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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