As presented at RMSGNA 2019: Of course, it's not about just avoiding nuts and seeds. However, do you know how many attacks you can endure before suggesting a resection? How to manage young or immunosuppressed patients with diverticulitis? How Eastern (asian)diverticulitis differs? The role of mesalamine in treatment? It's time to re-explore a disease that you thought you knew!

1. Diverticulitis:
Popular Misconceptions
& New Management
Patricia L. Raymond M.D. FACG
Rx For Sanity
1

2. Disclosure: Relationships with commercial interest organizations
whose products are related to program content include: None
2

3. http://www.themedifastplan.com/main/can-a-tick-bite-give-you-an-allergy-to-red-meat/
3

4. It’s about the
HOLES!
4

5. 5

6. http://www.foodmatters.tv/images/assets/sprouted-nuts-seeds.jpg
6

7. Nut and seed concerns are so yesterday…
• Nut, corn, and popcorn consumption are NOT associated with an increase
in risk of diverticulosis, diverticulitis or diverticular bleeding.
• Health Professionals Follow-up Study
> 47,228 men between the ages of 40 and 75 years
> Inverse association between the amount of nut and popcorn consumption and
the risk of diverticulitis (HR nuts 0.8, 95% CI 0.63-1.01; HR popcorn 0.72, 95%
CI 0.56-0.92)
> No association between consumption of corn and diverticulitis
> No association between nut, popcorn, or corn consumption and diverticular
bleeding or uncomplicated diverticulosis.
Strate LL, Liu YL, Syngal S, et al.
Nut, corn, and popcorn consumption
and the incidence of diverticular disease.
JAMA 2008; 300:907.
7

8. 8

9. 9

10. 10

11. Pathophysiology of
Diverticulosis
11

12. What percent of your screening
colonoscopy patients have
diverticulosis?
12

13. Prevalence
<20% @ 40 years
60% @ 60 years
• Western and
industrialized nations
have prevalence rates
of 5 to 45 %
• Diverticulosis is
ASYMPTOMATIC!
13

14. 95 % of patients with diverticula have sigmoid diverticula
65%
24%
7%4%
Only in sigmoid colon
Mainly in sigmoid colon
Thoughout colon
Not sigmoid colon
14

15. It’s about the taenia!
• The taenia coli run the
length of the large
intestine.
• The taenia coli are
shorter than the the
colon
> Gathers (“becomes
sacculated”) forming the
haustra of the colon
— shelf-like intraluminal
projections.
http://salerno.uni-muenster.de/data/bl/sobotta/pics_big/0960.jpg
15

16. 16

17. Wall weakness + pressure =
diverticulosis
• Weakness in wall where the vasa recta penetrate the
circular muscle layer of the colon.
• Abnormal colonic motility
> Exaggerated segmentation contractions in which
segmental muscular contractions separate the
lumen into chambers.
> Increase in intraluminal pressure predisposes to
herniation of mucosa and submucosa.
17

18. Sigmoid colon location
> Laplace’s law according to which pressure (P) is proportional to wall tension (T)
and inversely proportional to bowel radius (R), where k is a conversion factor
(P = kT/R).
— Sigmoid colon is the segment of the colon with the smallest diameter
(R), it is the site of the highest pressure during segmentation of the
colon
18

19. 20

20. 21

21. Asian (Right sided) diverticulosis
• Prevalence between <1
and 5 per million population
• Predominantly right-sided
• Increased prevalence with
adoption of more Western
lifestyle.
> Japan has experienced an
increase in the prevalence of
right-sided diverticulosis
similar to the increase in left-
sided diverticula in
westernized countries.
http://wholelifefengshui.com/home/attachment/the-entrance-to-an-asian-temple
22

22. Mild
Moderate
Severe
23

23. • Proposed by Hinchey et al. in 1978
• Classifies colonic perforation due to diverticular disease for surgeons.
> Hinchey I - localized abscess (para-colonic)
> Hinchey II - pelvic abscess
> Hinchey III - purulent peritonitis (pus in the abdominal cavity)
> Hinchey IV - feculent peritonitis.
Side Bar: there is NO classification system
for uncomplicated diverticulosis;
the ‘Mild’, ‘Moderate’, ‘Severe’ descriptions
we use endoscopically are not quantitative.
Grading diverticulitis- Hinchey classification
24

24. 25

25. Complicated Diverticulosis
SUDD
SCAD
Acute Diverticulitis
Complicated Diverticulitis
Diverticular Hemorrhage
26

26. Symptomatic uncomplicated diverticular disease (SUDD)
• Persistent abdominal pain
attributed to diverticula in
the absence of
macroscopically overt
colitis or diverticulitis.
• ‘Smouldering diverticulitis’
• Wall thickening is present
in the absence of
inflammatory changes on
computed tomography
(CT).
• Symptoms overlap with IBS
> Chronic colicky/Constant
lower abdominal pain
> Pain relieved with defecation,
passage of flatus
> Bloating, distension,
flatulence
> Associated alteration in bowel
habit
• No signs of inflammation (fever,
leukocytosis)
27

27. Segmental colitis associated with diverticula (SCAD)
> “Diverticular colitis”
> Characterized by
inflammation in the
interdiverticular mucosa
without involvement of
the diverticular orifices.
28

28. Mesalamine for SUDD & prevent -itis
29
Mesalazine for the Treatment of Symptomatic Uncomplicated Diverticular Disease of the Colon and
Picchio M Elisei W Brandimarte G et al 2016 Oct;50 Suppl 1:S64-9. doi: 1

29. SCAD as IBD variant?
• Prevalence varies between 1.15% and 11.4%
amongst those with diverticulosis
• Slightly more common in males
• Usually presents in the sixth decade
• Four subtypes
30
Segmental colitis associated with diverticulosis: is it the coexistence of colonic diverticulosis and infla

30. SCAD as IBD variant?
31
Segmental colitis associated with diverticulosis: is it the coexistence of colonic diverticulosis and infla

31. 32

32. What percent of your diverticulosis
patients get diverticulitis?
• How often do people under 50 get
diverticulitis?
• Who gets more diverticulitis, men or
women?
33

33. Diverticulitis— what’s my risk?
4 to 25 % with diverticulosis develop diverticulitis.
• Diverticulitis increases with age
> The mean age at admission for acute diverticulitis is 63 years.
> 16 percent of admissions for acute diverticulitis are in patients under 45
years of age.
— right-sided diverticulitis in only 1.5 percent of cases
• Increased incidence of diverticulitis
> Increase in admissions for acute diverticulitis by 26 percent from 1998 to
2005.
> The largest increase was in patients aged 18 to 44 years (82 percent).
34

34. Under age 50 years
Diverticulitis is more common in men
35

35. http://glenn-glenncardwell.blogspot.com/2011_11_01_archive.html
36

36. Young obese males & diverticulosis
Virulent diverticular disease in young obese men.
Schauer PR, Ramos R, Ghiatas AA, Sirinek KR Am J Surg. 1992;164(5):443.
• During a 9-year period ending in December 1990, 61 of 238 patients
treated for acute diverticulitis were 40 years of age or younger.
> Primarily obese Hispanic males in whom the correct diagnosis was
frequently missed.
> Younger patients more frequently required an operation on an urgent basis
for complications of diverticulitis during the initial hospitalization.
> The most common indication for operation in young patients was
perforation compared with recurrent disease for the older age group.
> Sevenfold incidence of enteric fistulas complicating their acute episode of
diverticulitis.
37

37. Between the ages of 50 and 70
Slight female preponderance of diverticulitis
38

38. Over age 70
Marked female preponderance of diverticulitis
39

39. Fecalith= DDB
40

40. Diverticulitis from fecalith? Not.
• Diverticulitis from
micro- or macroscopic
perforation of a
diverticulum.
> Erosion of the
diverticular wall by
increased intraluminal
pressure or inspissated
mucous or food
particles—Not a fecalith.
41

41. in·spis·sate
inˈspisˌāt verb
past tense: inspissated
1. thicken or congeal.
"inspissated secretions"
42

42. Treatment of acute diverticulitis
• Bowel rest
• Antibiotics (?) 10-14
days
> Cipro/Flagyl
> Cipro/Clindamycin
• No colonoscopy x 6
weeks
> Perforation risk
• 20-40% will have
recurrent attacks
> Similar to first attack, not
worse
• 5-20% will get SUDD
(symptomatic uncomplicated
diverticular disease)
AKA “smoldering
diverticulitis”
• Unknown percentage
with SCAD
43

43. Colonoscopy after acute diverticulitis
44

44. Acute diverticulitis complications in 25%
• Abscess —17% of patients
hospitalized with acute
diverticulitis
• Fistula —between the colon and
adjacent viscera. Fistulas occur
in approximately 20% of patients
with surgically treated
diverticulitis and most commonly
involve the bladder.
• Perforation —1 to 2 percent of
patients with acute diverticulitis
have a perforation with purulent
or fecal peritonitis
> Mortality rates approach 20 %
http://radiology.med.sc.edu/diverticularabscess.htm
45

45. Colonoscopy even more important in
complicated diverticulitis
46

46. Antibiotics in question for diverticulitis, 2012
• Multicenter randomized trial of 623 patients
> CT-scan uncomplicated diverticulitis
• No statistical difference in complication rates based upon use of
antibiotics
• No difference in rate of bowel perforation
• Similar rate of recurrent diverticulitis (16.2 versus 15.8 percent).
> 3 patients randomized no antibiotics - intra-abdominal abscess
• If additional studies support, selected patients who are diagnosed with
uncomplicated diverticulitis may be safely managed with close
observation without antibiotic therapy
47

47. 48

48. What percent of your diverticulosis patients bleed?
• What side bleeds?
• How many need intervention to stop?
• What’s the risk of rebleed?
49

49. Diverticular bleeding—it’s about the Vasa Recta
• The responsible vasa recta drapes over the dome of the
diverticulum
> Covered only with mucosa
> Over time, becomes injured
> Ruptures into lumen, with bleeding
• Diverticular bleeding typically occurs in the absence of
diverticulitis.
50

50. 51

51. Diverticular bleeding
• 5 to 15 percent with
diverticulosis
> Massive in a third of
patients
> The right colon is the
source of colonic
diverticular bleeding in
50 to 90 percent of
patients.
http://www.endoatlas.com/jpeg/co_ge_19.jpg
http://www.drvergilio.com/new_page_6.htm
52

52. 53

53. “Will I bleed again from my diverticula?”
• Bleeding stops spontaneously in
75 percent of patients overall
> 99 % transfused < four units/day
• Risk of rebleeding 14 to 38%
• After 2nd bleed, risk of further
bleed rises to 21 to 50%
• Morbidity and mortality rates from
diverticular bleeding 10 to 20 %
http://www.endoatlas.org/assets/media/img/xl/weo_colon_diverticulum_active_bleeding_brugge.jpg
54

54. Management of diverticular bleed
• Colonoscopy
• Scintigraphy
• Angiography
• Surgery
http://www.healio.com/gastroenterology/curbside-consultation/%7Bb6e2c2ea-9e74-499c-b26a-4f79166f6849%7D/when-do-i-need-to-refer-
55

55. 56

56. Endoscopic management of diverticular hemorrhage
48 patients with hematochezia and known diverticulosis
• A definite diverticular bleeding source (defined by
active bleeding from a diverticulum, a nonbleeding
visible vessel, or an adherent clot)
> Identified in 10 patients (21 %)
> Successful treatment with endoscopic therapy
57

57. 58

58. Endoscopic management of diverticular hemorrhage
48 patients with hematochezia and known diverticulosis
> Treatment included four-quadrant submucosal injection of
epinephrine (1 to 2 mL aliquots, dilution 1:20,000) or
endoscopic tamponade.
— Visualized non-bleeding diverticular vessel, the vessel was
treated with bipolar coagulation at a setting of 10 to 15
Watts of power with moderate pressure directly on the
vessel using one-second pulses until good coagulation and
flattening of the vessel were achieved .
— Nonbleeding adherent clots were injected with epinephrine
and shaved down to 3 to 4 mm above the attachment with
a cold polypectomy snare (without coagulation). The
underlying stigmata (usually visible vessels) were then
coagulated with a bipolar probe.
59

59. • No episodes of recurrent bleeding
> Median follow-up of 30 months
• No patient required emergency surgery
• In a separate group of 17 patients with definite diverticular bleeding who did
NOT receive endoscopic therapy, persistent bleeding after colonoscopy
occurred in nine (53 percent).
• Six with persistent bleeding underwent surgery, and two suffered
complications following surgery.
• EBL and hemoclips are being studied for diverticular bleeding
60

60. 61
How do we prevent these things from happening?

61. Expectant Management of
Diverticulosis
62

62. 63

63. What lifestyle modifications have been
proved to help diverticulosis?
• We know about nuts and seeds, but…
• High fiber diet?
• Reduce animal fat and meat?
• Vigorous exercise?
• Weight management?
• Stop smoking?
• Reduce caffeine?
• Stop drinking alcohol?
65

64. 66

65. Dietary Fiber- unclear, but good maintenance
• CAUSE: Low dietary fiber predisposes to the development of
diverticular disease- conflicting results
• TREATMENT of Symptomatic: Reduction symptoms in patients with
symptomatic uncomplicated diverticular disease (SUDD) –NO
• PREVENTION of Attacks: Reduction the incidence of symptomatic
diverticular disease –Yes
> By decreasing intestinal inflammation and altering the intestinal microbiota
— Study > 47,000 men
— Adjustment for age, energy-adjusted total fat intake, and physical activity
— Total dietary fiber intake was inversely associated with the risk of
symptomatic diverticular disease (RR 0.58 highest quintile versus lowest
quintile for fiber intake).
67

66. 68

67. Fat and Red Meat—Bad for your diverticula
> Same cohort study as fiber
• High-total-fat, low-fiber diet
the RR 2.35 (95% CI 1.38,
3.98) verses low-total-fat,
high-fiber diet
• High-red-meat, low-fiber
diet RR 3.32 (95% CI 1.46,
7.53) verses low-red-meat,
high-fiber diet.
69

68. 70

69. Sedentary lifestyle and Obesity- Bad for your tics
• Vigorous physical activity= reduction in risk of diverticulitis and
diverticular bleeding.
> 8,000 men aged 40 - 75
> Risk of developing symptomatic diverticular disease was inversely related
to overall physical activity (RR 0.63 for highest versus lowest extremes)
after adjustment for age and dietary fat and fiber
> Most of the decrease in risk was associated with vigorous activity such as
jogging and running.
• Obesity = increased risk of diverticulitis and diverticular bleeding.
> 47,228 male health professionals
> 801 incident cases of diverticulitis and 383 cases of diverticular bleeding
during 18 years of follow-up
> Risk of diverticulitis and diverticular bleeding was significantly higher in
those with the highest quintile of waist circumference as compared with the
lowest (RR diverticulitis 1.56, 95% CI 1.18-2.07; RR diverticular bleeding
1.96, 95% CI 1.30-2.97).
71

70. Cigs- NO, Caffeine and alcohol OK
• Current smokers at
increased risk for
perforated diverticulitis and
a diverticular abscess as
compared with nonsmokers
(OR 1.89, 95% CI 1.15-
3.10)
• Caffeine and alcohol are
not associated with an
increased risk for
symptomatic diverticular
disease
72

71. 74
Questions remain about diverticulosis…

72. DIVA Trial Mesalamine (2013)
• 1-year double-blind, randomized, placebo-controlled study
> CT-scan confirmed acute diverticulitis
> placebo, mesalamine, or mesalamine+Bifidobacterium infantis 35624
(Align) for 12 weeks and followed for 9 additional months.
• Global symptom score (GSS) of 10 symptoms (abdominal pain,
abdominal tenderness, nausea/vomiting, bloating, constipation,
diarrhea, mucus, urgency, painful straining, and dysuria). Patients
were required to have a GSS≥12 at baseline, including an abdominal
pain score>2.
• One hundred seventeen patients (placebo, 41; mesalamine, 40;
mesalamine+probiotic, 36)
75

73. DIVA Trial Mesalamine (2013)
• GSS decreased in all groups during treatment without a statistically
significant difference between mesalamine and placebo, however;
scores were consistently lower for mesalamine at all time points.
• The rate of complete response (GSS=0) was significantly higher with
mesalamine than placebo at weeks 6 and 52 (P<0.05), and was
particularly high for rectosigmoid symptoms at weeks 6, 12, 26, and
52.
• Recurrence of diverticulitis was low and comparable across groups.
• Probiotic in combination with mesalamine did not provide additional
efficacy.
• CONCLUSIONS:
• Mesalamine demonstrated a consistent trend in reducing symptoms.
• Addition of probiotic did not increase mesalamine efficacy.
76

74. 78

75. The Diverticulitis Song
(to the tune of
“Taking Care Of Business”)
79
Bachman Turner Overdrive

76. So you feel your left side achin’
Lower belly starts makin’
Crampy pain, and B-Ms are narrow.
You have low grade fever
And then shakes that make you quweever
And wow, you ache to the marrow.
80
The ER doc is right on time
The lab draws tubes times nine
And they shoot some belly X-rays
And tho you’re far from overjoyed
With the stat results deployed
Tune in to what the doc says!
You’ve got DIVERTICULITIS, yes it bites!
Diverticulitis, sigmoid site—
Diverticulitis, liquid diet.
Diverticulitis from a microperfori
Bowel leak!
If your family is Asian
Look to a strange location
Cause tics occur in the right colon!
And if you’re a husky boy
Weight loss you should employ
Your tics will more likely get a hole-in!
If blood it starts to run
With red clots out of your bum
The bleeding stops in most in a day.
If pesky seeds you do avoid
That infos null and void
Our studies prove that nuts are OK.
You’ve got DIVERTICULOSIS, me-o-my!
Mini hernias due to vasa recti
Diverticulosis, it’s benign.
Diverticulosis, and nuts & seeds are fine.
Munch out!

77. http://www.themedifastplan.com/main/can-a-tick-bite-give-you-an-allergy-to-red-meat/
86
Questions?