Diverticulitis Dis Col & Rect 2011; 54: 283

42 Increased Risk of IBS After Acute Diverticulitis P =.006 Clin Gastro Hep 2013; 11: 1614

43 Increased Risk of Depression or Mood Disorder After Acute Diverticulitis P <.001 Clin Gastro Hep 2013; 11: 1614

44 Prevention of Recurrence Traditional High fiber No nuts or seeds

45 No Demonstrated Benefit of High Fiber Diet After Diverticulitis No high quality studies, , demonstrating treatment or recurrence benefit for high fiber after initial episode of diverticulitis Int J Colorectal Dis 2012; 27: 419

46 Nuts, Corn and Popcorn in Diverticulitis Health Professional Follow-up Study n= 47,228 for 18 yrs Number of Servings <1 / mon 1-3 / mon 1 / wk > 2 /wk p Nuts ( ) 1.10 ( ) 0.77 ( ).006 Corn ( ) 0.95 ( ) 1.0 ( ) 0.64 Popcorn ( ) 0.88 ( ) 0.71 ( ).004 Strate. JAMA 2008: 300: 907

47 Lack of Benefit From Mesalazine in Diverticulitis Recurrence APT 2017; 46: 282

48 No benefit from Mesalazine to Prevent Recurrent Diverticulitis APT 2017; doi /apt.14180

49 Physical Activity Reduces Risk of Diverticulitis Am J Gastro 2009; 104: 1221

50 Is Colonoscopy Required After Acute Diverticulitis?

51 Inconsistent Association Between Diverticulosis and Colorectal Cancer J Clin Gastro 2008; 42: 763

52 Diverticulosis Not Associated With Colonic Adenomas Am J Gastro 2015; 110: 1694

53 Risk of Being Admitted for Diverticular Disease Before Colon Cancer Diagnosis Swedish Population Based Study Time of diverticular disease admission before cancer diagnosis mos ( ) 31.5 ( ) 25.3 ( ) 7-12 mos 1.67 ( ) 2.18 ( ) 5.3 ( ) mos 0.93 ( ) 1.77 ( ) 2.11 ( ) mos 1.6 ( ) 2.14 ( ) 0.67 ( ) >25 mos 0.85 ( ) 1.14 ( ) 0.88 ( ) Granlund. APT 2011; 34: 675

54 Increased Risk of Colon Cancer After Diverticulitis An 18 year Danish National Survey (40,496 cases of diverticulitis) Ann Surg 2017; 265: 954

55 Survival From Colon Cancer With or Without Diverticular Disease Colon Cancer Mortality Overall Mortality APT 2011; 34: 675

56 Summary - What we have learned about divertiulosis and itis There is spectrum of disease Role of diet likely not important Genetics plays a role in diverticulosis Lifestyle factors play a role Risk of diverticulitis less than we thought Antibiotics may not always be required Risk of cancer may be increased especially if complicated presentation

57 References Mosadeghi S. Diverticular disease. Curr Opin Gastro 2015; 31: 50 Peery A. Diverticular disease: Reconsidering conventional wisdom. Clin Gastro Hep 2013; 11: 1532 Collins D. Modern concepts in diverticular disease. J Clin Gastro 2015; 49: 358 Morris A. Sigmoid diverticulitis. JAMA 2014; 311: 287 Humes DJ. Review article: Pathogenesis and management of acute diverticulitis. APT 2014; 39: 359 AGA Tech Rev on Man of Acute Diverticulitis. Gastro 2015; 149: 1950 Diverticulosis and Diverticulitis. Mayo Clin Proc 2016; 91: 1094