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Diverticulosis andDiverticulitis
13
BindaGianAndrea, CassiniDiletta, GianandreaBaldazzi,
andNascimbeniRiccardo
13.1 Definitions
According to the currently accepted denition, “diverticulosis” is merely the presence of colonic diverticula; “diverticular disease (DD)” is dened as clinically signicant and symptomatic diverticulosis. Diverticular disease may be subclassied
into symptomatic uncomplicated diverticular disease (SUDD) and symptomatic
complicated diverticular disease (perforation, stula, obstruction, bleeding) [1].
Diagnosis and treatment of colonic diverticulitis in older patients may be more difcult than in young patients because of more frequent comorbidities. Precise diagnosis and accurate treatment of colonic diverticular disease are important topics in
geriatric clinical practice [2].
13.2 Epidemiology
Diverticulosis of the colon is one of the most common diseases of the digestive
tract, and its frequency increases with age. The prevalence of diverticulosis and
diverticular disease is increasing in Western countries in parallel with increased
B.G. Andrea (*)
Department of Surgery, Galliera Hospital, Genoa, Italy
e-mail: gian.andrea.binda@galliera.it
C. Diletta • G. Baldazzi
Department of General Minimally-invasive and Robotic Surgery, Policlinic of Abano Terme,
Padua, Italy
N. Riccardo
Department of Molecular & Translational Medicine, University of Brescia, Brescia, Italy
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_13
207
208
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B.G. Andrea et al.
life expectancy; several studies conrmed these data. This is particularly true in
industrialized Western countries where the incidence of diverticular disease
increases with age; the disease is uncommon in those under the age of 40, the
prevalence of which is estimated at approximately 5%; this increases to 65% in
those over 65years of age [3]. A recent, large study on 1091 patients who underwent CT colonography for various reasons has demonstrated a steady increase
of the disease prevalence parallel with ageing and, moreover, has found that age
was the strongest predictor of diverticula. The diverticula incidence appears to
be higher than expected without signicant differences according to gender. As
regards anatomic distribution, in the Western population, right colon diverticula
do not appear to be an uncommon nding, with their prevalence again increasing with patient age. In asymptomatic patients, the highest prevalence of severe
diverticulosis was found in the left-sided colon in the sixth and seventh decades.
In particular, prevalence was 17.5–20.8% in the sigmoid colon, 15.7–16.2% in
the descending colon, 9.7–8.7% in the transverse colon, 6.7–9.8% in the ascending colon and 6.7–7.5% in the caecum [4].
An epidemiological study in the USA has shown that frequency of diverticulitis
and diverticular bleeding increases with age [5]. According to another study, age
was associated with an increased risk of local and systemic complications [6].
13.2.1 Hospitalization
Diverticular disease and its complications are a relevant cause of hospitalization
and not without mortality, particularly in elderly patients [7]. An epidemiological study in the USA has shown that diverticular disease imposes an impressive
clinical burden. According to the data from the 2004 National Hospital Discharge
Survey, it is responsible for 312,000 admissions and 1.5 million days of inpatient care per year [1]. The annual cost of treatment within the USA is estimated
at over 2.6 billion dollars per year [2]. Nowadays whereas the overall number of
hospitalizations is declining, the hospitalizations due to diverticular disease and
diverticulitis are rising, especially in younger patients [8, 9]. Etzioni et al.
reported a 26% increase in admissions coded as acute diverticulitis from 1998
to 2005 (120,500–151,000 admissions). The greatest increase in admissions was
in the age ranges of 15–44 and 45–64years [8]. A further study of NIS data from
1998 to 2005 reported an overall age-adjusted increase in hospital admissions
from 61.8 per 100,000 to 75.5 per 100,000 hospitalizations, with equal gender
and age distribution [9].
On the other hand, the temporal trends of prevalence of hospitalization for diverticulitis and its complications among elderly patients have been stable during the
last decade, except those for bleeding which is becoming more frequent especially
among octogenarians [5].
13 Diverticulosis andDiverticulitis
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13.3 Pathogenesis
13.3.1 Diverticulosis andDiverticular Disease
As regards pathogenesis, it is well known that diverticula develop at well-dened
points of weakness, which correspond to where the vasa recta enter the circular
muscle layer of the colon. Change in the extracellular matrix and altered collagen
structure with age partly explains this pattern. In addition, emerging evidence suggests that vascular smooth muscle cell behaviour is modied by age. Abnormal
colonic motility is another important predisposing factor in the development of
diverticula. On this basis, several authors speculate that ageing could be a prominent
risk factor for both cardiovascular disease and diverticulosis [10].
Higher prevalence of diverticulosis in older subjects is consistent with several
observations. Changes in traditional lifestyle and diet of Western populations probably play some role, of course under the inuence of genetic factors [7], but to date,
the inherent genetic risk remains unknown [11].
Another risk factor called into play is the Western toilet, described as an unnatural method of defecation [12]. Moreover, current studies have demonstrated a strong
association between smoking and symptomatic diverticular disease. In his Swedish
cohort study on 4209 individuals with a diagnosis of symptomatic diverticular disease, Humes [13] demonstrated that smoking is associated with symptomatic diverticular disease with an increased risk of developing complicated diverticular disease.
In fact, heavy smokers (≥15 cigarettes a day) had a 1.6-fold increased risk of developing symptomatic diverticular disease compared with nonsmokers.
About cardiovascular disease as a risk factor, several studies have provided evidence suggesting a link between diverticular disease and cardiovascular disease.
The pathogeneses of diverticular disease and cardiovascular disease are multifactorial and complex. Chronic inammation contributes to both diseases, particularly in
the elderly. As regards physiologic changes, Aldoori etal. [14] found that overall
physical inactivity was associated with the risk of diverticular disease, while
Williams etal. [15] demonstrated that vigorous physical activity was inversely associated with the risk of incident diverticular disease among older men and women.
Obesity is also a signicant risk factor for diverticulitis and diverticular bleeding.
The Health Care Professionals Follow-Up Study demonstrated after an 18-year
follow-up that subjects with a BMI >30kg/m
developing diverticulitis or diverticular bleeding compared with those with a BMI
of <21kg/m2 [16]. Moreover, a Swedish study conrmed that a BMI>30kg/m2
increased the risk of being hospitalized with symptomatic diverticular disease over
a 28-year follow-up [17].
As regards comorbidity, atherosclerosis is considered the main cause of diverticular bleeding, but also cerebrovascular disease and hyperuricemia are signicant
predictors of diverticular bleeding [18].
2
had a signicantly increased risk of
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B.G. Andrea et al.
A recent meta-analysis has demonstrated that various medications of common use,
especially in aged persons, are implicated in complications of diverticular disease,
with pooled data showing signicantly increased odds of perforation and abscess formation with steroids (OR: 9.08), opioids (OR: 2.52) and NSAIDs (OR: 2.49).
Increased odds of diverticular bleeding from NSAIDs (OR=2.69), aspirin (OR=3.24)
and calcium-channel blockers (OR=2.50) were also demonstrated [19].
All factors associated with the development of diverticulitis and complications
should be explored in subjects presenting with symptoms of diverticulitis, as they
may facilitate diagnosis and suggest possible evolution of disease. Intuitively in
aged persons, these roles harbour an enhanced meaning and should be carefully
weighed together with outcome predictors.
13.3.2 Complicated Diverticular Disease
In general, of patients with diverticula, 80–85% remain asymptomatic, while, for unknown
reasons, only three-fourths of the remaining 15–20% of patients develop symptomatic
diverticular disease comparatively. It is estimated that 10–30% of patients with diverticulosis will suffer from complications such as diverticulitis and gastrointestinal bleeding, and
the associated mortality is estimated at 23,600 deaths per year in Europe [20].
Elderly patients are traditionally thought to be most commonly affected not only
by diverticulosis but also by diverticular disease and its complications. The increased
risk of diverticulitis, of its septic complications and bleeding in the elderly has been
associated with several factors inherent to physiologic changes, comorbidities and
chronic medical treatments typical of advanced age.
Moreover, older patients with diverticulitis and complications are at a higher risk
of poor outcome [6]. Even if in several studies the impact of age may have been
confounded by comorbidity, a large population study, based on the English “Hospital
Episode Statistics” database between 1996 and 2006, has demonstrated that age per
se is an important predictor of mortality, extended length of stay and early readmission [21]. More specically, the authors showed that the largest number of admissions was in the 70–79 age group, but the worst outcomes were in the oldest over 80
patients. Further independent predictors of poor outcomes were comorbidity, as
measured by the Charlson Index, emergency admission and emergency surgery. The
authors concluded that these factors should be identied, allowing management
modication to optimize outcomes. Another population study in Olmsted County,
Minnesota, found that among people with diverticulitis, the risk of death was greater
in older people (HR per decade 2.12; 95% CI, 2.00–2.25, p<0.001) [
In accordance with the overall risk of mortality of older patients with diverticulitis, emergent colorectal surgery in the elderly is associated with signicant morbidity and mortality [22]. In octogenarians, up to sixfold higher mortality rate has
been reported after emergency colorectal surgery [23]. According to these studies,
identication of high-risk individuals, aggressive resuscitation and prompt treatment may help in optimizing the outcome of elderly patients undergoing emergency
colorectal surgery.
6].
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