Charlotte L. Kvasnovsky

Increased diverticular complications with nonsteriodal anti- inflammatory drugs and other medications: a systematic review and meta-analysis

Complications of colonic diverticula, perforation and bleeding are a source of morbidity and mortality. A variety of drugs have been implicated in these complications. We present a systemic review and meta‐analysis of the literature to assess the importance of this relationship.

Nonsteroidal anti-inflammatory drugs and exacerbations of inflammatory bowel disease.

Abstract Background. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly prescribed analgesics for treatment of variety of pain and inflammatory conditions. Their effects on the gastrointestinal tract are well described, but their possible propensity to cause clinical relapse in patients with inflammatory bowel disease (IBD) remains somewhat unclear. Aim. We reviewed case reports, case–control and cohort studies, as well as clinical trials of NSAIDs in patients with quiescent IBD in order to better assess the magnitude and type of effect. Results. The published literature on this subject is of mixed quality and many of the studies are open to criticism. The majority of patients with IBD tolerate these medications, while in the sole clinical trial of NSAIDs 20% experienced a clinical and laboratory documented relapse of disease, within 7–10 days of NSAID ingestion. The data on cyclooxygenase (COX)-2-selective anti-inflammatory analgesic are somewhat unclear, but nimesulide, celecoxib and etoricoxib do not appear to be associated with relapse of disease. Conclusion. Conventional NSAIDs may cause clinical relapse in about 20% of patients with quiescent IBD, which may be due to dual inhibition of the COX enzymes. Certain COX-2-selective NSAIDs appear to be safe.

Contrasting Pattern of Chronic Inflammatory Bowel Disease in Primary and Autoimmune Sclerosing Cholangitis

Background Primary sclerosing cholangitis (PSC) and autoimmune sclerosing cholangitis (AISC) are related, but distinct chronic liver diseases. PSC is associated with a high prevalence of ulcerative colitis while the intestinal inflammation associated with AISC is less well characterised. Aims To assess and contrast aspects of intestinal inflammation in patients with AISC and PSC and compare the clinical features with those of patients with ulcerative colitis and Crohns disease. Methods 23 and 22 patients with AISC and PSC, respectively, underwent review of colonoscopy and biopsy findings, capsule enteroscopy and assessment of clinical and inflammatory (faecal calprotectin) disease activity, which was compared with that of patients with ulcerative colitis and Crohns disease (n = 55 each). Findings Five and 6 patients with AISC and PSC, respectively, had normal colonoscopy and faecal calprotectin levels of 34.4 ± 8.3 and 39.7 ± 8.4 μg/g, respectively (normal < 50 μg/g), whereas 18 and 16, respectively, had identical variably severe, right sided colitis with frequent rectal sparing, consistent with ulcerative colitis. Mean (± SD) faecal calprotectin levels did not differ significantly (p > 0.05) between patients with intestinal inflammation in AISC (588 ± 549 μg/g), PSC (421 ± 351 μg/g), ulcerative colitis (501 ± 656 μg/g) or Crohns disease (476 ± 571 μg/g). Capsule enteroscopy showed that 7 of 18 (39%) (p < 0.03) of those with AISC had small bowel mucosal breaks whereas no patient with PSC had these findings. Interpretation Collectively these findings lend support to the suggestion that the chronic inflammatory bowel disease associated with PSC and in particular AISC may represent a distinct nosologic entity different from classic ulcerative colitis and Crohns disease.

Elderly patients have more infectious complications following laparoscopic colorectal cancer surgery.

Elderly patients may be at higher risk of postoperative complications, particularly infective, than younger patients.

What colorectal surgeons should know about probiotics: a review

Our understanding of the human microbiome and host–microbiome interactions is rapidly evolving, with increasing recognition that bacteria play an important and beneficial role in health. Probiotics can modulate the gut microbiome, providing a beneficial health effect, but research is at a nascent stage. The purpose of this study was to review the evidence currently available, to help clinicians and patients make informed decisions. Probiotics are regulated as food supplements, not medications, across Europe and the USA [1,2]. The European Food Safety Authority has rejected over 260 applications on the health benefits of probiotics (accepting none), and the United States Food and Drug Administration has also not approved a single probiotic for reducing the risk of disease [3,4]. Regardless, probiotics continue to be marketed to the general public with little scientific oversight, resulting in a European market of € 1.4 billion [5].

Diverticular disease as a chronic gastrointestinal condition: experience from a specialist clinic.

Background Although diverticular disease is a prevalent condition and a significant burden on the healthcare system, care is devolved across gastrointestinal, GP, and colorectal surgery clinics. We created a specialist Diverticular Disease Clinic to streamline care, enhance evidence-based practice and provide a base for research. The aim of this study was to assess patient referral sources, predictors of persistent disease and surgical outcomes. Methods We retrospectively reviewed all patients attending our clinic. Patients younger than 50 years of age on initial presentation were considered ‘younger’ patients. Persistent symptoms lasted for at least 3 months. Results Overall, 177 patients had confirmed diverticular disease. Patients were referred following hospital admission (82 patients, 46.3%) or from the community (95 patients, 53.7%). Ninety-five patients (53.7%) had persistent symptoms. Patients with more than two episodes of diverticulitis were more likely to have persistent symptoms (P<0.0001). Following hospitalization, younger patients were 3.98 times more likely to develop persistent symptoms (P=0.04). This was independent of the severity of the original infection, as a low peak C-reactive protein level of less than 50 mg/L was associated with persistent symptoms (odds ratio=3.62, P=0.03). Over the study period, 12 patients (6.9%) had elective surgery. Conclusion There is demand for dedicated care for patients with persistent symptoms from diverticular disease. Specialized clinics are a model for this care, provided by either gastroenterologists or surgeons, in centres with adequate demand. Our findings reinforce the hypotheses that chronic abdominal pain in diverticular disease may be related to sensation abnormalities similar to postinfective irritable bowel syndrome.

Expansion of Screening Mammography in the Veterans Health Administration: Implications for Breast Cancer Treatment

IMPORTANCE Women represent the fastest-growing demographic in the Veterans Health Administration. In 2008, we implemented programmatic changes to expand screening mammography, develop on-site breast care resources, and better coordinate care with non-Veterans Affairs (VA) facilities. OBJECTIVE To determine whether the programmatic changes would increase patient volumes, decrease time to definitive treatment, and increase the rate of breast conservation therapy (BCT). DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of all breast cancer cases treated from January 1, 2000, to May 31, 2012, at the Baltimore VA Medical Center. MAIN OUTCOMES AND MEASURES We compared process-of-care metrics before and after 2008, when programmatic changes were implemented. Metrics evaluated included the number of mammograms performed annually, sex shift, the interval from clinical suspicion to tissue diagnosis and definitive treatment, and the rate of BCT. RESULTS From 2000 to 2012, a total of 7355 mammograms were performed and 76 patients with breast cancer received treatment. Most mammograms (n = 6720) were performed after 2008. A median of 1453 (interquartile range [IQR], 592-1458) mammograms were performed and 6.33 patients received cancer treatment annually after 2008, representing 1200% and 49% increases, respectively, compared with the 2000 to 2007 interval. Most patients (86.7%) received screening and diagnostic imaging, biopsy, and surgery between multiple institutions. The interval between screening mammography and tissue diagnosis was 34 days (IQR, 20-52), with no significant difference between study intervals (P = .18). Time from tissue diagnosis to initiation of definitive treatment increased from 33 days (IQR, 26-51) to 51 days (IQR, 36-75) (P = .03) between 2008 and 2012. Thirty-three patients eligible for BCT (67.3%) received it, while 16 patients (32.7%) underwent mastectomy. CONCLUSIONS AND RELEVANCE Our institution has rapidly and successfully expanded screening mammography. Higher mammography volumes have been associated with increased use of non-VA breast care services and increased time to definitive treatment. Appropriate counseling regarding BCT was consistently documented, and mastectomy in BCT-eligible patients was largely the result of patient preference or clinical/social factors. Our data suggest that as patient volumes increase with intensified screening, VA hospitals may benefit from acquiring a full complement of on-site breast care services rather than improving flow between VA hospitals and non-VA breast care centers having specialized resources.

Clinical and symptom scores are significantly correlated with fecal microbiota features in patients with symptomatic uncomplicated diverticular disease: a pilot study.

Background There is growing consensus that symptomatic uncomplicated diverticular disease is a chronic inflammatory condition, and that alterations in the fecal microbiota may contribute to its pathogenesis. Objective The aim of this study was to relate the fecal microbiota composition in symptomatic uncomplicated diverticular disease to measures of inflammation, symptoms, and history of previous acute diverticulitis. Participants and methods Fecal microbiota composition in 28 individuals with symptomatic uncomplicated diverticular disease was characterized by 16S RNA gene amplicon sequencing. Microbiota composition was related to clinical history, symptom and inflammation measures, and demographic variables. Results Previous acute diverticulitis was associated with higher relative abundance of Pseudobutyrivibrio, Bifidobacterium, Christensenellaceae family, and Mollicutes RF9 order (P=0.004, 0.006, 0.010, and 0.019, respectively), but not microbiota alpha or beta diversity. A higher bloating severity score was significantly correlated with a higher relative abundance of Ruminococcus (P=0.032), and significantly inversely correlated with the relative abundance of the Roseburia (P=0.002). Fecal calprotectin levels were positively correlated with alpha diversity (Shannon index, P=0.005) and the relative abundance of Lactobacillus (P=0.004). Pain score was positively correlated with the relative abundance of Cyanobacterium (adjusted P=0.032). Conclusion Patient symptoms in symptomatic diverticular disease are significantly correlated with features of the fecal microbiota. Our findings suggest the potential utility of therapies that target intestinal microbiology, such as dietary prebiotic supplements.

Symptoms in patients with diverticular disease should not be labelled as IBS

Dear Editor: We read with great interest the article ‘Incidence and predictive factors of irritable bowel syndrome after acute diverticulitis in Korea’ published in October 2014 [1]. Upon reading it, we came to the conclusion that these patients were suffering from symptomatic diverticular disease following an attack of diverticulitis, not irritable bowel syndrome (IBS). The authors retrospectively identified patients admitted with diverticulitis and then conducted a telephone survey to assess symptoms post-diverticulitis. Of the patients, 12.8 % met criteria for IBS, although unfortunately they do not further detail patients’ post-discharge symptoms. Recurrent abdominal pain and change in stool consistency and/or pattern would be consistent with a definition of diverticular disease, a known syndrome following acute diverticulitis [2]. Remarkably, the authors do not identify a single patient with diverticular disease within their cohort. The pedantic point is that as a functional disorder, IBS cannot, by definition, have a structural deformity in the colon. As such, patients suffering from IBS-like symptoms who have colonic diverticula have diverticular disease. However, this is an issue with the definition of IBS (which should certainly include patients with asymptomatic diverticulosis and classic IBS pain), and to belabour it undermines the substantive issue in the manuscript by Jung et al. There is some evidence to suggest left lower quadrant pain may be the most specific symptom of diverticular disease, but this was not asked [3]. Additionally, patients with diverticular disease may have elevated levels of faecal calprotectin as compared to patients with IBS [4]. However, without these additional details, any persistent pain following diverticulitis should be diagnosed as diverticular disease. We further suggest that the Cox regression model (Figure 2) is unable to demonstrate time to symptoms following diverticulitis as described [1]. The researchers carried out follow-up only at one time point, in July 2013, on patients hospitalized between 2007 and 2012. They were thus unable to identify when patients developed abdominal symptoms following their episode of diverticulitis. (Indeed, we would imagine that those patients labelled here with IBS likely had persistent symptoms of diverticular disease following hospitalization.) Thus, the length of time to ‘development of IBS’ in their model is dependent only on the patients’ initial date of hospitalization, not on any disease process. In conclusion, these researchers found that 12.8 % of patients admittedwith acute diverticulitis had persistent symptoms of diverticular disease at follow-up, anywhere from 1 to 5 years following hospitalization. Following acute diverticulitis, patients are at risk of persistent symptoms and should be followed up after discharge.

Utilization of High-frequency Mini Probe Ultrasound in the Assessment of Colonic Wall Thickness in Patients With Diverticular Disease: A Feasibility Study.

Background: Assessment of diverticular disease (DD) is routinely undertaken by colonoscopy and computed tomography (CT) scan. Improvements in high-frequency ultrasound have enabled evaluation of the colon wall structure in detail. Our objective was to assess ultrasound in measuring colonic wall thickness in DD. Methods: High-frequency 20-MHz ultrasound was undertaken to measure individual layer and total colonic wall thickness. Case patients had symptomatic DD. Control patients underwent colonoscopy for other reasons. Select patients also underwent abdominal CT scan. Results: Thirty-three patients underwent colonoscopic ultrasound, 18 with sigmoid diverticula and 15 control patients. Total wall thickness was greater in patients with DD, 5.69 mm (1.68) versus 2.61 mm (1.29, P<0.0001). Patients with DD had significant thickening in each individual layer of the colonic wall measured (each P<0.0001). Greatest differences were in the muscularis propria, which was an average of 3.5 times thicker in patients with DD. In patients with DD, the segment of colonic wall measured was also thicker, with average mid-sigmoid thickness of 23.0 mm (SD 9.6 mm). Conclusions: Patients with DD have increased sigmoid thickness when compared with controls, especially the muscularis propria. Unlike CT, ultrasound was also able to identify thickening in the mucosa and submucosa.