Diverticular Disease of the GI Tract

Background

Diverticular disease, also known as diverticulosis or diverticulitis, is a common, and probably underrecognized disease primarily affecting the lower gastrointestinal tract.

OUTLINE

Epidemiology

Disease Associations

Pathogenesis

Laboratory/Radiologic/Other Diagnostic Testing

Gross Appearance and Clinical Variants

Histopathological Features and Variants

Differential Diagnosis

Prognosis and Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

SYNONYMS

INCIDENCE

Prevalence of polyps and diverticulosis of the large bowel in the Cretan population. An autopsy study.

Paspatis GA, Papanikolaou N, Zois E, Michalodimitrakis E.

Department of Gastroenterology, Benizelion General Hospital, Heraklion-Crete, Greece.
Int J Colorectal Dis 2001 Aug;16(4):257-61 Abstract quote
While a number of studies have been performed in the United States, northern Europe, and some other countries on the epidemiology of large bowel polyps and diverticulosis, information from southern Europe and especially Greece is very limited.

Our autopsy study sought to determine the prevalence of large bowel polyps and diverticulosis in the population on Crete. Specimens of colon and rectum were obtained during forensic postmortem autopsies and examined for the presence of polypoid lesions and diverticulosis. Data were collected from a total of 502 autopsies (320 men, 182 women; median age 65 years (range 16-93). Polyps were found in 106 cases (21.1%). These were adenomas in 73 cases (14.5%), hyperplastic polyps in 25 (4.9%), and mucosal tags in 8 (1.5%). Diverticulosis of the large bowel was found in 115 (22.9%). The prevalence of adenomas and diverticulosis increased with advanced age.

The prevalence of colonic diverticulosis in Crete is slightly lower than that which has been reported in most other studies in economically developed countries. The prevalence of colorectal adenomas in Crete is one of the lowest rates reported in Europe and is compatible to the known low incidence of colorectal cancer in Crete.

ASSOCIATIONS

A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men.

Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC.

Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.
Ann Epidemiol 1995 May;5(3):221-8 Abstract quote
The relationship between smoking, caffeine, and alcohol intake and the risk of symptomatic diverticular disease has not been investigated directly.

We examined these associations in a prospective cohort of 47,678 US men, 40 to 75 years old. During 4 years of follow-up (1988 to 1992), we documented 382 newly diagnosed cases of symptomatic diverticular disease. After adjustments for age, physical activity, and energy-adjusted intake of dietary fiber and total fat, alcohol intake (comparing those who drink > 30 g of alcohol/d to nondrinkers) was only weakly and nonsignificantly associated with risk of symptomatic diverticular disease (relative risk (RR) = 1.36; 95 percent confidence interval (CI), 0.94 to 1.97; P for trend = 0.37).

We observed no association between caffeine, specific caffeinated beverages, and decaffeinated coffee and the risk of symptomatic diverticular disease. Current smoking was not appreciably associated with risk of symptomatic diverticular disease compared to nonsmokers (RR = 1.25; 95 percent CI, 0.75 to 2.09) after adjustment for age, physical activity, and energy-adjusted intake of dietary fiber and total fat. In a subset analysis restricted to men who had undergone sigmoidoscopy or colonoscopy, a modest positive association was seen between smoking and risk of symptomatic diverticular disease.

These results suggest that smoking, caffeine, and alcohol intake are not associated with any substantially increased risk of symptomatic diverticular disease.

Prospective study of physical activity and the risk of symptomatic diverticular disease in men.

Aldoori WH, Giovannucci EL, Rimm EB, Ascherio A, Stampfer MJ, Colditz GA, Wing AL, Trichopoulos DV, Willett WC.

Department of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA 02115.
Gut 1995 Feb;36(2):276-82 Abstract quote
The relationship between physical activity and risk of symptomatic diverticular disease has not been investigated directly. This association was examined in a prospective cohort of 47,678 American men, 40 to 75 years of age, and free of diagnosed diverticular disease, colon or rectal polyp, ulcerative colitis, and cancer before 1988.

During four years of follow up, 382 newly diagnosed cases of symptomatic diverticular disease were documented. After adjustment for age, energy adjusted dietary fibre, and energy adjusted total fat, overall physical activity was inversely associated with the risk of symptomatic diverticular disease (for highest versus lowest extremes, relative risk (RR) = 0.63 (95% FIconfidence interval (CI) 0.45, 0.88). Most of the inverse association was attributable to vigorous activity, for extreme categories RR = 0.60 (95% CI 0.41, 0.87). For activity that was not vigorous the RR was 0.93 (95% CI 0.67, 1.69). Several specific activities were inversely associated with the risk of diverticular disease, but jogging and running combined was the only individual activity that was statistically significant (p for trend = 0.03).

For men in the lowest quintile for dietary fibre intake and total physical activity (compared with those in the opposite extreme), the RR was 2.56 (95% CI 1.36, 4.82). Physical activity, along with a high fibre diet, may be an important factor in the prevention of symptomatic diverticular disease.

FIBER

Changes in dietary fiber intake among Japanese in the 20th century: a relationship to the prevalence of diverticular disease.

Ohi G, Minowa K, Oyama T, Nagahashi M, Yamazaki N, Yamamoto S, Nagasako K, Hayakawa K, Kimura K, Mori B
Am J Clin Nutr 1983 Jul;38(1):115-21 Abstract quote
In view of the fact that Japanese dietary patterns have been undergoing rapid "Westernization," in part characterized by decrease in fiber, we assessed dietary and crude fiber content in the Japanese diet using food consumption tables for the period from 1911 to 1980, and studied the trend in the reported prevalence of diverticular disease of the colon. Fiber content declined in diphasic pattern: the first decline, which probably had started in the late 19th century, progressed until the Second World War.

Although records during the war period were unavailable, the high fiber content of the Japanese diet in the period immediately after the war reflects the tendency to supplement rice with more fiber-rich cereals, and to increase the amount of rice through reduced polishing during the war time.

The second decline in fiber content in the Japanese diet, which started in the 1950s and progressed throughout the period of "high economic growth," was mainly due to the decrease in cereal consumption. The changes in crude fiber content in the Japanese diet after the Second World War resemble the pattern of rapid decline noted in the United States during the 1930s to the 1950s. The prevalence of diverticular disease in both countries also shows sudden steep upward turns during the period between 1930 and 1950 in the United States and the late 1970s in Japan, suggesting the presence of threshold level(s) of fiber intake for the effective prevention of diverticular disease.

The prevalence of diverticular disease is still relatively low in Japan. However, if the current dietary trend continues, it may rise to a level currently found in the "Western" countries in the coming few decades.

A prospective study of diet and the risk of symptomatic diverticular disease in men.

Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC.

Department of Nutrition, Harvard School of Public Health, Boston, MA 02115.
Am J Clin Nutr 1994 Nov;60(5):757-64 Abstract quote
To examine the association between dietary fiber, sources of fiber, other nutrients, and the diagnosis of symptomatic diverticular disease, we analyzed data from a prospective cohort of 47,888 US men.

During 4 y of follow-up we documented 385 new cases of symptomatic diverticular disease. Total dietary fiber intake was inversely associated with the risk of diverticular disease after adjustment for age, energy-adjusted total fat intake, and physical activity [relative risk (RR) 0.58; 95% CI 0.41, 0.83; P for trend = 0.01 for men in the highest as compared with the lowest quintile of dietary fiber]. This inverse association was primarily due to fruit and vegetable fiber. For men on a high-total-fat, low-fiber diet, the RR was 2.35 (95% CI 1.38, 3.98) compared with those on a low-total-fat, high-fiber diet, and for men on a high-red-meat, low-fiber diet the RR was 3.32 (95% CI 1.46, 7.53) compared with those on a low-red-meat, high-fiber diet.

These prospective data support the hypothesis that a diet low in total dietary fiber increases the incidence of symptomatic diverticular disease. They also provide evidence that the combination of high intake of total fat or red meat and a diet low in total dietary fiber particularly augments the risk.

DISEASE ASSOCIATIONS CHARACTERIZATION

ENTERIC PERITONITIS

Diverticular disease and treatment with gastric acid inhibitors do not predispose to peritonitis of enteric origin in peritoneal dialysis patients.

del Peso G, Bajo MA, Gadola L, Millan I, Codoceo R, Celadilla O, Castro MJ, Aguilera A, Gil F, Selgas R.

Nephrology Service, Hospital Universitario La Paz, Madrid, Spain

Perit Dial Int 2001 Jul-Aug;21(4):360-4 Abstract quote

OBJECTIVE: Enteric peritonitis (EP) is an infrequent complication of peritoneal dialysis (PD), with severe consequences for peritoneal membrane viability and patient outcome. Factors such as diverticular disease and gastric acid inhibitors have been implicated in its appearance. We investigated several risk factors, including those mentioned below, that can influence the development of EP.

DESIGN: Retrospective cross-sectional study.

SETTING: Tertiary-care public university hospital.

PATIENTS: Fifty-seven PD patients treated in our PD unit during August 1998.

MAIN OUTCOME MEASURES: A barium enema was performed on 50 of the 57 patients (the remaining 7 patients refused it) in order to exclude the presence of diverticulosis. All episodes of peritonitis occurring in those patients, including EP, were registered. Enteric peritonitis was defined as that caused by gram-positive, gram-negative, or fungus micro-organisms that colonized the intestinal tract, excluding episodes secondary to genitourinary tract or peritoneal catheter exit-site infections.

RESULTS: Twenty-four patients showed diverticular disease in the barium enema, but only 5 of them (21%) had any EP episode. Five of the 26 patients with no diverticula (19%) had EP. Fifty-five episodes of peritonitis were reported in 21 patients; 15 episodes of EP (27.3% of all) developed in 11 patients. Seven of the 11 patients (64%) required peritoneal catheter removal and 3 of them (27%) finally were transferred to hemodialysis due to consequences of the EP episode. Logistic regression analysis did not find any of the independent variables analyzed (age, sex, time on PD, type of PD, peritoneal transport parameters, presence of polycystic kidney disease, constipation or diverticulosis, or treatment with gastric acid inhibitors, or phosphate-binding agents) to be risk factors for developing EP.

CONCLUSIONS: Neither diverticulosis nor treatment with gastric acid inhibitors seem to be risk factors for developing peritonitis of enteric origin in PD patients. This type of peritonitis has to be promptly identified and treated in order to diminish the high frequency of peritoneal catheter removal and PD dropout due to such episodes.

PATHOGENESIS CHARACTERIZATION

DYSMOTILITY

Twenty-four hour recordings of colonic motility in patients with diverticular disease: evidence for abnormal motility and propulsive activity.

Bassotti G, Battaglia E, Spinozzi F, Pelli MA, Tonini M.

Department of Clinical and Experimental Medicine, University of Perugia Medical School, Perugia, Italy.
Dis Colon Rectum 2001 Dec;44(12):1814-20 Abstract quote
INTRODUCTION: Diverticular disease of the colon is one of the most common pathologic entities in western countries. Although altered motility of the large bowel is commonly believed to be one of the major pathophysiologic mechanisms, no convincing evidence has been reported yet. In fact, only a few conflicting studies concerning distal colonic motility (with no information on forceful propulsive activity) are available in the literature.

PURPOSE: The purpose of the present study was to investigate basal and stimulated (postprandial) colonic motility from the transverse (not affected), descending, and sigmoid colon in patients with diverticular disease, together with detection of high-amplitude propagated contractions (mass movements). Motility data from patients were compared with those obtained in healthy control subjects.

METHODS: Ten patients and 16 control subjects of both sexes were recruited for the study. In all subjects, colonic motility was recorded for a 24-hour period by a colonoscopically positioned manometric catheter. Two 1000-kcal mixed meals were served during the study.

RESULTS: Compared with control subjects, patients with diverticular disease displayed significantly increased amounts of motility in the affected segments; the response to a physiologic stimulus (meal) was also abnormal in the patients' group. Diverticular disease patients also had a significant increase of forceful propulsive activity compared with control subjects (average = 10.3 +/- 2.7/subject/day high-amplitude propagated contractions for patients and 5.5 +/- 0.8/subject/day for control subjects; P = 0.051); interestingly, about 20 percent of such activity was abnormal, being propagated in a retrograde fashion.

CONCLUSIONS: We concluded that patients with diverticular disease of the colon have abnormal motor and propulsive activities of the large bowel, which are confined to the affected segments.

LABORATORY/RADIOLOGIC/
OTHER TESTS
CHARACTERIZATION

RADIOLOGIC

Inverted colonic diverticulum: air contrast barium enema findings in six cases.

Glick SN.

Department of Diagnostic Radiology, Hahnemann University Hospital, Philadelphia, PA 19102.
AJR Am J Roentgenol 1991 May;156(5):961-4 Abstract quote
A polypoid elevation of the colonic wall was identified on air contrast barium enema in six patients. The abnormality in each case was found to be an inverted colonic diverticulum. Inverted diverticula appeared as broad-based, smooth, sessile polyps measuring 1.5-2.0 cm. In five of the six patients a characteristic central umbilication and/or evidence of barium within the polyp could be identified.

The diagnosis was confirmed in three patients by demonstrating an everted diverticulum replacing the suspected lesion. In the remaining three patients, two of whom had normal findings on colonoscopy, the diagnosis was strongly suggested by the presence of barium extending into the substance of the mass. Additional radiologic maneuvers or a second study may permit accurate diagnosis if the possibility of inverted diverticulum is considered.

However, even when the diverticulum cannot be demonstrated, a central umbilication or barium within a smooth intraluminal projection should suggest inverted diverticulum and prevent unnecessary endoscopy or inadvertent diverticulectomy.

GROSS APPEARANCE/
CLINICAL VARIANTS CHARACTERIZATION

GENERAL

VARIANTS

GIANT

Giant colonic diverticulum: a rare manifestation of a common disease.

Custer TJ, Blevins DV, Vara TM.

Department of Surgery, Mount Carmel Health System, Columbus, Ohio, USA.
J Gastrointest Surg 1999 Sep-Oct;3(5):543-8 Abstract quote
Giant colonic diverticulum is a rare manifestation of a common disease primarily affecting patients over the age of 50 years.

We reviewed all 81 cases of giant colonic diverticulum reported in the medical literature and present herein an additional case in a younger patient. Published reports were summarized with regard to current epidemiology, clinical aspects, diagnosis, pathogenesis, treatment, and complications.

Giant colonic diverticulum can present as an acute, chronic, or incidental condition, or with complications. There are several suggested theories for the pathogenesis of giant colonic diverticulum, but none is universally satisfactory. A diagnosis can be made with plain films, barium enema, and CT scans. A combination of sigmoid resection and primary anastomosis was successful in 75% of the cases reported after the mid-1970s.

More than 90% of giant colonic diverticula are found in the sigmoid colon. Sigmoid resection with primary anastomosis is the preferred treatment, although patients presenting with complications typically should be treated with Hartmann's procedure for free perforation or percutaneous drainage for a localized abscess.

Because of the high risk of complications, we recommend segmental resection of the involved colon for those found incidentally.

RIGHT COLON

Dietary habits and right-sided colonic diverticulosis.

Lin OS, Soon MS, Wu SS, Chen YY, Hwang KL, Triadafilopoulos G.

Division of Gastroenterology, ChangHua Christian Medical Center, Taiwan.
Dis Colon Rectum 2000 Oct;43(10):1412-8 Abstract quote
PURPOSE: In Asian populations, there is a high prevalence of right-sided colonic diverticulosis, the cause of which is uncertain. It is suspected that dietary habits may interact with a congenital predilection to cause this condition. To evaluate the relationship between long-term dietary habits and the prevalence of right-sided diverticulosis in the general population, we performed a retrospective case-control study.

METHODS: We reviewed the records of 3,105 screening colonoscopies performed on healthy, asymptomatic adults. All cases of right-sided diverticulosis were selected, and a similar number of gender-matched and age-matched controls with negative colonoscopies were randomly sampled from the same cohort. All case and control subjects were interviewed by a single-blinded nurse to establish their dietary habits during the past decade, in addition to other demographic characteristics. Based on consumption frequency, they were assigned to one of three diet classes for each of three food categories of interest: meat, vegetable, and fruit products. Staple foods such as rice were not included. Odds ratios were then calculated using multivariate conditional logistic regression and tests for trend were performed.

RESULTS: A total of 86 cases of right-sided diverticulosis were included, whereas 106 controls were randomly selected. There was a marked association between meat consumption frequency and right-sided diverticulosis, with a trend P value of <0.01 and an odds ratio of 24.81 between the most and least frequent consumers of meat products.

CONCLUSIONS: The prevalence of right-sided diverticulosis is strongly positively associated with past meat consumption frequency. There is no association with vegetable or fruit consumption frequency, laxative use, supplemental fiber intake, smoking, or family history.

Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital.

Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK.

First Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.
Dis Colon Rectum 2000 Oct;43(10):1383-9 Abstract quote
PURPOSE: Diverticulosis of the right colon has been increasing in the Far East; however, a considerable proportion of these patients includes cases of solitary right-sided diverticular disease. This study aimed to determine whether the incidence of such solitary diverticula (defined as 1 or 2 diverticula in this study) and multiple (3 or more) diverticula of the right colon is increasing in Japan.

METHODS: A total of 13,947 consecutive barium enema examinations, performed in the period from 1982 to 1997, were reviewed. Changes in the frequency (detection rate) and number of diverticula across time and with aging of three types of diverticula, right-sided, left-sided, and bilateral, were investigated, with special interest in those patients with one or two diverticula of the right colon.

RESULTS: Right-sided and bilateral diverticula have increased in frequency across time; however, left-sided diverticula have not. Patients with one or two diverticula in the right colon of right-sided disease, unexpectedly, have increased across time in both genders, and patients with three or more diverticula in the right colon of right-sided disease have shown an increase in males. The number of diverticula of the right colon showed no increase across time or with aging.

CONCLUSIONS: Diverticulosis of the right colon, both solitary and multiple, has been increasing steadily in Japan; therefore, diverticulitis and bleeding diverticula of the right colon may continue to increase. Diverticula of the right colon might be an acquired disease and self-limiting in development, because the frequency did not increase substantially in the elderly and because the number changed little across time and with aging.

SENTINEL CLOT

Diverticular bleeding and the pigmented protuberance (sentinel clot): clinical implications, histopathological correlation, and results of endoscopic intervention.

Foutch PG, Zimmerman K.

Department of Pathology, Desert Samaritan Hospital, Mesa, Arizona, USA.
Am J Gastroenterol 1996 Dec;91(12):2589-93 Abstract quote
Over a 3-yr period, we performed colonoscopy on five patients (mean age 71 yr) in whom a specific diverticulum that contained a pigmented protuberance (PiP) was unequivocally identified as the cause for hemorrhage. Four of these individuals had endoscopic bipolar cauterization of the PiP, and two patients had surgery.

AIM: To (1) determine the clinical significance of an intradiverticular PiP, (2) correlate endoscopic features of a PiP with histopathological findings and, (3) assess results of endoscopic treatment for affected patients with lower GI bleeding.

METHODS: Medical charts were reviewed to garner data and assess outcome for patients. The bleeding diverticulum in one surgical case was detected in the resected specimen, and histological examination was performed.

RESULTS: The mean number of transfusions, bleeding days, and lowest hemoglobin concentration before definitive treatment was 4.8, 3.4, and 8.4 gm%, respectively. All patients rebled before treatment. In all instances, the PiP projected through the neck of the diverticulum, which was actively bleeding in two patients. Endoscopic bipolar cautery directed at the PiP achieved permanent hemostasis in three of four subjects (75%) (morbidity 0%). Endoscopic therapy failed in one subject, and a hemicolectomy was performed. Histological evaluation of the resected specimen showed erosion of a medium sized artery into the diverticulum. The PiP represented a sentinel clot (not a visible vessel) adherent to a breach in the vessel wall. A patient who had surgery instead of endoscopic therapy had a prolonged, complicated postoperative course.

CONCLUSIONS: (1) The presence of an intradiverticular PiP may identify a subset of patients at risk for severe recurrent diverticular bleeding. (2) Histopathological analysis showed the PiP to be a sentinel clot rather than a visible vessel. (3) In patients with severe recurrent diverticular bleeding, endoscopic treatment of the vessel beneath this lesion may be a viable alternative to surgery.

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL

VARIANTS

ABERRANT CRYPT FOCI

Aberrant crypt foci in the human colon: frequency and histologic patterns in patients with colorectal cancer or diverticular disease.

Nascimbeni R, Villanacci V, Mariani PP, Di Betta E, Ghirardi M, Donato F, Salerni B.

Department of Surgery, University of Brescia, Italy.
Am J Surg Pathol 1999 Oct;23(10):1256-63 Abstract quote
Aberrant crypt foci are considered potential markers of colorectal cancer risk. The aim of this study was to analyze a large series of human aberrant crypt foci according to frequency, distribution, and histology.

Aberrant crypt foci were identified in methylene blue-stained colonic mucosa from 103 patients undergoing surgery for colorectal cancer or diverticular disease. Foci were histologically classified into surface hyperplastic type, surface and glandular hyperplastic type, mixed hyperplastic and adenomatous type, and adenomatous type.

The mean frequency of aberrant crypt foci (n = 720) was higher in the colorectal cancer group (0.20/cm2) than in the diverticular disease group (0.07/cm2), and in distal colonic segments than in proximal segments. Most of the histologically examined foci (n = 366) were hyperplastic (88.8%). Surface hyperplasia accounted for 30.6% and prevailed in small lesions. Surface and glandular hyperplasia accounted for 58.2% and prevailed in medium-sized to large foci. Partially or totally dysplastic foci accounted for 10.1% of examined lesions (10.8% and 2.8% in the colorectal cancer and diverticular disease groups, respectively).

Most of them (94.6%) were composed of mixed hyperplastic and adenomatous crypts and prevailed in large lesions. The higher frequency of aberrant crypt foci in patients with colorectal cancer sustains their putative role as preneoplastic markers. The high rate of mixed hyperplastic and adenomatous lesions supports the possible adenomatous transformation of hyperplastic lesions.

CROHN'S CHANGES

Crohn's-like reaction in diverticular disease.

Gledhill A, Dixon MF.

Department of Histopathology, Harrogate General Hospital, UK.
Gut 1998 Mar;42(3):392-5 Abstract quote
BACKGROUND: Diverticulitis and Crohn's disease affecting the colon occur at similar sites in older individuals, and in combination are said to carry a worse prognosis than either disease in isolation. It is possible that diverticulitis may initiate inflammatory changes which resemble Crohn's disease histologically, but do not carry the clinical implications of chronic inflammatory bowel disease.

AIMS: To evaluate histological features and clinical outcome in individuals initially diagnosed histologically as having both Crohn's colitis and diverticulitis.

PATIENTS: Eleven consecutive individuals having a colonic resection showing histological features of both Crohn's disease and diverticulitis.

METHODS: Retrospective review of histological specimens, case notes, and discharge letters.

RESULTS: In nine patients, the Crohn's-like reaction was confined to the segment bearing diverticula. They had no clinical evidence of Crohn's disease.

CONCLUSION: A Crohn's-like inflammatory response can be a localised reaction to diverticulitis and does not necessarily indicate chronic inflammatory bowel disease.

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

CROHN'S DISEASE

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSTIC FACTORS

GENERAL

Diverticulitis: the effect of age and location on the course of disease.

Reisman Y, Ziv Y, Kravrovitc D, Negri M, Wolloch Y, Halevy A.

Department of Surgery, Assaf Harofeh Medical Center, Tel-Aviv University, Israel.
Int J Colorectal Dis 1999 Nov;14(4-5):250-4 Abstract quote
To examine the effect of patient's age and the location of diverticular disease on the course of the acute disease we retrospectively collected demographic data, symptoms, laboratory findings, imaging techniques, type of treatment (conservative vs. surgical), early and late complications, and follow-up data on 119 patients with acute diverticulitis (74 women, 45 men; mean age 64+/-14 years; follow-up 7-102 months, median 40).

Patients were divided by their age into two groups (42 aged 60 years or younger, 77 aged over 60) and on the location of their disease (108 to the left of the middle transverse, 11 to the right). Lower abdominal pain, abdominal tenderness, and fever were the most common complaints (70-97%). In the younger patients we found a significantly greater preponderance in the right colon (P = 0.02) than in older patients. Abdominal abscesses and fistulas were more common in right-sided diverticulitis (P = 0.01).

Patients with right-sided colon diverticulitis were treated surgically (82%) and on an emergency basis more often than patients with left-side colon diverticulitis (25%; P = 0.001). Older patients treated conservatively suffered more than younger patients (61% and 33% respectively; P = 0.04) from recurrent abdominal pain but not from recurrent, confirmed diverticulitis. Patients with right-sided diverticulitis treated conservatively suffered more from recurrent diverticulitis episodes than patients with left-sided diverticulitis (P = 0.05).

Younger patients thus do not have a more aggressive form of diverticulitis than older patients. Patients with acute diverticulitis in the right colon are likely to be operated earlier and for mistaken diagnoses than patients with left-sided diverticulitis.

NSAID USE

Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study.

Goh H, Bourne R.

Department of General Surgery, North Devon District Hospital, UK.
Ann R Coll Surg Engl 2002 Mar;84(2):93-6 Abstract quote
Non-steroidal anti-inflammatory drugs (NSAIDs) have a wide range of side-effects in the gastrointestinal tract and the large intestine. This study examines the hypothesis that the use of NSAIDs is associated with colonic perforation in diverticular disease. Histological evidence was used to confirm perforation.

A retrospective review of case records and pathology reports identified 20 patients admitted over 3 consecutive years. A total of 125 age- and sex-matched patients diagnosed with diverticular disease not complicated by perforation formed the control group. The incidences of NSAID use in the two groups were compared. A second control group consisted of 600 age- and sex-matched randomly selected patients with no known diverticular disease admitted as emergencies in the same period. Of the 20 patients with perforation, 9 were taking NSAIDs for 4 weeks or longer, compared with 19 (15%) of the 125 patients who did not have perforation (relative risk 2.961, 95% confidence interval 1.507-5.348, P < 0.01). 19% of all patients with diverticular disease were taking NSAIDs compared with 10% of the second control group (relative risk 1.869, 95% confidence interval 1.237-2.781, P < 0.01).

The findings indicate a strong association between the use of NSAIDs and the perforation of colonic diverticula. The majority of the indications for the use of NSAIDs were cardiovascular and musculoskeletal conditions. Prescribing NSAIDs to patients with diverticular disease carries an increased risk of colonic perforation.

PERFORATION

How frequently do large bowel diverticula perforate? An incidence and cross-sectional study.

Hart AR, Kennedy HJ, Stebbings WS, Day NE.

Institute of Public Health, University Forvie Site, Cambridge, UK.
Eur J Gastroenterol Hepatol 2000 Jun;12(6):661-5 Abstract quote
The aetiology of perforation of large bowel diverticula is poorly understood and a case-control study is required to identify the causes. Before such a study can be attempted, the incidence must be determined and groups at particular risk identified. Cases of perforated large bowel diverticula living in the Norwich postal code region treated between 1995 and 1997 were identified.

Fifty-eight cases presented in a population of 531 241. The incidence was 4.0 cases per 100,000 per year, increased with age and was higher in men than women (5.8 vs 3.1). The most frequently used drugs were non-steroidal anti-inflammatory drugs (NSAIDs) (29%) and opiate analgesics (26% of cases).

This is the first report of the incidence of perforated diverticular disease and allows a calculation of the population size needed to recruit sufficient cases for an aetiological investigation. The differences in incidence between genders should prompt a search for factors which differ between the sexes such as diet. NSAIDs are a known risk factor, although the data show that opiate analgesics should be investigated.

TREATMENT

SURGERY

The natural history diverticular disease: is there a role for elective colectomy?

Somasekar K, Foster ME, Haray PN.

Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan.
J R Coll Surg Edinb 2002 Apr;47(2):481-2, 484 Abstract quote
BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications.

MATERIALS AND METHODS: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients.

RESULTS: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications.

CONCLUSIONS: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.

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Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences.

Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW.

Department of Colorectal Surgery and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Dis Colon Rectum 2002 Apr;45(4):485-90 Abstract quote
PURPOSE: Although laparoscopic colectomy has demonstrated a variety of advantages, it remains unclear whether the reductions in length of stay and faster return of bowel function will offset potential increases in cost caused by operating time and instrumentation. The purpose of this study was to compare the direct cost structure of elective open and laparoscopic resection for sigmoid diverticulitis.

METHODS: We compared consecutive elective open and laparoscopic sigmoid colectomies (n = 71 and n = 61, respectively) performed from March 1, 1999, through December 31, 2000. Data collected included age, gender, body mass index, American Society of Anesthesia score, indication for surgery, morbidity, mortality, conversion (laparoscopic only), operating time, and length of hospital stay. Direct cost data were provided by Stanford's integrated hospital cost management and decision software. Indirect costs and total costs were not addressed. Data were analyzed by Student's t-test and chi-squared test where appropriate. Significance was set at P < 0.05. All data are presented as mean +/- standard error of the mean.

RESULTS: There were 132 elective sigmoid colectomies for diverticular disease (61 laparoscopic and 71 open procedures). There were no significant differences between the groups with respect to age, male/female ratio, or body mass index. Operating time was similar (109 +/- 7 minutes for laparoscopic procedures vs. 101 +/- 7 minutes for open procedures). The laparoscopic group had a significantly shorter length of stay (3.1 +/- 0.2 vs. 6.8 +/- 0.4 days), fewer pulmonary complications (1 (1.6 percent) vs. 4 (5.6 percent)) and fewer wound infections (0 vs. 5 (7 percent)). Conversion to open colectomy was required in 4 (6.6 percent) of 61 patients. Readmission occurred in three laparoscopic colectomy patients (4.9 percent) and four open colectomy patients (5.6 percent). There was one operative death in the laparoscopic group (1.6 percent) and no deaths in the open group. Total direct cost per case was significantly less for laparoscopic procedures ($3,458 +/- 437) than for open colectomies ($4321 +/- 501; P < 0.05, Student's t-test), and operating costs were not significantly different between the groups.

CONCLUSION: The data demonstrate that laparoscopic colectomy is a cost-effective means of electively managing sigmoid diverticular disease. This operative approach may become very important in an era of increasing constraints on hospital occupancy rates and access to nursing services in many regions of the country.

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.

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EPIDEMIOLOGY	CHARACTERIZATION
SYNONYMS
INCIDENCE
Prevalence of polyps and diverticulosis of the large bowel in the Cretan population. An autopsy study. Paspatis GA, Papanikolaou N, Zois E, Michalodimitrakis E. Department of Gastroenterology, Benizelion General Hospital, Heraklion-Crete, Greece.	Int J Colorectal Dis 2001 Aug;16(4):257-61 Abstract quote While a number of studies have been performed in the United States, northern Europe, and some other countries on the epidemiology of large bowel polyps and diverticulosis, information from southern Europe and especially Greece is very limited. Our autopsy study sought to determine the prevalence of large bowel polyps and diverticulosis in the population on Crete. Specimens of colon and rectum were obtained during forensic postmortem autopsies and examined for the presence of polypoid lesions and diverticulosis. Data were collected from a total of 502 autopsies (320 men, 182 women; median age 65 years (range 16-93). Polyps were found in 106 cases (21.1%). These were adenomas in 73 cases (14.5%), hyperplastic polyps in 25 (4.9%), and mucosal tags in 8 (1.5%). Diverticulosis of the large bowel was found in 115 (22.9%). The prevalence of adenomas and diverticulosis increased with advanced age. The prevalence of colonic diverticulosis in Crete is slightly lower than that which has been reported in most other studies in economically developed countries. The prevalence of colorectal adenomas in Crete is one of the lowest rates reported in Europe and is compatible to the known low incidence of colorectal cancer in Crete.
ASSOCIATIONS
A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC. Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.	Ann Epidemiol 1995 May;5(3):221-8 Abstract quote The relationship between smoking, caffeine, and alcohol intake and the risk of symptomatic diverticular disease has not been investigated directly. We examined these associations in a prospective cohort of 47,678 US men, 40 to 75 years old. During 4 years of follow-up (1988 to 1992), we documented 382 newly diagnosed cases of symptomatic diverticular disease. After adjustments for age, physical activity, and energy-adjusted intake of dietary fiber and total fat, alcohol intake (comparing those who drink > 30 g of alcohol/d to nondrinkers) was only weakly and nonsignificantly associated with risk of symptomatic diverticular disease (relative risk (RR) = 1.36; 95 percent confidence interval (CI), 0.94 to 1.97; P for trend = 0.37). We observed no association between caffeine, specific caffeinated beverages, and decaffeinated coffee and the risk of symptomatic diverticular disease. Current smoking was not appreciably associated with risk of symptomatic diverticular disease compared to nonsmokers (RR = 1.25; 95 percent CI, 0.75 to 2.09) after adjustment for age, physical activity, and energy-adjusted intake of dietary fiber and total fat. In a subset analysis restricted to men who had undergone sigmoidoscopy or colonoscopy, a modest positive association was seen between smoking and risk of symptomatic diverticular disease. These results suggest that smoking, caffeine, and alcohol intake are not associated with any substantially increased risk of symptomatic diverticular disease.
Prospective study of physical activity and the risk of symptomatic diverticular disease in men. Aldoori WH, Giovannucci EL, Rimm EB, Ascherio A, Stampfer MJ, Colditz GA, Wing AL, Trichopoulos DV, Willett WC. Department of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA 02115.	Gut 1995 Feb;36(2):276-82 Abstract quote The relationship between physical activity and risk of symptomatic diverticular disease has not been investigated directly. This association was examined in a prospective cohort of 47,678 American men, 40 to 75 years of age, and free of diagnosed diverticular disease, colon or rectal polyp, ulcerative colitis, and cancer before 1988. During four years of follow up, 382 newly diagnosed cases of symptomatic diverticular disease were documented. After adjustment for age, energy adjusted dietary fibre, and energy adjusted total fat, overall physical activity was inversely associated with the risk of symptomatic diverticular disease (for highest versus lowest extremes, relative risk (RR) = 0.63 (95% FIconfidence interval (CI) 0.45, 0.88). Most of the inverse association was attributable to vigorous activity, for extreme categories RR = 0.60 (95% CI 0.41, 0.87). For activity that was not vigorous the RR was 0.93 (95% CI 0.67, 1.69). Several specific activities were inversely associated with the risk of diverticular disease, but jogging and running combined was the only individual activity that was statistically significant (p for trend = 0.03). For men in the lowest quintile for dietary fibre intake and total physical activity (compared with those in the opposite extreme), the RR was 2.56 (95% CI 1.36, 4.82). Physical activity, along with a high fibre diet, may be an important factor in the prevention of symptomatic diverticular disease.
FIBER
Changes in dietary fiber intake among Japanese in the 20th century: a relationship to the prevalence of diverticular disease. Ohi G, Minowa K, Oyama T, Nagahashi M, Yamazaki N, Yamamoto S, Nagasako K, Hayakawa K, Kimura K, Mori B	Am J Clin Nutr 1983 Jul;38(1):115-21 Abstract quote In view of the fact that Japanese dietary patterns have been undergoing rapid "Westernization," in part characterized by decrease in fiber, we assessed dietary and crude fiber content in the Japanese diet using food consumption tables for the period from 1911 to 1980, and studied the trend in the reported prevalence of diverticular disease of the colon. Fiber content declined in diphasic pattern: the first decline, which probably had started in the late 19th century, progressed until the Second World War. Although records during the war period were unavailable, the high fiber content of the Japanese diet in the period immediately after the war reflects the tendency to supplement rice with more fiber-rich cereals, and to increase the amount of rice through reduced polishing during the war time. The second decline in fiber content in the Japanese diet, which started in the 1950s and progressed throughout the period of "high economic growth," was mainly due to the decrease in cereal consumption. The changes in crude fiber content in the Japanese diet after the Second World War resemble the pattern of rapid decline noted in the United States during the 1930s to the 1950s. The prevalence of diverticular disease in both countries also shows sudden steep upward turns during the period between 1930 and 1950 in the United States and the late 1970s in Japan, suggesting the presence of threshold level(s) of fiber intake for the effective prevention of diverticular disease. The prevalence of diverticular disease is still relatively low in Japan. However, if the current dietary trend continues, it may rise to a level currently found in the "Western" countries in the coming few decades.
A prospective study of diet and the risk of symptomatic diverticular disease in men. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC. Department of Nutrition, Harvard School of Public Health, Boston, MA 02115.	Am J Clin Nutr 1994 Nov;60(5):757-64 Abstract quote To examine the association between dietary fiber, sources of fiber, other nutrients, and the diagnosis of symptomatic diverticular disease, we analyzed data from a prospective cohort of 47,888 US men. During 4 y of follow-up we documented 385 new cases of symptomatic diverticular disease. Total dietary fiber intake was inversely associated with the risk of diverticular disease after adjustment for age, energy-adjusted total fat intake, and physical activity [relative risk (RR) 0.58; 95% CI 0.41, 0.83; P for trend = 0.01 for men in the highest as compared with the lowest quintile of dietary fiber]. This inverse association was primarily due to fruit and vegetable fiber. For men on a high-total-fat, low-fiber diet, the RR was 2.35 (95% CI 1.38, 3.98) compared with those on a low-total-fat, high-fiber diet, and for men on a high-red-meat, low-fiber diet the RR was 3.32 (95% CI 1.46, 7.53) compared with those on a low-red-meat, high-fiber diet. These prospective data support the hypothesis that a diet low in total dietary fiber increases the incidence of symptomatic diverticular disease. They also provide evidence that the combination of high intake of total fat or red meat and a diet low in total dietary fiber particularly augments the risk.

GROSS APPEARANCE/ CLINICAL VARIANTS	CHARACTERIZATION
GENERAL
VARIANTS
GIANT
Giant colonic diverticulum: a rare manifestation of a common disease. Custer TJ, Blevins DV, Vara TM. Department of Surgery, Mount Carmel Health System, Columbus, Ohio, USA.	J Gastrointest Surg 1999 Sep-Oct;3(5):543-8 Abstract quote Giant colonic diverticulum is a rare manifestation of a common disease primarily affecting patients over the age of 50 years. We reviewed all 81 cases of giant colonic diverticulum reported in the medical literature and present herein an additional case in a younger patient. Published reports were summarized with regard to current epidemiology, clinical aspects, diagnosis, pathogenesis, treatment, and complications. Giant colonic diverticulum can present as an acute, chronic, or incidental condition, or with complications. There are several suggested theories for the pathogenesis of giant colonic diverticulum, but none is universally satisfactory. A diagnosis can be made with plain films, barium enema, and CT scans. A combination of sigmoid resection and primary anastomosis was successful in 75% of the cases reported after the mid-1970s. More than 90% of giant colonic diverticula are found in the sigmoid colon. Sigmoid resection with primary anastomosis is the preferred treatment, although patients presenting with complications typically should be treated with Hartmann's procedure for free perforation or percutaneous drainage for a localized abscess. Because of the high risk of complications, we recommend segmental resection of the involved colon for those found incidentally.
RIGHT COLON
Dietary habits and right-sided colonic diverticulosis. Lin OS, Soon MS, Wu SS, Chen YY, Hwang KL, Triadafilopoulos G. Division of Gastroenterology, ChangHua Christian Medical Center, Taiwan.	Dis Colon Rectum 2000 Oct;43(10):1412-8 Abstract quote PURPOSE: In Asian populations, there is a high prevalence of right-sided colonic diverticulosis, the cause of which is uncertain. It is suspected that dietary habits may interact with a congenital predilection to cause this condition. To evaluate the relationship between long-term dietary habits and the prevalence of right-sided diverticulosis in the general population, we performed a retrospective case-control study. METHODS: We reviewed the records of 3,105 screening colonoscopies performed on healthy, asymptomatic adults. All cases of right-sided diverticulosis were selected, and a similar number of gender-matched and age-matched controls with negative colonoscopies were randomly sampled from the same cohort. All case and control subjects were interviewed by a single-blinded nurse to establish their dietary habits during the past decade, in addition to other demographic characteristics. Based on consumption frequency, they were assigned to one of three diet classes for each of three food categories of interest: meat, vegetable, and fruit products. Staple foods such as rice were not included. Odds ratios were then calculated using multivariate conditional logistic regression and tests for trend were performed. RESULTS: A total of 86 cases of right-sided diverticulosis were included, whereas 106 controls were randomly selected. There was a marked association between meat consumption frequency and right-sided diverticulosis, with a trend P value of <0.01 and an odds ratio of 24.81 between the most and least frequent consumers of meat products. CONCLUSIONS: The prevalence of right-sided diverticulosis is strongly positively associated with past meat consumption frequency. There is no association with vegetable or fruit consumption frequency, laxative use, supplemental fiber intake, smoking, or family history.
Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital. Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK. First Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan.	Dis Colon Rectum 2000 Oct;43(10):1383-9 Abstract quote PURPOSE: Diverticulosis of the right colon has been increasing in the Far East; however, a considerable proportion of these patients includes cases of solitary right-sided diverticular disease. This study aimed to determine whether the incidence of such solitary diverticula (defined as 1 or 2 diverticula in this study) and multiple (3 or more) diverticula of the right colon is increasing in Japan. METHODS: A total of 13,947 consecutive barium enema examinations, performed in the period from 1982 to 1997, were reviewed. Changes in the frequency (detection rate) and number of diverticula across time and with aging of three types of diverticula, right-sided, left-sided, and bilateral, were investigated, with special interest in those patients with one or two diverticula of the right colon. RESULTS: Right-sided and bilateral diverticula have increased in frequency across time; however, left-sided diverticula have not. Patients with one or two diverticula in the right colon of right-sided disease, unexpectedly, have increased across time in both genders, and patients with three or more diverticula in the right colon of right-sided disease have shown an increase in males. The number of diverticula of the right colon showed no increase across time or with aging. CONCLUSIONS: Diverticulosis of the right colon, both solitary and multiple, has been increasing steadily in Japan; therefore, diverticulitis and bleeding diverticula of the right colon may continue to increase. Diverticula of the right colon might be an acquired disease and self-limiting in development, because the frequency did not increase substantially in the elderly and because the number changed little across time and with aging.
SENTINEL CLOT
Diverticular bleeding and the pigmented protuberance (sentinel clot): clinical implications, histopathological correlation, and results of endoscopic intervention. Foutch PG, Zimmerman K. Department of Pathology, Desert Samaritan Hospital, Mesa, Arizona, USA.	Am J Gastroenterol 1996 Dec;91(12):2589-93 Abstract quote Over a 3-yr period, we performed colonoscopy on five patients (mean age 71 yr) in whom a specific diverticulum that contained a pigmented protuberance (PiP) was unequivocally identified as the cause for hemorrhage. Four of these individuals had endoscopic bipolar cauterization of the PiP, and two patients had surgery. AIM: To (1) determine the clinical significance of an intradiverticular PiP, (2) correlate endoscopic features of a PiP with histopathological findings and, (3) assess results of endoscopic treatment for affected patients with lower GI bleeding. METHODS: Medical charts were reviewed to garner data and assess outcome for patients. The bleeding diverticulum in one surgical case was detected in the resected specimen, and histological examination was performed. RESULTS: The mean number of transfusions, bleeding days, and lowest hemoglobin concentration before definitive treatment was 4.8, 3.4, and 8.4 gm%, respectively. All patients rebled before treatment. In all instances, the PiP projected through the neck of the diverticulum, which was actively bleeding in two patients. Endoscopic bipolar cautery directed at the PiP achieved permanent hemostasis in three of four subjects (75%) (morbidity 0%). Endoscopic therapy failed in one subject, and a hemicolectomy was performed. Histological evaluation of the resected specimen showed erosion of a medium sized artery into the diverticulum. The PiP represented a sentinel clot (not a visible vessel) adherent to a breach in the vessel wall. A patient who had surgery instead of endoscopic therapy had a prolonged, complicated postoperative course. CONCLUSIONS: (1) The presence of an intradiverticular PiP may identify a subset of patients at risk for severe recurrent diverticular bleeding. (2) Histopathological analysis showed the PiP to be a sentinel clot rather than a visible vessel. (3) In patients with severe recurrent diverticular bleeding, endoscopic treatment of the vessel beneath this lesion may be a viable alternative to surgery.

PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSTIC FACTORS
GENERAL
Diverticulitis: the effect of age and location on the course of disease. Reisman Y, Ziv Y, Kravrovitc D, Negri M, Wolloch Y, Halevy A. Department of Surgery, Assaf Harofeh Medical Center, Tel-Aviv University, Israel.	Int J Colorectal Dis 1999 Nov;14(4-5):250-4 Abstract quote To examine the effect of patient's age and the location of diverticular disease on the course of the acute disease we retrospectively collected demographic data, symptoms, laboratory findings, imaging techniques, type of treatment (conservative vs. surgical), early and late complications, and follow-up data on 119 patients with acute diverticulitis (74 women, 45 men; mean age 64+/-14 years; follow-up 7-102 months, median 40). Patients were divided by their age into two groups (42 aged 60 years or younger, 77 aged over 60) and on the location of their disease (108 to the left of the middle transverse, 11 to the right). Lower abdominal pain, abdominal tenderness, and fever were the most common complaints (70-97%). In the younger patients we found a significantly greater preponderance in the right colon (P = 0.02) than in older patients. Abdominal abscesses and fistulas were more common in right-sided diverticulitis (P = 0.01). Patients with right-sided colon diverticulitis were treated surgically (82%) and on an emergency basis more often than patients with left-side colon diverticulitis (25%; P = 0.001). Older patients treated conservatively suffered more than younger patients (61% and 33% respectively; P = 0.04) from recurrent abdominal pain but not from recurrent, confirmed diverticulitis. Patients with right-sided diverticulitis treated conservatively suffered more from recurrent diverticulitis episodes than patients with left-sided diverticulitis (P = 0.05). Younger patients thus do not have a more aggressive form of diverticulitis than older patients. Patients with acute diverticulitis in the right colon are likely to be operated earlier and for mistaken diagnoses than patients with left-sided diverticulitis.
NSAID USE
Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study. Goh H, Bourne R. Department of General Surgery, North Devon District Hospital, UK.	Ann R Coll Surg Engl 2002 Mar;84(2):93-6 Abstract quote Non-steroidal anti-inflammatory drugs (NSAIDs) have a wide range of side-effects in the gastrointestinal tract and the large intestine. This study examines the hypothesis that the use of NSAIDs is associated with colonic perforation in diverticular disease. Histological evidence was used to confirm perforation. A retrospective review of case records and pathology reports identified 20 patients admitted over 3 consecutive years. A total of 125 age- and sex-matched patients diagnosed with diverticular disease not complicated by perforation formed the control group. The incidences of NSAID use in the two groups were compared. A second control group consisted of 600 age- and sex-matched randomly selected patients with no known diverticular disease admitted as emergencies in the same period. Of the 20 patients with perforation, 9 were taking NSAIDs for 4 weeks or longer, compared with 19 (15%) of the 125 patients who did not have perforation (relative risk 2.961, 95% confidence interval 1.507-5.348, P < 0.01). 19% of all patients with diverticular disease were taking NSAIDs compared with 10% of the second control group (relative risk 1.869, 95% confidence interval 1.237-2.781, P < 0.01). The findings indicate a strong association between the use of NSAIDs and the perforation of colonic diverticula. The majority of the indications for the use of NSAIDs were cardiovascular and musculoskeletal conditions. Prescribing NSAIDs to patients with diverticular disease carries an increased risk of colonic perforation.
PERFORATION
How frequently do large bowel diverticula perforate? An incidence and cross-sectional study. Hart AR, Kennedy HJ, Stebbings WS, Day NE. Institute of Public Health, University Forvie Site, Cambridge, UK.	Eur J Gastroenterol Hepatol 2000 Jun;12(6):661-5 Abstract quote The aetiology of perforation of large bowel diverticula is poorly understood and a case-control study is required to identify the causes. Before such a study can be attempted, the incidence must be determined and groups at particular risk identified. Cases of perforated large bowel diverticula living in the Norwich postal code region treated between 1995 and 1997 were identified. Fifty-eight cases presented in a population of 531 241. The incidence was 4.0 cases per 100,000 per year, increased with age and was higher in men than women (5.8 vs 3.1). The most frequently used drugs were non-steroidal anti-inflammatory drugs (NSAIDs) (29%) and opiate analgesics (26% of cases). This is the first report of the incidence of perforated diverticular disease and allows a calculation of the population size needed to recruit sufficient cases for an aetiological investigation. The differences in incidence between genders should prompt a search for factors which differ between the sexes such as diet. NSAIDs are a known risk factor, although the data show that opiate analgesics should be investigated.
TREATMENT
SURGERY
The natural history diverticular disease: is there a role for elective colectomy? Somasekar K, Foster ME, Haray PN. Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan.	J R Coll Surg Edinb 2002 Apr;47(2):481-2, 484 Abstract quote BACKGROUND: The natural history of colonic diverticular disease is unclear leading to a debate on the value of elective colectomy in preventing complications of the disease. AIM: To assess whether the complications of diverticular disease requiring emergency surgery are related to previous episodes of diverticulitis and whether elective colectomy might prevent such complications. MATERIALS AND METHODS: A retrospective study was done on all patients admitted with complicated diverticular disease in two adjacent district general hospitals between 1995 and 2000. Information was collected on the details of management of the complications and past history of the investigations and treatment for diverticular disease in these patients. RESULTS: A total of 108 patients were admitted with complicated diverticular disease. Ninety eight (91%) patients were admitted as an emergency for perforated diverticular disease and rectal bleeding. Ten patients were urgent admissions for fistulae and diverticular phlegmons. Ninety eight patients underwent a Hartmann's operation, two had a subtotal colectomy and 4 patients had a sigmoid colectomy. Thirty four (31.4%) patients died in hospital post-operatively. Of the 108 patients, only 28 (26%) patients were known to have diverticular disease previously. Only three (2.7%) patients had had an episode of acute diverticulitis before they presented with further complications. CONCLUSIONS: Complications of diverticular disease occur de novo in the majority of patients who have no previous history of the disease. Further studies are needed to identify risk factors for complicated diverticular disease before adopting a policy of elective interval colectomy.
\ Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences. Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW. Department of Colorectal Surgery and the Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA.	Dis Colon Rectum 2002 Apr;45(4):485-90 Abstract quote PURPOSE: Although laparoscopic colectomy has demonstrated a variety of advantages, it remains unclear whether the reductions in length of stay and faster return of bowel function will offset potential increases in cost caused by operating time and instrumentation. The purpose of this study was to compare the direct cost structure of elective open and laparoscopic resection for sigmoid diverticulitis. METHODS: We compared consecutive elective open and laparoscopic sigmoid colectomies (n = 71 and n = 61, respectively) performed from March 1, 1999, through December 31, 2000. Data collected included age, gender, body mass index, American Society of Anesthesia score, indication for surgery, morbidity, mortality, conversion (laparoscopic only), operating time, and length of hospital stay. Direct cost data were provided by Stanford's integrated hospital cost management and decision software. Indirect costs and total costs were not addressed. Data were analyzed by Student's t-test and chi-squared test where appropriate. Significance was set at P < 0.05. All data are presented as mean +/- standard error of the mean. RESULTS: There were 132 elective sigmoid colectomies for diverticular disease (61 laparoscopic and 71 open procedures). There were no significant differences between the groups with respect to age, male/female ratio, or body mass index. Operating time was similar (109 +/- 7 minutes for laparoscopic procedures vs. 101 +/- 7 minutes for open procedures). The laparoscopic group had a significantly shorter length of stay (3.1 +/- 0.2 vs. 6.8 +/- 0.4 days), fewer pulmonary complications (1 (1.6 percent) vs. 4 (5.6 percent)) and fewer wound infections (0 vs. 5 (7 percent)). Conversion to open colectomy was required in 4 (6.6 percent) of 61 patients. Readmission occurred in three laparoscopic colectomy patients (4.9 percent) and four open colectomy patients (5.6 percent). There was one operative death in the laparoscopic group (1.6 percent) and no deaths in the open group. Total direct cost per case was significantly less for laparoscopic procedures ($3,458 +/- 437) than for open colectomies ($4321 +/- 501; P < 0.05, Student's t-test), and operating costs were not significantly different between the groups. CONCLUSION: The data demonstrate that laparoscopic colectomy is a cost-effective means of electively managing sigmoid diverticular disease. This operative approach may become very important in an era of increasing constraints on hospital occupancy rates and access to nursing services in many regions of the country.

Epidemiology
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Gross Appearance and Clinical Variants
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HISTOLOGICAL TYPES	CHARACTERIZATION
GENERAL
VARIANTS
ABERRANT CRYPT FOCI
Aberrant crypt foci in the human colon: frequency and histologic patterns in patients with colorectal cancer or diverticular disease. Nascimbeni R, Villanacci V, Mariani PP, Di Betta E, Ghirardi M, Donato F, Salerni B. Department of Surgery, University of Brescia, Italy.	Am J Surg Pathol 1999 Oct;23(10):1256-63 Abstract quote Aberrant crypt foci are considered potential markers of colorectal cancer risk. The aim of this study was to analyze a large series of human aberrant crypt foci according to frequency, distribution, and histology. Aberrant crypt foci were identified in methylene blue-stained colonic mucosa from 103 patients undergoing surgery for colorectal cancer or diverticular disease. Foci were histologically classified into surface hyperplastic type, surface and glandular hyperplastic type, mixed hyperplastic and adenomatous type, and adenomatous type. The mean frequency of aberrant crypt foci (n = 720) was higher in the colorectal cancer group (0.20/cm2) than in the diverticular disease group (0.07/cm2), and in distal colonic segments than in proximal segments. Most of the histologically examined foci (n = 366) were hyperplastic (88.8%). Surface hyperplasia accounted for 30.6% and prevailed in small lesions. Surface and glandular hyperplasia accounted for 58.2% and prevailed in medium-sized to large foci. Partially or totally dysplastic foci accounted for 10.1% of examined lesions (10.8% and 2.8% in the colorectal cancer and diverticular disease groups, respectively). Most of them (94.6%) were composed of mixed hyperplastic and adenomatous crypts and prevailed in large lesions. The higher frequency of aberrant crypt foci in patients with colorectal cancer sustains their putative role as preneoplastic markers. The high rate of mixed hyperplastic and adenomatous lesions supports the possible adenomatous transformation of hyperplastic lesions.
CROHN'S CHANGES
Crohn's-like reaction in diverticular disease. Gledhill A, Dixon MF. Department of Histopathology, Harrogate General Hospital, UK.	Gut 1998 Mar;42(3):392-5 Abstract quote BACKGROUND: Diverticulitis and Crohn's disease affecting the colon occur at similar sites in older individuals, and in combination are said to carry a worse prognosis than either disease in isolation. It is possible that diverticulitis may initiate inflammatory changes which resemble Crohn's disease histologically, but do not carry the clinical implications of chronic inflammatory bowel disease. AIMS: To evaluate histological features and clinical outcome in individuals initially diagnosed histologically as having both Crohn's colitis and diverticulitis. PATIENTS: Eleven consecutive individuals having a colonic resection showing histological features of both Crohn's disease and diverticulitis. METHODS: Retrospective review of histological specimens, case notes, and discharge letters. RESULTS: In nine patients, the Crohn's-like reaction was confined to the segment bearing diverticula. They had no clinical evidence of Crohn's disease. CONCLUSION: A Crohn's-like inflammatory response can be a localised reaction to diverticulitis and does not necessarily indicate chronic inflammatory bowel disease.

DIFFERENTIAL DIAGNOSIS	KEY DIFFERENTIATING FEATURES
CROHN'S DISEASE