Erica R. Cohen

Diverticular Disease as a Chronic Illness: Evolving Epidemiologic and Clinical Insights

Diverticular disease imposes a significant burden on Western and industrialized societies. The traditional pathogenesis model posits that low dietary fiber predisposes to diverticulosis, and fecalith obstruction prompts acute diverticulitis that is managed with broad-spectrum antibiotics or surgery. However, a growing body of knowledge is shifting the paradigm of diverticular disease from an acute surgical illness to a chronic bowel disorder composed of recurrent abdominal symptoms and considerable psychosocial impact. New research implicates a role for low-grade inflammation, sensory-motor nerve damage, and dysbiosis in a clinical picture that mimics irritable bowel syndrome (IBS) and even inflammatory bowel disease (IBD). Far from being an isolated event, acute diverticulitis may be the catalyst for chronic symptoms including abdominal pain, cramping, bloating, diarrhea, constipation, and “post-diverticulitis IBS.” In addition, studies reveal lower health-related quality of life in patients with chronic diverticular disease vs. controls. Health-care providers should maintain a high index of suspicion for the multifaceted presentations of diverticular disease, and remain aware that it might contribute to long-term emotional distress beyond traditional diverticulitis attacks. These developments are prompting a shift in therapeutic approaches from widespread antimicrobials and supportive care to the use of probiotics, mesalamine, and gut-directed antibiotics. This review addresses the emerging literature regarding epidemiology, pathophysiology, and management of chronic, symptomatic diverticular disease, and provides current answers to common clinical questions.

Long-term Risk of Acute Diverticulitis Among Patients With Incidental Diverticulosis Found During Colonoscopy

BACKGROUND & AIMS Colonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10% to 25% lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. We measured the long-term risk of acute diverticulitis among patients with confirmed diverticulosis discovered incidentally on colonoscopy. METHODS We performed a retrospective study using administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System, collecting data on patients who underwent colonoscopies from January 1996 through January 2011. We identified patients diagnosed with diverticulosis, determined incidence rates per 1000 patient-years, and analyzed a subgroup of patients with rigorously defined events confirmed by imaging or surgery. We used a Cox proportional hazards model to identify factors associated with the development of diverticulitis. RESULTS We identified 2222 patients with baseline diverticulosis. Over an 11-year follow-up period, 95 patients developed diverticulitis (4.3%; 6 per 1000 patient-years); of these, 23 met the rigorous definition of diverticulitis (1%; 1.5 per 1000 patient-years). The median time-to-event was 7.1 years. Each additional decade of age at time of diagnosis reduced the risk for diverticulitis by 24% (hazard ratio, 0.76; 95% confidence interval, 0.6-0.9). CONCLUSIONS Based on a study of the Veterans Affairs Greater Los Angeles Healthcare System, only about 4% of patients with diverticulosis develop acute diverticulitis, contradicting the common belief that diverticulosis has a high rate of progression. We also found that younger patients have a higher risk of diverticulitis, with risk increasing per year of life. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.

Increased Risk for Irritable Bowel Syndrome After Acute Diverticulitis

BACKGROUND & AIMS Individuals with diverticulosis frequently also have irritable bowel syndrome (IBS), but there are no longitudinal data to associate acute diverticulitis with subsequent IBS, functional bowel disorders, or related emotional distress. In patients with postinfectious IBS, gastrointestinal disorders cause long-term symptoms, so we investigated whether diverticulitis might lead to IBS. We compared the incidence of IBS and functional bowel and related affective disorders among patients with diverticulitis. METHODS We performed a retrospective study of patients followed up for an average of 6.3 years at a Veterans Administration medical center. Patients with diverticulitis were identified based on International Classification of Diseases, 9th revision codes, selected for the analysis based on chart review (cases, n = 1102), and matched with patients without diverticulosis (controls, n = 1102). We excluded patients with prior IBS, functional bowel, or mood disorders. We then identified patients who were diagnosed with IBS or functional bowel disorders after the diverticulitis attack, and controls who developed these disorders during the study period. We also collected information on mood disorders, analyzed survival times, and calculated adjusted hazard ratios. RESULTS Cases were 4.7-fold more likely to be diagnosed later with IBS (95% confidence interval [CI], 1.6-14.0; P = .006), 2.4-fold more likely to be diagnosed later with a functional bowel disorder (95% CI, 1.6-3.6; P < .001), and 2.2-fold more likely to develop a mood disorder (CI, 1.4-3.5; P < .001) than controls. CONCLUSIONS Patients with diverticulitis could be at risk for later development of IBS and functional bowel disorders. We propose calling this disorder postdiverticulitis IBS. Diverticulitis appears to predispose patients to long-term gastrointestinal and emotional symptoms after resolution of inflammation; in this way, postdiverticulitis IBS is similar to postinfectious IBS.

Low uptake of colorectal cancer screening among African Americans in an integrated Veterans Affairs health care network

BACKGROUND African Americans have the highest incidence and mortality from colorectal cancer (CRC). Despite guidelines to initiate screening with colonoscopy at age 45 in African Americans, the CRC incidence remains high in this group. OBJECTIVE To examine the rates and predictors of CRC screening uptake as well as time to screening in a population of African Americans and non-African Americans in a health care system that minimizes variations in insurance and access. DESIGN Retrospective cohort study. SETTING Greater Los Angeles Veterans Affairs (VA) Healthcare System. PATIENTS Random sample (N = 357) of patients eligible for initial CRC screening. MAIN OUTCOME MEASUREMENTS Uptake of any screening method; uptake of colonoscopy, in particular; predictors of screening; and time to screening in African Americans and non-African Americans. RESULTS The overall screening rate by any method was 50%. Adjusted rates for any screening were lower among African Americans than non-African Americans (42% vs 58%; odds ratio [OR] 0.49; 95% confidence interval [CI], 0.31-0.77). Colonoscopic screening was also lower in African Americans (11% vs 23%; adjusted OR 0.43; 95% CI, 0.24-0.77). In addition to race, homelessness, lower service connectedness, taking more prescription drugs, and not seeing a primary care provider within 2 years of screening eligibility predicted lower uptake of screening. Time to screening colonoscopy was longer in African Americans (adjusted hazard ratio 0.43; 95% CI, 0.25-0.75). LIMITATIONS The sample may not be generalizable. CONCLUSIONS We found marked disparities in CRC screening despite similar access to care across races. Despite current guidelines aimed at increasing CRC screening in African Americans, participation in screening remained low, and use of colonoscopy was infrequent.

Development and validation of a disease-targeted quality of life instrument for chronic diverticular disease: the DV-QOL.

BackgroundColonic diverticular disease is typically conceived as acute diverticulitis attacks surrounded by periods of clinical silence. However, evolving data indicate that many patients have persistent symptoms and diminished health-related quality of life (HRQOL) long after acute attacks. We developed a disease-targeted HRQOL measure for symptomatic uncomplicated diverticular disease (SUDD)—the diverticulitis quality of life (DV-QOL) instrument.MethodsWe conducted a systematic literature review to craft a conceptual model of SUDD HRQOL. This was complemented by three focus groups including 45 SUDD patients. We developed items based on our literature search, focus groups, and cognitive debriefings. We administered the items to SUDD patients with persistent symptoms following a confirmed diverticulitis event. We created scales based on factor analysis and evaluated the scales for reliability and validity.ResultsConcept elicitation revealed a range of illness experiences attributed to SUDD. Coding of 20,490 transcribed words yielded a 52-code network with four primary, condition-related concepts: (1) physical symptoms (e.g., bloating); (2) behaviors (e.g., restrictions); (3) cognitions and concerns (e.g., fear); and (4) impact and consequences (e.g., absenteeism, anxiety). Based on patient language, we developed the 17-item DV-QOL instrument. In a cross-sectional validation sample of 197 patients, DV-QOL discriminated between patients with recent versus distant diverticulitis events and correlated highly with Short Form 36 and hospital anxiety and depression scores.ConclusionsPatients with SUDD attribute a wide range of negative psychological, social, and physical symptoms to their condition, both during and after acute attacks; DV-QOL captures these symptoms in a valid, reliable manner.

Making a Case for Patient-Reported Outcomes in Clinical Inflammatory Bowel Disease Practice

© 2018 by the AGA Institute 1542-3565/

Hepatitis B in the Female Population

36.00 https://doi.org/10.1016/j.cgh.2017.12.027 Pdeterioration in their health. Gastroenterologists and health care providers are trained to seek out clinical, laboratory, radiologic, and endoscopic evidence of pathology. Conventional endpoints in inflammatory bowel disease (IBD) clinical trials and clinical care may fail to capture the full health status and disease experience from the patient perspective. The Food and Drug Administration (FDA) has called for the development of coprimary endpoints in research trials to include an objective measure of inflammation in conjunction with patient-reported outcomes (PROs). The objective is to support labelling claims and improve safety and effectiveness in the drug approval process. There is also growing recognition that high-value care includes management of biologic and psychosocial factors to enable patients with chronic diseases to regain their health. Clinicians might follow suit by incorporating valid, reliable PRO measures to usual IBD care in order better to achieve patient-centered care, inform decision making, and improve the quality of the care provided.

Autoimmunity as a Potential Cause of Post-Infectious Gut Dysmotility: A Longitudinal Observation

Chronic hepatitis B infection in the female population has implications not just for the individual but for her children as well. This article discusses the natural history of hepatitis B and how it plays an important role in hepatitis B virus (HBV) transmission, the current strategies and new strategies to control HBV and reduce transmission, and the updated guidelines for the management of HBV.

Jaundice and Pregnancy: Why Going Viral Is Out of Style

Autoimmunity as a Potential Cause of Post-Infectious Gut Dysmotility: A Longitudinal Observation

GERD Symptoms in the General Population: Prevalence and Severity Versus Care-Seeking Patients

Management of the pregnant woman with abnormal liver tests is a common, albeit challenging, clinical endeavor. A multidisciplinary collaboration between obstetrician and gastroenterologist is required in considering both expectant mother and fetus in management decisions. Diagnosing pregnancy-related causes of abnormal liver function tests is important as urgent obstetric intervention and delivery may be needed. Conversely, conditions not related to pregnancy might be exacerbated by fetal delivery. The spectrum of symptoms caused by abnormal liver tests ranges from mild illness to significant risk of morbidity and mortality to the mother and fetus. Understanding the prevalence of each possible etiology of abnormal liver tests in the pregnant patient is critical to appropriate and timely clinical management. The prevalence of abnormal liver function tests among expectant mothers is 0.3–3% [1]. For 70 years, acute viral hepatitis was thought to be the leading cause worldwide, based on epidemiologic studies conducted primarily outside of the USA [2, 3], although one US study also reported that hepatitis B accounted for 40% of expectant mothers with symptoms and signs of acute hepatitis [4]. Importantly, these landmark studies were conducted prior to 1991, after which widespread hepatitis vaccination was implemented. Recently, geographically diverse studies have revisited the epidemiologic dogma informing the causes of liver function abnormalities in present-day expectant mothers. In this issue of Digestive Diseases and Sciences, Duraiswamy et al. [5] likewise re-examine this clinical axiom, hypothesizing that acute viral hepatitis is no longer the leading cause of hyperbilirubinemia in expectant mothers in the USA. The authors investigated causes of hyperbilirubinemia in a relatively homogenous contemporary population in Dallas, Texas. This single-institution retrospective review identified 397 deliveries from mothers with total bilirubin levels [1.2 mg/dl obtained from prenatal care testing. A thorough chart review of cases from 2005 to 2011 was used to determine the etiology of the elevated plasma bilirubin concentrations. In indeterminate cases, an experienced hepatologist and obstetrician applied standard definitions of the relevant pregnancyand non-pregnancyrelated causes of hyperbilirubinemia delineated in the study in order to best ascertain etiology. Among the total number of deliveries during the study (80,408), the rate of hyperbilirubinemia (0.5%) was consistent with data previously reported in the literature [1]. Greater than 75% of the maternal population in this study—both hyperbilirubinemic and control groups—was Hispanic. Gallstone-related disease was the single most common cause of hyperbilirubinemia (25%). Pre-eclampsia/eclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome (24%) and intrahepatic cholestasis of pregnancy (13%) were the next most common etiologies. Of the four pregnant women with ‘‘acute hepatitis’’ only one mother had acute hepatitis B and none were diagnosed with hepatitis A or E. Patients with acute hepatitis had higher plasma concentrations of aspartate and alanine aminotransferases (AST and ALT, & Erica R. Cohen Erica.Cohen@cshs.org