Prior abdominal surgery as a potential risk factor for colonic diverticulosis or diverticulitis

BACKGROUND Abnormal colonic pressure profiles have been associated with an increased risk of colonic diverticulosis.A surgical history is a known risk factor for abdominal adhesions and these may lead to increased intraluminal colonic pressure.AIM To assess whether previous abdominal surgery is associated with colonic divertic-ulosis or diverticulitis.METHODS We analyzed data from a study of patients undergoing colonoscopy for different indications from 2020 through 2021.Patients completed a structured question-naire concerning previous abdominal surgeries,dietary and lifestyle exposures including smoking,alcohol use and co-morbidities.RESULTS Three hundred and fifty-nine patients were included in the study.The mean age was 67.6 and 46%were females.Diabetes mellitus,hypertension,ischemic heart disease,chronic obstructive pulmonary disease,chronic renal failure,and body mass index were similar in the diverticulosis and control groups.The overall prevalence of colonic diverticulosis was 25%(91/359)and 48%of the patients had previous abdominal surgery.As expected,the prevalence of diverticulosis increased with age.There was no difference in the rate of previous abdominal surgery between patients with or without diverticulosis(49%vs 47%,P=0.78).In regards to specific surgeries,inguinal hernia repair was significantly associated with diverticulosis(52%vs 20%,P=0.001),but not diverticulitis.In contrast,appendectomy was not associated with diverticulosis(6%vs 14%,P=0.048).CONCLUSION These findings suggest that post-operative abdominal adhesions inducing high colonic intraluminal pressures do not appear to be the mechanism for diverticula formation.Rather,inguinal hernia and diverticulosis may share similar connective tissue pathologies with no causative relationship between them.

Complicated small-bowel diverticulosis: A case report and review of the literature

While jejunoileal diverticula are rare and often asymptomatic, they may lead to chronic non-specific or acute symptoms. The large majority of complications present with an acute abdomen similar to appendicitis, cholecystitis or colonic diverticulitis but they also may appear with atypical symptoms. As a result, diagnosis of complicated jejunoileal diverticulosis can be quite difficult, and may solely depend on the result of surgical exploration. In the absence of contra-indications, diagnostic laparoscopy has the benefit of thorough examination of the abdominal contents and helps to reach an absolute diagnosis. Surgical resection of the involved small-bowel segment with primary anastomosis is the preferred treatment in patients with symptomatic complicated jejunoileal diverticular disease. An atypical presentation of complicated jejunal diverticulitis in conjunction with sigmoid diverticulitis diagnosed with laparoscopy and treated with surgical resection is presented.

Jejunal diverticulosis is not always a silent spectator:A report of 4 cases and review of the literature

Jejunal diverticulosis (JD) is a rare clinical entity. The potential complications of this condition are discussed here through a series of cases presented to our centre. A retrospective analysis of four cases, which were diagnosed and treated, was performed. These included two cases of gastrointestinal haemorrhage, one case of perforation and one case of enterolith obstruction. All of these cases were secondary to jejunal diverticulosis and treated surgically. This was accompanied by a literature search to identify the different modalities for diagnosis and treatment of this condition. JD is rare and may lead to a diagnostic delay. Awareness of the wide spectrum of potential complications can prevent this delay.

Pattern and distribution of colonic diverticulosis:Analysis of 2877 barium enemas in Thailand

AIM:To determine the pattern and distribution of colonic diverticulosis in Thai adults.METHODS:A review of the computerized radiology database for double contrast barium enema(DCBE)in Thai adults was performed at the Faculty of Medicine Siriraj Hospital,Mahidol University,Bangkok,Thailand.Incomplete studies and DCBE examinations performed in non-Thai individuals were excluded.The pattern and distribution of colonic diverticulosis detected during DCBE studies from June 2009 to October 2011 were determined.The occurrence of solitary cecal diverticulum,rectal diverticulum and giant diverticulum were reported.Factors influencing the presence of colonic diverticulosis were evaluated.RESULTS:A total of 2877 suitable DCBE examinations were retrospectively reviewed.The mean age of patients was 59.8±14.7 years.Of these patients,1778(61.8%)were female and 700(24.3%)were asymptomatic.Colonic diverticulosis was identified in 820patients(28.5%).Right-sided diverticulosis(641 cases;22.3%)was more frequently reported than left-sided diverticulosis(383 cases;13.3%).Pancolonic diverticulosis was found in 98 cases(3.4%).The occurrence of solitary cecal diverticulum,rectal diverticulum and giant diverticulum were 1.5%(42 cases),0.4%(12 cases),and 0.03%(1 case),respectively.There was no significant difference in the overall occurrence of colonic diverticulosis between male and female patients(28.3%vs 28.6%,P=0.85).DCBE examinations performed in patients with some gastrointestinal symptoms revealed the frequent occurrence of colonic diverticulosis compared with those performed in asymptomatic individuals(29.5%vs 25.3%,P=0.03).Change in bowel habit was strongly associated with the presence of diverticulosis(a relative risk of 1.39;P=0.005).The presence of diverticulosis was not correlated with age in symptomatic patients or asymptomatic individuals(P>0.05).CONCLUSION:Colonic diverticulosis was identified in28.5%of DCBE examinations in Thai adults.There was no association between the presence of diverticulosis and gender or age.

Prevalence and clinical features of colonic diverticulosis in a Middle Eastern population

AIM: To determine the prevalence, location, associations and clinical features of colonic-diverticulosis and its role as a cause of lower-gastroenterology-bleeding. METHODS: We retrospectively reviewed the medical records of 3649 consecutive patients who under-went a colonoscopy for all indications between 2007 and 2011 at King Khalid University Hospital, Riyadh, Saudi Arabia. The demographic data were collected retrospectively through the hospital's information system, electronic file system, endoscopic e-reports, and manual review of the files by two research assistants. The demographic information included the age, sex, comorbidities and indication for the colonoscopy. The association among colonic polyps, comorbidities and diverticular disease was also measured.RESULTS: A total of 270 patients out of 3649 were diagnosed with colonic diverticulosis, with a prevalence of 7.4%. The mean age was 60.82 years ± 0.833, (range 12-110). Females comprised 38.89% (95%CI: 33-44.7) of the study population. The major symp-toms were rectal bleeding in 33.6%, abdominal pain in 19.3%, constipation in 12.8% and anemia in 6%. Diverticula were predominantly left-sided (sigmoid and descending colon) in 62%, right-sided in 13% and in multiple locations in 25%. There was an association between the presence of diverticulosis and adenomatous polyps (Pvalue < 0.001), hypertension (P-value < 0.0001) and diabetes mellitus (P-value < 0.0016). Diverticular disease was the second most common cause of lower gastrointestinal bleeding, in 33.6% (95%CI: 27.7-39.4), after internal hemor-rhoids, in 44.6% (95%CI: 40.3-48.9). On multivariable logistic regression, hypertension (OR = 2.30; 95%CI: 1.29-4.10), rectal bleeding (OR = 2.57; 95%CI: 1.50-4.38), and per year increment in age (OR = 1.05; 95%CI: 1.03-1.07) were associated with diverticulosis but not with bleeding diverticular disease. Limitations: A small proportion of the patients included had colo-noscopies performed as a screening test.CONCLUSION: Colonic-diverticulosis was found to have a low prevalence, be predominantly left-sided and associated with adenomatous-polyps. Age, hypertension and rectal bleeding predict the presence of diverticular disease.

Segmental colitis associated diverticulosis syndrome

Segmental colitis associated diverticulosis(SCAD) has become increasingly appreciated as a form of inflammatory disease of the colon. Several features suggest that SCAD is a distinct disorder. SCAD tends to develop almost exclusively in older adults, predominately, but not exclusively, males. The inflammatory process occurs mainly in the sigmoid colon, and usually remains localized to this region of the colon alone. SCAD most often presents with rectal bleeding and subsequent endoscopic visualization reveals a well localized process with non-specific histopathologic inflammatory changes. Granulomas are not seen, and if present, may be helpful in definition of other disorders such as Crohn's disease of the colon, an entity often confused with SCAD. Bacteriologic and parasitic studies for an infectious agent are negative. Normal rectal mucosa(i.e., "rectal sparing") is present and can be confirmed with normal rectal biopsies. SCAD often resolves spontaneously without treatment, or completely after a limited course of therapy with only a 5-aminosalicylate. Recurrent episodes may occur, but most often, patients with this disorder have an entirely self-limited clinical course. Occasionally, treatment with other agents, including corticosteroids, or surgical resection has been required.

Segmental colitis associated with diverticulosis syndrome

An inflammatory process that involves the sigmoid colonic segment associated with diverticular disease(SCAD) appears to be a distinct clinical and pathological disorder.It has been described in older adults,often presenting with rectal bleeding.Most of the patients seem to respond to treatment only with a 5-aminosalicylate,but some spontaneously resolve with no treatment.Endoscopic evaluation usually shows a non-specific inflammatory process localized in the sigmoid colon alone that may resolve completely with histologically normal colonic mucosa.Repeated symptomatic events with discrete episodes of segmental colitis may occur,but most patients have an entirely benign clinical course.Definition of the underlying molecular events that occur with SCAD may be critically important in understanding the critical elements present in a colonic inflammatory process that can completely resolve without pharmacological or biological treatment.

Prevalence of diverticulosis in recurrent Clostridium difficile infection

AIM:To re-evaluate the theory that colonic diverticulosis is associated with relapse of Clostridium difficile associated disease (CDAD) in light of data suggesting increasing rates of CDAD infection and relapse.METHODS: Charts were reviewed for patients with recurrent CDAD who had also had a prior colonoscopy or flexible sigmoidoscopy. An age and gender matched control group was used to compare the prevalence of diverticulosis.RESULTS: Twenty-two patients met the study criteria, and the prevalence of diverticulosis in patients with CDAD relapse was 23% compared to 32% in age and sex matched controls (P=0.44). A significant proportion of patients with CDAD relapse had comorbidities associated with immune suppression.CONCLUSION: Diverticulosis does not appear to be associated with CDAD relapse.

Age, alcohol, sex, and metabolic factors as risk factors for colonic diverticulosis

BACKGROUND The pathogenesis of colonic diverticulosis is not well understood.Moreover,only a few studies on colonic diverticulosis have been reported in China's Mainland.AIM To evaluate the prevalence of and risk factors for asymptomatic colorectal diverticulosis in Eastern China.METHODS From August 2016 to July 2020,6180 asymptomatic individuals were enrolled in this cross-sectional study.These individuals had undergone physical examinations,laboratory testing,and colonoscopy.Data regarding the baseline characteristics and their general health status were obtained through interviews.RESULTS The prevalence of colonic diverticulosis was 7.3%(449/6180).Colonic diverticulosis was detected predominantly on the right side of the colon(88.4%).Logistic regression analysis revealed that an age≥60 years(adjusted odds ratio[OR]2.149,95%confidence interval[CI]1.511-3.057,P<0.001),male sex(adjusted OR:1.878,95%CI:1.373-2.568,P<0.001),obesity(adjusted OR:1.446,95%CI:1.100-1.902,P=0.008),alcohol intake(adjusted OR:1.518,95%CI:1.213-1.901,P<0.001),hypertension(adjusted OR:1.454,95%CI:1.181-1.789,P<0.001),hypertriglyceridemia(adjusted OR:1.287,95%CI:1.032-1.607,P=0.025),and hyperuricemia(adjusted OR:1.570,95%CI:1.257-1.961,P<0.001)significantly increased the risk of colonic diverticulosis.CONCLUSION Advanced age,male sex,alcohol intake,obesity,and other metabolic-related factors,such as hypertension,hypertriglyceridemia,and hyperuricemia,were independent risk factors for colonic diverticulosis.Understanding the true prevalence of colonic diverticulosis and its associated risk factors will aid in its prevention and treatment.

Diverticulosis of the jejunum with intestinal obstruction: A case report

A diagnosis of intestinal diverticulosis is difficult to make pre-operatively because the clinical symptoms are usually non-specific. We report the case of a 70-year-old man who had suffered from three episodes of intestinal obstruction in 1 year. He experienced dull pain and a sensation of fullness over the whole abdomen. The symptoms did not improve after conservative treatment.The presumptive diagnosis was intestinal obstruction, and an exploratory laparotomy found diverticulosis of the proximal jejunum, with an adhesion band formed from the base of one diverticulum. Strangulation of a segment of the jejunum resulted from the internal herniation caused by the band. The band was removed and the proximal jejunum segmentally resected. His postoperative course was uneventful.

Sigmoid Micro-Perforation and Pelvic Abscess Masquerading as Hyperactive Delirium

Diagnoses Background: Delirium is a common finding in elderly patients with sepsis. Early identification of the cause of delirium and treatment is important to avoid any worsening of mental or physical status. Sepsis secondary to colonic micro-perforation (CMP) in a patient with a history of diverticulosis should be high on the list of differential diagnosis. Case Report: We present a case of a patient who presented with hyperactive sepsis-associated delirium (SAD). Six days after the presentation, the patient started complaining of abdominal pain. An abdominal and pelvic computed tomography (CT) scan showed free air in the abdomen. The patient underwent surgical intervention and treatment with intravenous antibiotics. Pathological examination showed CMP connected to the patient’s history of diverticulosis. Delirium superimposed on dementia (DSD) resulted in the worsening of both the mental and physical status of our patient with the need for placement in a nursing home.

Jejunal diverticulosis found in a patient with long-standing pneumoperitoneum and pseudo-obstruction on imaging:a case report

Small bowel diverticulosis is a rare finding within the general population and jejunal diverticulosis,specifically,is even rarer.Clinical manifestations can range from post-prandial pain,constipation and malabsorption to serious complications,such as gastro-intestinal hemorrhage,perforation and acute intestinal obstruction.Here we describe the case of an 81-yearold gentleman who presented with a three-year history of abdominal pain and weight loss.Despite unremarkable physical examination and laboratory tests,persistent pneumoperitoneum and dilated loops of small bowel were found on imaging.Having been given a diagnosis of small bowel bacterial overgrowth,the patient underwent capsule endoscopy study for further evaluation of his small bowel.The capsule did not reach the colon and the patient never noted passing the capsule in his stool so,six months post-procedure,a computed tomography(CT)scan seemed to reveal the retained capsule.Subsequent exploratory laparotomy revealed 200 cm of atonic,dilated jejunum with impressive diverticula along the antimesenteric border.This case report is an example of an unusual set of presenting signs and symptoms of jejunal diverticulosis,including persistent pneumoperitoneum,pseudo-obstruction and small bowel bacterial overgrowth.A literature review has revealed that these signs have been present in other cases of jejunal diverticulosis,although the etiology and pathophysiology is not clearly understood.

Recurrent small bowel obstruction secondary to jejunal diverticular enterolith: A case report

BACKGROUND Small bowel diverticulosis is an uncommon condition which is usually asymptomatic and is discovered incidentally. One rare complication is enteroliths forming in the diverticula causing bowel obstruction. Only a few cases of such have been described in literature, and recurrence from this aetiology has not been reported previously. This case report outlines the management of a 68-year-old male who presented with recurrent small bowel obstruction secondary to jejunal diverticular enterolith impaction, seven months following a previous episode.CASE SUMMARY A 68-year-old male presented with symptoms of small bowel obstruction.Computed tomography(CT) of the abdomen demonstrated small bowel obstruction from an enterolith formed in one of his extensive jejunal diverticula. He required a laparotomy, an enterotomy proximal to the enterolith, removal of the enterolith, closure of the enterotomy, and resection of a segment of perforated ileum with stapled side-to-side anastomosis. Seven months later, he represented to emergency department with similar symptoms. Another CT scan of his abdomen revealed a recurrent small bowel obstruction secondary to enterolith impaction. He underwent another laparotomy in which it was evident that a large enterolith was impacted at the afferent limb of the previous small bowel anastomosis. A part of the anastomosis was excised to allow removal of the enterolith and the defect was closed with cutting linear stapler. In the following two years, the patient did not have a recurrent episode of enterolith-related bowel obstruction.CONCLUSION The pathophysiology underlying enterolith formation is unclear, so it is difficult to predict if or when enteroliths may form and cause bowel obstruction. More research could provide advice to prevent recurrent enterolith formation and its sequelae.

Fiber and colorectal diseases: Separating fact from fiction

Whilst fruits and vegetables are an essential part of our dietary intake, the role of fiber in the prevention of colorectal diseases remains controversial. The main feature of a high-fiber diet is its poor digestibility. Soluble fiber like pectins, guar and ispaghula produce viscous solutions in the gastrointestinal tract delaying small bowel absorption and transit. Insoluble fiber, on the other hand, pass largely unaltered through the gut. The more fiber is ingested, the more stools will have to be passed. Fermentation in the intestines results in build up of large amounts of gases in the colon. This article reviews the physiology of ingestion of fiber and defecation. It also looks into the impact of dietary fiber on various colorectal diseases. A strong case cannot be made for a protective effect of dietary fiber against colorectal polyp or cancer. Neither has fiber been found to be useful in chronic constipation and irritable bowel syndrome. It is also not useful in the treatment of perianal conditions. The diverticulosis theory should also be challenged. The authors urge clinicians to keep an open mind about fiber. One must be aware of the truths and myths about fiber before recommending it.

Small bowel volvulus with jejunal diverticulum: Primary or secondary?

Small bowel volvulus,which is torsion of the small bowel and its mesentery,is a medical emergency,and is categorized as primary or secondary type. Primary type often occurs without any apparent intrinsic anatomical anomalies,while the secondary type is common clinically and could be caused by numerous factors including postoperative adhesions,intestinal diverticulum,and/or tumors. Here,we report a rare case of a 60-year-old man diagnosed with small bowel volvulus using multidetector computed tomography(MDCT) angiography. Further discovery by laparotomy showed one jejunal diverticulum,longer corresponding mesentery with a narrower insertion,and a lack of mesenteric fat. This case report includes several etiological factors of small bowel volvulus,and we discuss the possible cause of small bowel volvulus in this patient. We also highlight the importance of MDCT angiography in the diagnosis of volvulus and share our experience in treating this disease.

Enterolithiasis

Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis in the presence of the intestinal diverticula, surgical enteroanastomoses, blind pouches, afferent loops, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, and stenosing or stricturing Crohn&#x02019;s disease and intestinal tuberculosis. Enterolithiasis is classified into primary and secondary types. Its prevalence ranges from 0.3% to 10% in selected populations. Proximal primary enteroliths are composed of choleic acid salts and distal enteroliths are calcified. Clinical presentation includes abdominal pains, distention, nausea, and vomiting of occasionally sudden but often fluctuating subacute nature which occurs as a result of the enterolith tumbling through the bowel lumen. Thorough history and physical exam coupled with radiologic imaging helps establish a diagnosis in a patient at risk. Complications include bowel obstruction, direct pressure injury to the intestinal mucosa, intestinal gangrene, intussusceptions, afferent loop syndrome, diverticulitis, iron deficiency anemia, gastrointestinal hemorrhage, and perforation. Mortality of primary enterolithiasis may reach 3% and secondary enterolithiasis 8%. Risk factors include poorly conditioned patients with significant obstruction and delay in diagnosis. Treatment relies on timely recognition of the disease and endoscopic or surgical intervention. With advents in new technology, improved outcome is expected for patients with enterolithiasis.

Surgical management of colonic diverticular disease:Discrepancy between right- and left-sided diseases

AIM:To compare the outcome of the surgical management of left-sided and right-sided diverticular disease.METHODS:The medical records of 77 patients who were surgically treated for diverticular disease between 1999 and 2010 in a tertiary referral hospital were retrospectively reviewed.The study population was limited to cases wherein the surgical specimen was confirmed as diverticulosis by pathology.Rightsided diverticula were classified as those arising from the cecum,ascending colon,and transverse colon,and those from the descending colon,sigmoid colon,and rectum were classified as left-sided diverticulosis.To assess the changing trend of occurrence of diverticulosis,data were compared with two previous studies of 51 patients.RESULTS:The proportion of left-sided disease cases was significantly increased compared to the results of our previous studies in 1994 and 2001,(27.5%vs48.1%,P<0.05).Moreover,no differences in gender,body mass index,multiplicity of the diverticula,fever,or leukocytosis were noted between patients with rightsided and left-sided disease.However,patients with right-sided disease were significantly younger(50.9year vs 64.0 year,P<0.01).Furthermore,left-sided disease was significantly associated with a higher incidence of complicated diverticulitis(89.2%vs 57.5%,P<0.01),combined resection due to extensive inflammation(21.6%vs 5.0%,P<0.05),operative complications(51.4%vs 27.5%,P<0.05),and in-hospital mortality(10.8%vs 0%,P<0.05),along with longer post-operative hospitalization duration(21.3±10.2 d vs 10.6±8.1 d,P<0.05).CONCLUSION:Compared with right-sided diverticular disease,the incidence of left-sided disease in Korea has increased since 2001 and is associated with worse surgical outcomes.

Colonoscopy can miss diverticula of the left colon identified by barium enema

AIM: To identify the diagnostic value of colonoscopy for diverticulosis as determined by barium enema. METHODS: A total of 65 patients with hematochezia who underwent colonoscopy and barium enema were analyzed, and the diagnostic value of colonoscopy for diverticula was assessed. The receiver operating characteristic area under the curve was compared in relation to age (< 70 or ≥ 70 years), sex, and colon location. The number of diverticula was counted, and the detection ratio was calculated. RESULTS: Colonic diverticula were observed in 46 patients with barium enema. Colonoscopy had a sensitivity of 91% and specificity of 90%. No significant differences were found in the receiver operating characteristic area under the curve (ROC-AUC) for age group or sex. The ROC-AUC of the left colon was significantly lower than that of the right colon (0.81 vs 0.96, P=0.02). Colonoscopy identified 486 colonic diverticula, while barium enema identified 1186. The detection ratio for the entire colon was therefore 0.41 (486/1186). The detection ratio in the left colon (0.32, 189/588) was significantly lower than that of the right colon (0.50, 297/598) (P < 0.01). CONCLUSION: Compared with barium enema, only half the number of colonic diverticula can be detected by colonoscopy in the entire colon and even less in the left colon.

Role of endoscopy in the management of acute diverticular bleeding

Colonic diverticulosis is one of the most common causes of lower gastrointestinal bleeding. Endoscopy is not only a useful diagnostic tool for localizing the bleeding site, but also a therapeutic modality for its management. To date, haemostatic methods have included adrenaline injection, mechanical clipping, thermal and electrical coagulation or combinations of them. The results of all published data are herein reviewed.

Pathophysiological aspects of diverticular disease of colon and role of large bowel motility

Colonic diverticular disease (diverticulosis) is one of the most common gastrointestinal disorders in Western countries. This disorder is strictly related to aging and fibre intake, and still bears a discrete amount of morbidity. Numerous etiological co-factors have to date been implicated in the pathogenesis of the disease, yet the supporting evidence is still far from absolute. The present review considers the pathophysiology of colonic diverticular disease, with a special emphasis on factors related to abnormal colonic motility.