Diverticulitis, a disease to be reckoned with
Written by:With diverticular disease refers to various conditions associated with the presence of diverticula of the colon, herniation of the mucosa of the colon through the muscle layer. The professor. Maurizio Koch, Gastroenterologist, speaks more specifically of diverticulitis
Diverticular disease of the colon: a considerable expense
Diverticular Disease (MD) of the colon has more and more weight on the health service, because of hospital admissions for complications, mortality and frequency of surgical interventions. The prevalence of the disease increases with age, and most of diverticulosis are identified eventually with colonoscopy. Many times the disease remains asymptomatic for a lifetime, and only in 4% of cases develop diverticulitis.
This low percentage, however, a good slice of the patients present a relapse and develop complications, so that the shelters cost to our country of 63 million euros per year and the hospital mortality rate reaches 0.5%.
Diverticulosis, diverticulitis and diverticular disease: let's clear
With diverticulosis it will indicate the presence of at least one diverticulum of the colon, in the absence of signs or symptoms of disease. The diverticula are small pockets that form in the final tract of the intestine, which remain harmless until they are flammable.
With diverticular disease, instead, it indicates the presence of diverticula and symptoms, such as abdominal pain, in the absence of diverticulitis. It can be both acute and chronic.
Diverticulitis, finally, is the inflammation of the diverticula. It may be complicated (you may develop complications such as bowel perforation, fistulas, intestinal obstruction, bleeding), or uncomplicated. In the latter case, the CT scan or ultrasound will show a thickening of the colon wall, with stratification of the surrounding fat (fat stranding).
What are the risk factors of diverticulitis?
The risk factors of diverticulitis have expanded over the past six years:
1) Age: the percentage of cases of diverticulitis increases much above 70 years of age, perhaps because of the connective tissue alterations.
2) of the Western Lifestyle: little physical activity and little fruit and vegetable consumption increases the risk of diverticulitis.
3) disorders of intestinal motility.
4) Genetic factors: diverticulitis is more frequent in patients with Marfan syndrome, Williams-Beuren syndrome or Ehlers-Danlos Syndrome.
5) intestinal innervation: some patients show signs of neuropathy enteric and visceral hypersensitivity.
6) microbiota, the microorganisms that are found in the digestive tract: intestinal dysbiosis, ie the alteration of the bacterial flora, has been associated with diverticulitis.
How is the diagnosis of diverticulitis?
The diagnosis of diverticulitis is based on clinical history, on laboratory tests and imaging tests (ultrasound, CT, MRI).
The white blood cell count and determination of the ESR (erythrocyte sedimentation rate) and CRP are the first examinations to be performed. However, their diagnostic value, in the presence of abdominal pain, although good, is not enough.
Important are the ultrasound and CT scan, able to display the tissue around the colon wall, which is just what happens diverticulitis.
As regards the magnetic resonance imaging, it has the same advantages of the TAC, but the studies conducted to date are few and do not allow comparisons. Ultrasound, therefore, for the reduced time frame and the reduced cost, is still the main diagnostic technique.
Colonoscopy, however, is not indicated in the acute period.
How you treat diverticular disease?
In patients with asymptomatic diverticulosis do not need any specific treatment. It may be recommended to avoid the risk of diverticulitis, a diet rich in fiber, regular physical activity and, if necessary, the weight loss.
But when there is abdominal pain, then you need to evaluate a pharmacological approach:
1) Mesalazine is used in diverticular disease for the control of inflammation. However recent studies, in particular the American double trial PREVENT PREVENT 1 and 2 exclude a role of mesalazine for the prevention of a relapse after an episode of diverticulitis.
2) The rifaximin is traditionally regarded as an antibiotic, to be taken orally: It regulates the intestinal microbiota. Furthermore, the rifaximin reduces the bacterial adhesiveness to epithelial cells. A meta-analysis suggests a good power of the drug on symptoms of diverticular disease. It is being published in an observational study that has documented efficacy in the prevention of recurrence.
3) Probiotics, or live bacteria that are beneficial to the body. At the time the studies are still few and the evidence is not sufficient to define their role.
Diverticulitis: the probability of recurrence
According to several studies, in a period of 10 years, about 25% of patients treated with antibiotics for diverticulitis presents symptoms of relapse and need a new hospitalization, or even surgery. The patients most at risk are those under age 50 and those who have had more than three previous episodes of diverticulitis.
A good strategy to avoid the occurrence of relapses is knowing how to carefully consider the risk factors. For example, NSAIDs (nonsteroidal anti-inflammatory drugs), in combination with aspirin, cause damage to the colon, altering the integrity of the mucosa and inhibit the synthesis of prostaglandins. However, aspirin has a very important role in the prevention of chronic diseases, especially in the secondary prevention of cardiovascular disease. If aspirin and NSAIDs are identified as risk factors for the first episode of diverticulitis, it has not yet been directly quantified the weight of their use in those who have already had diverticulitis.
Another strategy would be to make better use of medical therapies such as antibiotics, anti-inflammatories and probiotics to reduce the risk of diverticulitis and relapses. One of the possible mechanisms of inflammation diverticular, in fact, is represented by the alteration of the microbiota. As reported, the main role seems to be to not assorbili antibiotics, such as rifaximin, in cycles of 7-10 days per month. They expect, however, prospective randomized clinical trials to define the real gain.
Probiotics inhibit enteric pathogens and stimulate the system of local immunological defense. Still, however, a role does not appear defined.
Editor Karin Moscow