Diverticulosis of the colon –Differential Diagnosis &

PrognosisStephan HollerbachStephan Hollerbach

DeptDept. of . of GastroenterologyGastroenterology, AKH Celle, AKH CelleUniversity of Hannover University of Hannover MedicalMedical SchoolSchool

DIVERTICULAR DISEASEDIVERTICULAR DISEASEUncomplicatedUncomplicated Div.:Div.:

NonNon--specificspecific painpain (LLQ)(LLQ)BloatingBloating, , constipationconstipationLooseLoose stoolsstoolsChange in Change in bowelbowel habitshabits

Complicated Div.:Rectal bleedingObstructionFever, pyrexiaFrank rebound / guarding

DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS –– SEVERE SEVERE COURSECOURSE

„„ACUTE ABDOMEN“:ACUTE ABDOMEN“:

Perforation / Perforation / rupturerupture of hollow organs(i.e., Colon, small bowel, gastric ulcer, gallbladder…)

Acute PancreatitisPancreatitisIntra-abdominal abscess

⇒⇒ EmergencyEmergency roomroom !!

Differential diagnosis –I-CarcinomaCarcinoma of of thethe coloncolon (CRC)(CRC)IBSIBDPseudo-membranouscolitisOther infectious colitidesAppendicitisIschemic colitis

SyxSyx: : - LLQ pain- GI GI bleedingbleeding-- ObstructionObstruction

Common risc factors in diverticulosis and colon cancer

AgeAgeObesityObesity, Lack of , Lack of exerciseexerciseLowLow--fiberfiber, , fatfat--enhancedenhanced dietdiet(„(„red red meatmeat“) “) AlcoholAlcohol, , NicotineNicotineReducedReduced coloniccolonic diameterdiameter+ + reducedreduced wall wall compliancecomplianceLuminalLuminal obstructionobstruction ((stoolstool, , polypspolyps))

Prophylaxis

„Do you want that with Chemotherapy ?“

CarcinomaCarcinoma of of thethe coloncolon

IBSIBSIBD

NSAIDNSAID--enteropathyenteropathyPseudo-membranous colitisOther infectious colitidesAppendicitisIschemic colitis

Differential diagnosis –II-

IBS and diverticular disease

Rose BD, UpToDate in Medicine 1997

Common Common symptomssymptoms : : -- NonNon--specificspecific lowerlower abdominalabdominal

painpain-- ChangesChanges in in bowelbowel habitshabits-- No No causalcausal relationshiprelationship establishedestablished

Treatment:Treatment:-- symptomaticsymptomatic-- similarsimilar

CarcinomaCarcinoma of of thethe coloncolon

IBSIBS

IBDNSAIDNSAID--enteropathyenteropathy

Pseudo-membranous colitisOther infectious colitidesAppendicitisIschemic colitis

Differential diagnosis –III-

PC

UC

CD

Lower GI bleeding –> DD –IV-

CarcinomaCarcinoma of of thethe coloncolonIBDIBDInfectiousInfectious colitidescolitidesIschemicIschemic colitiscolitisNSAIDNSAID--enteropathyenteropathyAngiodysplasiaAngiodysplasia

Differential diagnosis –V-

WomenWomen::-- OvarianOvarian cystscysts//abscessabscess-- AdnexitisAdnexitis

UrinaryUrinary tracttract infectionsinfections (UTI)(UTI)NephrolithiasisNephrolithiasisGroinGroin HerniaHernia ((incarceratedincarcerated))

PROGNOSISof

Diverticular Disease

Diverticulosis

Asymptomatic

Diverticular Bleeding

DiverticulitisDiverticulitisSimple

Complicated

AbscessObstructionPerforation

Fistula

70 %

5-10%

10- 25 %75 %

25 %

Rose BD, UpToDate in Medicine 1997YoungYoung--FadokFadok TM, TM, ColonColon and and RectalRectal SurgerySurgery 20012001Dunn G, Dunn G, MedscapeMedscape 20042004

Diverticulosis & Prognosis: -I-

„Simple“ „Simple“ DiverticulitisDiverticulitis::-- singlesingle attackattack: : excellentexcellent prognosisprognosis=>=> ConservativeConservative ThxThx::

-- 85% 85% completecomplete responseresponse-- 15 % 15 % surgerysurgery-- 2 % 2 % readmissionreadmission rate / rate / yearyear

RecurrentRecurrent diseasedisease::-- up to 30up to 30--40 % 40 % surgerysurgery-- double rate double rate complicationscomplications & & mortalitymortality

Diverticulosis – Prognosis: -II-ComplicatedComplicated DiverticulitisDiverticulitis:

-- 1515--29%29% of of firstfirst attackattack of of acuteacutediverticulitisdiverticulitis

-- almostalmost invariablyinvariably => => surgerysurgery-- mortalitymortality: : 1.31.3––5%5%-- postoppostop. . progressprogress: : 15 %15 %

Number of inflammatory episodesImmunosuppressionYoung age @ onset

RFRF::

PrognosisPrognosis in in specialspecial situationssituations

•• DiverticulitisDiverticulitis::-- in 2in 2--5% of 5% of patientspatients <40 <40 yearsyears-- RF:RF: Male Male gendergender, , ObesityObesity (!)(!)

•• Young age Young age groupgroup::-- moremore „virulent“ „virulent“ diseasedisease-- 6666--88%88% ⇒⇒ urgenturgent surgerysurgery at at initialinitialepisodeepisode

-- high high riskrisk of of recurrencerecurrence / / complicationscomplicationsParks TG 1969, Konvolinka CW 1994, Acosta JA1992,

Freischlag J 1986, Schauer PR 1992

Special Special situationssituations –– partpart IIII

ChallengesChallenges of of thethe „„youngyoung--ageage = high = high riskrisk““–– conceptsconcepts1,2,31,2,3:: casecase seriesseries, , nonnon--controlledcontrolledstudiesstudies & & otherother flawsflaws

OtherOther riskrisk groupsgroups::ImmunocompromisedImmunocompromised patientspatients„„SilentSilent“ “ diseasediseaseLessLess benefitbenefit fromfrom medicalmedical treatmenttreatment↑↑ riskrisk of of perforationperforation, , surgerysurgery, , mortalitymortality

1Wong WD 2000; 2Reisman Y 1999; 3Spivak H 1997Perkins JD 1984; Tyau ES 1991

ConclusionsConclusions –– specialspecial situationssituations

1) 1) DiverticulitisDiverticulitis inin patientspatients <40 <40 yearsyears⇒ early elective surgery advocated

2) DiverticulitisDiverticulitis inin immunoimmuno--compromisedcompromised patientspatients

⇒ Elective sigmoid resection afterone episode

Stollman, NH, Raskin JB: Am J Gastroenterol 1999

Diverticulosis – Course & Prognosis

Of all subjects with diverticulosis- 30% => clinical symptoms

10-25% of pts. => Diverticulitis~ 20% of symptomatic pts. =>

inflammation and scarring~ 10% of symptomatic pts. =>

colonic bleeding~ 10-20% of these => surgery

YoungYoung--FadokFadok TM, TM, ColonColon and and RectalRectal SurgerySurgery 20012001Dunn G, Dunn G, MedscapeMedscape 20042004

Polyp – Darmkrebs („Karzinom“)

Adenom Karzinom

Adenoma Adenoma -- CarcinomaCarcinoma -- SequenceSequence-- ColonColon --

JaenneJaenne, NEJM 2000, NEJM 2000

Überernährung

Asterix und die Belgier

DIVERTICULOSIS:DIVERTICULOSIS: SIGNIFICANCESIGNIFICANCE

WestWest: Most : Most commoncommon coloniccolonic diseasediseaseDiseaseDisease of of thethe ElderlyElderly=> => IncreasingIncreasing workloadworkload due to

aging population !

Major burden forhealth care

Polypenvorbeugung 2003- Diät-Einflüsse -

Effekte fraglich

• Faserreiche Kost 1905 Menschen RR 1.0+ 1303 Menschen RR 0.99SchatzkinSchatzkin, NEJM 2000; , NEJM 2000; Alberts, NEJM 2000Alberts, NEJM 2000

• Calcium ? 930 Menschen RR 0.85Baron, NEJM 1999

• Folsäure ? 14.407 (Fall/Kontroll) RR 0.4SuSu, Ann , Ann EpidemiolEpidemiol 20012001 (XY, Alkohol )

• Selen ? Tiermodell, Effekt +Rao, Rao, CarcinogenesisCarcinogenesis 20002000

Vorbeugung Polypen 2003- Diät-Einflüsse -

Schatzkin, NEJM 2000; Alberts, NEJM 2000

Faserreiche Kost - keine Effekte !

Schatzkin, NEJM 2000; Alberts, NEJM 2000

Darmkrebs-Vorsorge - Gute Voraussetzungen

Risikogruppen gut charakterisiert:

Beschwerdefr. Bevölkerung, keine Familienvorgeschichte

Beschwerdefreie Bevölkerung, + Fam.-Geschichte

Colitis ulcerosa

HNPCC

FAP u.a.

Krebs-Vorstufen bekannt

Effektive Vorsorgemethoden verfügbar

Risiko

FAZIT FAZIT –– was kann ich tun ?was kann ich tun ?

•• Vorbeugung:Vorbeugung:-- regelmäßigeregelmäßige BewegungBewegung-- ausgewogeneausgewogene vitaminreiche vitaminreiche MischkostMischkost-- Alkohol mäßig, Rauchen einstellenAlkohol mäßig, Rauchen einstellen-- bei „bei „Risikogruppe“Risikogruppe“ ggf. ggf. +ASS+ASS

•• Ab Ab 45. LJ45. LJ:: jährlicher Test auf verstecktes Blut im jährlicher Test auf verstecktes Blut im Stuhl (Stuhl (HämokkultHämokkult))

•• VorsorgeVorsorge--DickdarmDickdarm--SpiegelungSpiegelung wahrnehmenwahrnehmen(ab 55.LJ)(ab 55.LJ)

•• Familien Familien -- Vorgeschichte auf Vorkommen von Vorgeschichte auf Vorkommen von Dickdarmkrebs prüfenDickdarmkrebs prüfen

Gefahr erkannt ...

... Gefahr gebannt!

DIVERTICULOSIS: EPIDEMIOLOGYDIVERTICULOSIS: EPIDEMIOLOGY

PrevalencePrevalence::-- AutopsyAutopsy studiesstudies/ Barium / Barium enemaenema: : 22--10 %10 %

IncreasingIncreasing withwith age:-- < 40 < 40 yearsyears: : prevalenceprevalence <10 %<10 %-- > 80 > 80 yearsyears: : prevalenceprevalence 5050--66 %66 %-- nono gendergender--relatedrelated differencesdifferences

GeographicGeographic variabilityvariability::-- highesthighest in USA, Europe, in USA, Europe, AustraliaAustralia-- lowestlowest in in AfricaAfrica, , AsiaAsia

DietaryDietary influencesinfluences::-- „„urbanizationurbanization“ “ increasesincreases prevalenceprevalence PainterPainter NS, BMJ 1971NS, BMJ 1971

Painter NS, Clin Gastroenterol 1975Parks TG, Clin Gastroenterol 1975

Ogunbiyi OA, Afr J Med Med Scie 1989