Lisa L. Strate

Obesity Increases the Risks of Diverticulitis and Diverticular Bleeding

BACKGROUND & AIMS Studies of obesity and diverticular complications are limited. We assessed the relationship between body mass index (BMI), waist circumference, and waist-to-hip ratio and diverticulitis and diverticular bleeding. METHODS A prospective cohort study of 47,228 male health professionals (40-75 years old) who were free of diverticular disease in 1986 (baseline) was performed. Men reporting newly diagnosed diverticular disease on biennial follow-up questionnaires were sent supplemental questionnaires. Weight was recorded every 2 years, and data on waist and hip circumferences were collected in 1987. RESULTS We documented 801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding during 18 years of follow-up. After adjustment for other risk factors, men with a BMI >or= 30 kg/m(2) had a relative risk (RR) of 1.78 (95% confidence interval [CI], 1.08-2.94) for diverticulitis and 3.19 (95% CI, 1.45-7.00) for diverticular bleeding compared with men with a BMI of <21 kg/m(2). Men in the highest quintile of waist circumference, compared with those in the lowest, had a multivariable RR of 1.56 (95% CI, 1.18-2.07) for diverticulitis and 1.96 (95% CI, 1.30-2.97) for diverticular bleeding. Waist-to-hip ratio was also associated with the risk of diverticular complications when the highest and lowest quintiles were compared, with a multivariable RR of 1.62 (95% CI, 1.23-2.14) for diverticulitis and 1.91 (95% CI, 1.26-2.90) for diverticular bleeding. Adjustment for BMI did not change the associations seen for waist-to-hip ratio. CONCLUSIONS In this large prospective cohort, BMI, waist circumference, and waist-to-hip ratio significantly increased the risks of diverticulitis and diverticular bleeding.

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.

Use of Aspirin or Nonsteroidal Anti-inflammatory Drugs Increases Risk for Diverticulitis and Diverticular Bleeding

BACKGROUND & AIMS Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have been implicated in diverticular complications. We examined the influence of aspirin and NSAID use on risk of diverticulitis and diverticular bleeding in a large prospective cohort. METHODS We studied 47,210 US men in the Health Professionals Follow-up Study cohort who were 40-75 years old at baseline in 1986. We assessed use of aspirin, nonaspirin NSAIDs, and other risk factors biennially. We identified men with diverticulitis or diverticular bleeding based on responses to biennial and supplementary questionnaires. RESULTS We documented 939 cases of diverticulitis and 256 cases of diverticular bleeding during a 22-year period of follow-up evaluation. After adjustment for risk factors, men who used aspirin regularly (≥2 times/wk) had a multivariable hazard ratio (HR) of 1.25 (95% confidence interval [CI], 1.05-1.47) for diverticulitis and a HR of 1.70 (95% CI, 1.21-2.39) for diverticular bleeding, compared with nonusers of aspirin and NSAIDs. Use of aspirin at intermediate doses (2-5.9 standard, 325-mg tablets/wk) and frequency (4-6 days/wk) were associated with the highest risk of bleeding (multivariable HR, 2.32; 95% CI, 1.34-4.02, and multivariable HR, 3.13; 95% CI, 1.82-5.38, respectively). Regular users of nonaspirin NSAIDs also had an increased risk of diverticulitis (multivariable HR, 1.72; 95% CI, 1.40-2.11) and diverticular bleeding (multivariable HR, 1.74; 95% CI, 1.15-2.64), compared with men who denied use of these medications. CONCLUSIONS Regular use of aspirin or NSAIDs is associated with an increased risk of diverticulitis and diverticular bleeding. Patients at risk of diverticular complications should carefully consider the potential risks and benefits of using these medications.

Nut, corn and popcorn consumption and the incidence of diverticular disease

CONTEXT Patients with diverticular disease are frequently advised to avoid eating nuts, corn, popcorn, and seeds to reduce the risk of complications. However, there is little evidence to support this recommendation. OBJECTIVE To determine whether nut, corn, or popcorn consumption is associated with diverticulitis and diverticular bleeding. DESIGN AND SETTING The Health Professionals Follow-up Study is a cohort of US men followed up prospectively from 1986 to 2004 via self-administered questionnaires about medical (biennial) and dietary (every 4 years) information. Men reporting newly diagnosed diverticulosis or diverticulitis were mailed supplemental questionnaires. PARTICIPANTS The study included 47,228 men aged 40 to 75 years who at baseline were free of diverticulosis or its complications, cancer, and inflammatory bowel disease and returned a food-frequency questionnaire. MAIN OUTCOME MEASURES Incident diverticulitis and diverticular bleeding. RESULTS During 18 years of follow-up, there were 801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding. We found inverse associations between nut and popcorn consumption and the risk of diverticulitis. The multivariate hazard ratios for men with the highest intake of each food (at least twice per week) compared with men with the lowest intake (less than once per month) were 0.80 (95% confidence interval, 0.63-1.01; P for trend = .04) for nuts and 0.72 (95% confidence interval, 0.56-0.92; P for trend = .007) for popcorn. No associations were seen between corn consumption and diverticulitis or between nut, corn, or popcorn consumption and diverticular bleeding or uncomplicated diverticulosis. CONCLUSIONS In this large, prospective study of men without known diverticular disease, nut, corn, and popcorn consumption did not increase the risk of diverticulosis or diverticular complications. The recommendation to avoid these foods to prevent diverticular complications should be reconsidered.

Timing of colonoscopy: impact on length of hospital stay in patients with acute lower intestinal bleeding

ObjectivePrevious studies suggest that urgent colonoscopic evaluation of massive lower intestinal bleeding (LIB) can reduce hospital length of stay (LOS). We sought to determine if time to colonoscopy impacts hospital LOS in patients admitted with all sources and severities of acute LIB.MethodsA total of 252 consecutive patients admitted to a tertiary care hospital with acute LIB were identified. Cox proportional hazards regression was used to determine independent predictors of hospital LOS. Time from admission to colonoscopy was analyzed as a time-varying covariate.ResultsA total of 144 patients (57%) underwent an inpatient colonoscopy: 14 were done in <12 h, 55 in 12–24 h, 46 in 24–48 h, and 29 in >48 h. After controlling for the other independent correlates, earlier colonoscopy was significantly associated with a shorter hospital LOS (hazards ratio = 2.02, 95% CI = 1.5–2.6, p < 0.0001). The absence of visible blood or active bleeding at the time of colonoscopy was also independently related to a shorter hospital LOS (hazards ratio = 1.5, 95% equals; CI 1.1–2.0, p equals; 0.01).ConclusionsTime to colonoscopy is an independent predictor of hospital LOS. In a wide spectrum of patients with LIB, this reduction in hospital LOS seems to be primarily related to improved diagnostic yield rather than therapeutic interventions.

Are patients with inflammatory bowel disease receiving optimal care

OBJECTIVES:Guidelines have been published as a framework for therapy of patients with inflammatory bowel disease (IBD). The purpose of this study was to determine whether patients referred for a second opinion were receiving therapy in accordance with practice guidelines.METHODS:Patients with luminal IBD under the care of a gastroenterologist who sought a a second opinion at Brigham and Womens Hospital between January 2001 and April 2003 were enrolled in this study. Clinical information was obtained by direct patient interview at the time of initial patient visit and by a review of prior records. Data obtained included the diagnosis, clinical symptoms, prior medical therapy, preventive measures for metabolic bone disease, and colon-cancer screening.RESULTS:The study population consisted of 67 consecutive patients: 21 with ulcerative colitis, 44 with Crohns disease and 2 in whom the diagnosis of IBD could not be confirmed. Of the 65 patients with confirmed IBD, 56 patients had symptoms of active disease and 9 were asymptomatic. All analyses were carried out on the 56 patients with active disease. Of the 33 patients treated with aminosalicylates, 21 (64%) were not receiving maximal doses. Nine of 12 (75%) patients with distal ulcerative colitis were not receiving rectal aminosalicylate therapy. Within 6 months of their clinic visit, 35 patients had received corticosteroid therapy, and 27 (77%) patients had been treated with corticosteroids for greater than 3 months. In 16 of 27 (59%) there was no attempt to start steroid sparing medications such as 6-mercaptopurine (6MP), azathioprine, or infliximab. Of the 11 patients treated with either 6MP or azathioprine, 9 (82%) were suboptimally dosed without an attempt to increase dosage. Of the 27 patients on prolonged corticosteroid therapy 21 (78%) received inadequate treatment to prevent metabolic bone disease. Three of 9 patients (33%) meeting indications for surveillance colonoscopy for dysplasia had not undergone colonoscopy at the appropriate interval.CONCLUSIONS:Patients with IBD often do not receive optimal medical therapy. In particular, there is suboptimal dosing of 5-ASA and immunomodulatory medications, prolonged use of corticosteroids, failure to use steroid-sparing agents, inadequate measures to prevent metabolic bone disease, and inadequate screening for colorectal cancer.

Hereditary colorectal cancer syndromes

The purpose of this article is to review the genetic colorectal cancer syndromes including Hereditary Nonpolyposis Colorectal Cancer (HNPCC), Family Polyposis (FAP) and the hamartomatous polyposis syndromes. HNPCC is the most common of the hereditary colorectal cancer syndromes, and is the result of defects in the mismatch repair genes. Individuals with HNPCC have an 80 lifetime risk of colorectal cancer, and in females a 30–50% risk of endometrial cancer, as well as predisposition for a number of other malignancies. Early screening and interval surveillance for colorectal and endometrial cancer are recommended. In FAP, mutations in the Adenomatous Polyposis Coli (APC) tumor suppressor gene give rise to hundreds to thousands of colorectal polyps, some of which will inevitably progress to cancer. Early diagnosis and timely prophylactic colectomy prevent this outcome. Chemoprevention with nonsteroidal anti-inflammatory drugs can reduce adenoma number and size in FAP, but the effect is incomplete. In addtion, surveillance for upper gastrointestinal tract malignancies is necessary. Attenuated forms of FAP may be the result of mutations in the APC gene, or in the recently described MYH gene. Mutations in the MYH gene should be considered in individuals with multiple adenomas whose family history does not reflect an autosomal dominant pattern of inheritance. The hamartomatous polyposis syndromes are uncommon but distinctive disorders in which multiple hamartomatous polyps develop at a young age. Our understanding of the genetic basis of these disorders is improving, and a predisposition for gastrointestinal and other malignancies has recently been recognized. This article summarizes the genetics, clinical manifestations and clinical management of each of these syndromes with an emphasis on genetic testing and prevention.

Physical Activity Decreases Diverticular Complications

OBJECTIVES:Little is known about the effect of physical activity on diverticular complications. This study prospectively examined the associations between physical activity and diverticular bleeding and diverticulitis.METHODS:We studied 47,228 US males in the Health Professionals Follow-up Study cohort who were aged 40–75 years and free of diverticular disease, gastrointestinal cancer, and inflammatory bowel disease at baseline in 1986. Men reporting newly diagnosed diverticular disease on biennial follow-up questionnaires were sent supplemental questionnaires outlining details of diagnosis and treatment. Physical activity was assessed every 2 years. Men recorded the average time per week spent in eight recreational activities, and flights of stairs climbed per day. Cox proportional hazards regression was used to calculate relative risks (RRs).RESULTS:During 18 years of follow-up, 800 cases of diverticulitis and 383 cases of diverticular bleeding were identified. Total cumulative physical activity was associated with a decreased risk of diverticulitis and diverticular bleeding. After adjustment for potential confounders, the RR for men in the highest quintile of total activity (≥57.4 metabolic equivalent hours per week (MET-h/week) was 0.75 (95% confidence interval, CI, 0.58–0.95) for diverticulitis and 0.54 (95% CI, 0.38–0.77) for bleeding, as compared with men in the lowest quintile (≤8.2 MET-h/week). Vigorous activity was inversely related to diverticulitis in a high vs. low comparison (multivariable RR, 0.66; 95% CI, 0.51–0.86) and bleeding (multivariable RR, 0.61; 95% CI, 0.41–0.90), whereas nonvigorous activity was not. These results were similar for recent (simple updated) and baseline activity.CONCLUSIONS:Data from this large prospective cohort suggest that physical activity lowers the risk of diverticulitis and diverticular bleeding. Vigorous activity appears to account for this association.

Risk factors for mortality in lower intestinal bleeding.

BACKGROUND & AIMS Previous studies of lower intestinal bleeding (LIB) have limited power to study mortality. We sought to identify characteristics associated with in-hospital mortality in a large cohort of patients with LIB. METHODS We used the 2002 Healthcare Cost and Utilization Project Nationwide Inpatient Sample to study a cross-sectional cohort of 227,022 hospitalized patients with discharge diagnoses indicating LIB. Predictors of mortality were identified by using multiple logistic regression. RESULTS In 2002, an estimated 8737 patients with LIB (3.9%) died while hospitalized. Independent predictors of in-hospital mortality were age (age >70 vs <50 years; odds ratio [OR], 4.91; 95% confidence interval [CI], 2.45-9.87), intestinal ischemia (OR, 3.47; 95% CI, 2.57-4.68), comorbid illness (>or=2 vs 0 comorbidities, OR, 3.00; 95% CI, 2.25-3.98), bleeding while hospitalized for a separate process (OR, 2.35; 95% CI, 1.81-3.04), coagulation defects (OR, 2.34; 95% CI, 1.50-3.65), hypovolemia (OR, 2.22; 95% CI, 1.69-2.90), transfusion of packed red blood cells (OR, 1.60; 95% CI, 1.23-2.08), and male gender (OR, 1.52; 95% CI, 1.21-1.92). Colorectal polyps (OR, 0.26; 95% CI, 0.15-0.45), and hemorrhoids (OR, 0.42; 95% CI, 0.28-0.64) were associated with a lower risk of mortality, as was diagnostic testing for LIB when added to the multivariate model (OR, 0.37; 95% CI, 0.28-0.48). Hospital characteristics were not significantly related to mortality. Predictors of mortality were similar in an analysis restricted to patients with diverticular bleeding. CONCLUSIONS The all-cause in-hospital mortality rate in LIB was low (3.9%). Advanced age, intestinal ischemia, and comorbid illness were the strongest predictors of mortality.

The Role of Colonoscopy and Radiological Procedures in the Management of Acute Lower Intestinal Bleeding

There are multiple strategies for evaluating and treating lower intestinal bleeding (LIB). Colonoscopy has become the preferred initial test for most patients with LIB because of its diagnostic and therapeutic capabilities and its safety. However, few studies have directly compared colonoscopy with other techniques and there are controversies regarding the optimal timing of colonoscopy, the importance of colon preparation, the prevalence of stigmata of hemorrhage, and the efficacy of endoscopic hemostasis. Angiography, radionuclide scintigraphy, and multidetector computed tomography scanning are complementary modalities, but the requirement of active bleeding at the time of the examination limits their routine use. In addition, angiography can result in serious complications. This review summarizes the available evidence regarding colonoscopy and radiographic studies in the management of acute LIB.