Diverticulosis of the colon Differential Diagnosis & Prognosis

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1 Diverticulosis of the colon Differential Diagnosis & Prognosis Stephan Hollerbach Dept.. of Gastroenterology,, AKH Celle University of Hannover Medical School

2 DIVERTICULAR DISEASE Uncomplicated Div.: Non-specific pain (LLQ) Bloating, constipation Loose stools Change in bowel habits Complicated Div.: Rectal bleeding Obstruction Fever, pyrexia Frank rebound / guarding

3 DIFFERENTIAL DIAGNOSIS SEVERE COURSE ACUTE ABDOMEN : Perforation / rupture of hollow organs (i.e., Colon, small bowel, gastric ulcer, gall bladder ) Acute Pancreatitis Intra-abdominal abscess Emergency room!

4 Differential diagnosis I- Carcinoma of the colon (CRC) IBS IBD Pseudo-membranous colitis Other infectious colitides Appendicitis Ischemic colitis Syx: - LLQ pain - GI bleeding - Obstruction

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6 Age Common risc factors in diverticulosis and colon cancer Obesity,, Lack of exercise Low-fiber fiber, fat-enhanced diet ( red meat ) Alcohol, Nicotine Reduced colonic diameter + reduced wall compliance Luminal obstruction (stool, polyps)

7 Prophylaxis Do you want that with Chemotherapy?

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9 Differential diagnosis II- Carcinoma of the colon IBS IBD NSAID-enteropathy Pseudo-membranous colitis Other infectious colitides Appendicitis Ischemic colitis

10 IBS and diverticular disease Common symptoms : - Non-specific lower abdominal pain - Changes in bowel habits - No causal relationship established Treatment: - symptomatic - similar Rose BD, UpToDate in Medicine 1997

11 Differential diagnosis III- Carcinoma of the colon IBS IBD NSAID-enteropathy Pseudo-membranous colitis Other infectious colitides Appendicitis Ischemic colitis

12 UC PC CD

13 Lower GI bleeding > DD IV- Carcinoma of the colon IBD Infectious colitides Ischemic colitis NSAID-enteropathy Angiodysplasia

14 Differential diagnosis V- Women: - Ovarian cysts/abscess - Adnexitis Urinary tract infections (UTI) Nephrolithiasis Groin Hernia (incarcerated)

15 PROGNOSIS of Diverticular Disease

16 Asymptomatic 70 % Diverticulosis 5-10% % Diverticular Bleeding Diverticulitis 75 % 25 % Simple Complicated Rose BD, UpToDate in Medicine 1997 Young-Fadok TM, Colon and Rectal Surgery 2001 Dunn G, Medscape 2004 Abscess Obstruction Perforation Fistula

17 Diverticulosis & Prognosis: -I- Simple Diverticulitis: - single attack: excellent prognosis => Conservative Thx: - 85% complete response - 15 % surgery - 2 % readmission rate / year Recurrent disease: - up to % surgery - double rate complications & mortality

18 Diverticulosis Prognosis: -II- Complicated Diverticulitis: % of first attack of acute diverticulitis - almost invariably => surgery - mortality: % - postop. progress: 15 % RF: Number of inflammatory episodes Immunosuppression Young onset

19 Prognosis in special situations Diverticulitis: - in 2-5% 2 of patients <40 years - RF: Male gender, Obesity (!) Young age group: - more virulent disease % urgent surgery at initial episode - high risk of recurrence / complications Parks TG 1969, Konvolinka CW 1994, Acosta JA1992, Freischlag J 1986, Schauer PR 1992

20 Special situations part II Challenges of the young-age = high concepts 1,2,3 : case series, non-controlled studies & other flaws Other risk groups: = high risk Immunocompromised patients Silent disease Less benefit from medical treatment risk of perforation, surgery, mortality 1 Wong WD 2000; 2 Reisman Y 1999; 3 Spivak H 1997 Perkins JD 1984; Tyau ES 1991

21 Conclusions special situations 1) Diverticulitis in patients <40 years early elective surgery advocated 2) Diverticulitis in immuno- compromised patients Elective sigmoid resection after one episode Stollman, NH, Raskin JB: Am J Gastroenterol 1999

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24 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 Young-Fadok TM, Colon and Rectal Surgery 2001 Dunn G, Medscape 2004

25 Polyp Darmkrebs ( Karzinom ) Adenom Karzinom

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27 Adenoma - Carcinoma - Sequence - Colon - Jaenne,, NEJM 2000

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29 Überernährung Asterix und die Belgier

30 DIVERTICULOSIS: SIGNIFICANCE West: : Most common colonic disease Disease of the Elderly => Increasing workload due to aging population! Major burden for health care

31 Polypenvorbeugung Diät-Einflüsse - Effekte fraglich Faserreiche Kost 1905 Menschen RR Menschen RR 0.99 Schatzkin,, NEJM 2000; Alberts, NEJM 2000 Calcium? 930 Menschen RR 0.85 Baron, NEJM 1999 Folsäure? (Fall/Kontroll) RR 0.4 Su,, Ann Epidemiol 2001 (XY, Alkohol ) Selen? Tiermodell, Effekt + Rao, Carcinogenesis 2000

32 Vorbeugung Polypen Diät-Einflüsse - Faserreiche Kost - keine Effekte! Schatzkin, NEJM NEJM 2000; 2000; Alberts, NEJM NEJM

33 Darmkrebs-Vorsorge - Gute Voraussetzungen Risikogruppen gut charakterisiert: Risiko FAP u.a. HNPCC Colitis ulcerosa Beschwerdefreie Bevölkerung, + Fam.-Geschichte Beschwerdefr. Bevölkerung, keine Familienvorgeschichte Krebs-Vorstufen bekannt Effektive Vorsorgemethoden verfügbar

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35 FAZIT was kann ich tun? Vorbeugung: - regelmäßige Bewegung - ausgewogene ausgewogene vitaminreiche Mischkost - Alkohol mäßig, Rauchen einstellen - bei Risikogruppe ggf. +ASS Ab 45. LJ: jährlicher Test auf verstecktes Blut im Stuhl (Hämokkult( Hämokkult) Vorsorge-Dickdarm Dickdarm-Spiegelung wahrnehmen (ab 55.LJ) Familien - Vorgeschichte auf Vorkommen von Dickdarmkrebs prüfen

36 Gefahr erkannt Gefahr gebannt!

37 DIVERTICULOSIS: EPIDEMIOLOGY Prevalence: - Autopsy studies/ / Barium enema: 2-10 % Increasing with age: - < 40 years: prevalence <10 % - > 80 years: prevalence % - no gender-related related differences Geographic variability: - highest in USA, Europe, Australia - lowest in Africa, Asia Dietary influences: - urbanization increases prevalence Painter NS, BMJ 1971 Painter NS, Clin Gastroenterol 1975 Parks TG, Clin Gastroenterol 1975 Ogunbiyi OA, Afr J Med Med Scie 1989