Recurrent diverticulitis – risk factors

Česká verzia

Authors: Z. Adamová; R. Slováček; J. Sankot
Authors place of work: Chirurgické oddělení, Vsetínská nemocnice, a. s., primář: MUDr. J. Sankot
Published in the journal: Rozhl. Chir., 2013, roč. 92, č. 10, s. 563-568.
Category: Original articles

Summary

Introduction:
Colonic diverticular disease is a common illness, especially in the elderly population. It may be asymptomatic and cause chronic intestinal problems, colonic diverticular bleeding or inflammatory complications with considerable morbidity and mortality. We have attempted at finding factors that would help us identify patients with a higher risk of diverticulitis recurrence as well as patients with a higher likelihood of perforated diverticulitis.

Material and methods:
This retrospective study included all patients admitted to our surgical ward for inflammatory complications of diverticular disease between 2000 and 2012: 278 patients, 88 men and 190 women. We looked up the first attack of diverticulitis in our documentation as well as the relapses, if any, their number and course, and the time from the first attack to the relapse. We analyzed the influence of age, gender, comorbidities (diabetes mellitus, overweight, ischemic heart disease, chronic renal failure, gastroduodenal disease), nicotine abuse and medication (glucocorticoids and other immunosuppressive drugs, acetylsalicylic acid) on diverticulitis recurrence and its complicated course. We compared the results of conservative and surgical therapy. Statistical analysis was performed using Fisher’s exact test and Man-Whitney U tests.

Results:
We did not demonstrate any statistically significant dependence of diverticulitis recurrence on age or gender. Colectomy (both acute and elective surgery) clearly decreases the likelihood of recurrence (p=0.00007). Comorbidities, nicotine abuse and medication were not associated with an increased risk of recurrence. Steroid and immunosuppressive drugs use was significantly associated with higher perforation rates, without impacting on the likelihood of recurrence. Regular smoking of cigarettes had no impact on recurrence or on its severity.

Conclusion:
We did not find any reliable indicator of recurrent diverticulitis. Age, gender, comorbidities, smoking and medication are not significant. Immunocompromised patients have a higher probability of perforation and a more serious course of the illness. The problem is, however, that complicated diverticulitis is often the initial clinical presentation of the disease. Surgical treatment is more effective than conservative therapy in the prophylaxis of recurrent diverticulitis, but, according to our as well as foreign data, the relapse of diverticulitis occurs in a minority of the patients (14% in our study) and the recurrence tends to have a relatively benign course. These findings should be taken into consideration when counselling patients regarding potential benefits of prophylactic colectomy.

Key words:
diverticulitis – perforation – recurrence – risk factors

Zdroje

1. Chapman J, Davies M, Wolff B, et al. Complicated diverticulitis: is it time to rethink the rules? Ann Surg 2005;242:576–81.

2. Adamová Z. Divertikulární nemoc tračníku. Rozhl Chir 2011; 90:463–77.

3. Zonca P, Jacobi CA, Meyer GP. Současný pohled na chirurgickou léčbu divertikulární choroby. Rozhl Chir 2009;88:568–76.

4. Andeweg C, Peters J, Bleichrodt R, et al. Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease.World J Surg 2008;32:1501–6.

5. Mpofu S, Mpofu CM, Hutchinson D, et al. Steroids, non-steroidal anti-inflammatory drugs, and sigmoid diverticular abscess perforation in rheumatic conditions. Ann Rheum Dis 2004;63:588–90.

6. Papagrigoriadis S, Macey L, Bourantas N, Rennie JA. Smoking may be associated with complications in diverticular disease. Br J Surg 1999;86:923–6.

7. Thaler K, Baig MK, Berho M, et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003;46:385–8.

8. Klarenbeek BR, de Korte N, van der Peet DL, Cuesta MA. Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 2012;27:207–14.

9. Song ME, Jung SA, Shim KN, et al. Clinical characteristics and treatment outcome of colonic diverticulitis in young patients. Korean J Gastroenterol 2013;61:75–81.

10. Lopez-Borao J, Kreisler E, Millan M, et al. Impact of age on recurrence and severity of left colonic diverticulitis. Colorectal Dis 2012;14:e407–12.

11. van de Wall BJ, Poerink JA, Draaisma WA, et al. Diverticulitis in young versus elderly patients: a meta-analysis. Scand J Gastroenterol 2013;48:643–51.

12. Faria GR, Almeida AB, Moreira H, et al. Acute diverticulitis in younger patients: any rationale for a different approach? World J Gastroenterol 2011;17:207–12.

13. Lidor AO, Segal JB, Wu AW, et al. Older patients with diverticulitis have low recurrence rates and rarely need surgery. Surgery 2011;150:146–53.

14. Bose KP, Khorshidi I, Southern WN, Brandt LJ. The impact of ethnicity and obesity on the course of colonic diverticulitis. J Clin Gastroenterol 2013;47:160–4.

15. Buchs NC, Konrad-Mugnier B, Jannot AS, et al. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg 2013;100:976–9;Epub 2013 Apr 17.

16. Biondo S, Borao JL, Kreisler E, et al. Recurrence and virulence of colonic diverticulitis in immunocompromised patients. Am J Surg 2012;204:172–9.

17. Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011;54:283–8.

18. Ambrosetti P, Gervaz P, Fossung-Wiblishauser A. Sigmoid diverticulitis in 2011: many questions; few answers. Colorectal Dis 2012;14:e439–46.

19. Dobbins C, Defontgalland D, Duthie G, Wattchow DA. The relationship of obesity to the complications of diverticular disease. Colorectal Dis 2006;8:37–40.

20. Yoo PS, Garg R, Salamone LF, et al. Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis. Am J Surg 2008;196:710–4.

21. Binda GA, Arezzo A, Serventi A, et al. Multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg 2012;99:276–85.

22. Eglinton T, Nguyen T, Raniga S, et al. Patterns of recurrence in patients with acute diverticulitis. Br J Surg 2010;97:952–7.

23. Holmer C, Lehmann KS, Engelmann S, et al. Long-term outcome after conservative and surgical treatment of acute sigmoid diverticulitis. Langenbecks Arch Surg 2011;396:825–32.

24. Ritz JP, Gröne J, Engelmann S, et al. What is the actual benefit of sigmoid resection for acute diverticulitis?: Functional outcome after surgical and conservative treatment. Chirurg 2013;84:673–80.

25. Adamova Z. Comparison of long-term quality of life in patients with diverticular disease. Are there any benefits to surgery? Central European Journal of Medicine 2012;7:571–577.

26. Bargellini T, Martellucci J, Tonelli P, Valeri A. Long-term results of treatment of acute diverticulitis: still lessons to be learned? Updates Surg 2013;65:125–30. Epub 2012 Dec 28.

27. Ritz JP, Lehmann KS, Frericks B, et al. Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 2011;149:606–13.

28. Klarenbeek BR, Samuels M, van der Wal MA, et al. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010;251:670–4.

29. Holmer C, Lehmann KS, Gröne J, Buhr HJ, Ritz JP. Perforation risk and patient age. Risk analysis in acute sigmoid diverticulitis. Chirurg 2011;82:359–66.