Indications: Complicated DD after 6/52 Suspicion of malignancy on imaging Other red flags

Literature Risk of malignancy after radiologically- proven uncomplicated diverticulitis is low, and in the absence of other indications, routine colonoscopy may not be necessary. Selective approach based on higher risk features need to be considered e.g. Abscess, localised lymphadenopathy, relative absence of diverticula, mass effect, perforation, more than one site of inflammation or “fat stranding” Diverticular complications e.g. abscess/fistula are at higher risk of malignancy than those with uncomplicated diverticulitis- THESE NEED COLONOSCOPY Sharma P et al. Systematic review and meta-analysis of role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014 Brar MS et al. Colonoscopy following non-operative management of uncomplicated diverticulitis may not be warranted. DCS 2013

Literature “Diverticulitis did not increase the risk of being diagnosed with colorectal Cancer in the long term, and that the increased risk within 12 months of diverticulitis may be due to mis-classfication and increased surveillance” Granlund J et al. Diverticular disease and risk of colon cancer- Aliment Pharmacol Ther 2011

But…. Referral for colonoscopy should occur in patients with risk factors who present after uncomplicated diverticulitis: FOBT+ First-degree relative with CRC before age 55 2 first-degree or one-first degree and one second-degree relative with CRC Abnormal CT colonography

Risk of malignancy Risk of malignancy in uncomplicated DD: 0.7% Risk of malignancy in complicated DD: 10.8% Sharma P et al. Systematic review and meta-analysis of role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014

Literature “Diverticulitis did not increase the risk of being diagnosed with colorectal Cancer in the long term, and that the increased risk within 12 months of diverticulitis may be due to mis-classfication and increased surveillance” Granlund J et al. Diverticular disease and risk of colon cancer- Aliment Pharmacol Ther 2011

But…. Referral for colonoscopy should occur in patients with risk factors who present after uncomplicated diverticulitis: FOBT+ First-degree relative with CRC before age 55 2 first-degree or one-first degree and one second-degree relative with CRC Abnormal CT colonography

Role of fibre Consumption of high fibre diet was associated with lower risk of hospital admissions and death from DD Conclusion: Inconsistent data but there is some benefit to increased fibre intake in the reduction of DD complications AGA guidelines: recommend high dietary fibre intake in patients with history of acute diverticulitis Crowe et al. Source of dietary fibre and diverticular disease incidence. GUT 2014 Low dietary fibre intake results in higher intra-colonic pressures which leads to higher DD rates--- CONTROVERSIAL No association between dietary fibre intake and risk of diverticulosis Peer et al. A high fibre diet does not protect against asymptomatic diverticulosis. Gastroenterology 2012

Consumption of fruits and vegetables is associated with 30% reduced risk of DD Higher level of cellulose High intake of cereals is not associated with risk of hospitalization for DD 8.5g/day of extra fibre needed E.g. apple/orange 3g fibre

MEAT Red meat intake- associated with increased risk of diverticulitis Substitution of poultry or fish for one serving of red meat decreases risk by 20%

Patients with uncomplicated DD had statistically significantly higher serum Vitamin D levels compared with patients who required hospitalization with diverticulitis Maguire LH et al. Higher serum levels of vitamin D are associated with a reduced risk of diverticulitis. Clin Gastroenterol Hepatol 2013

Diet Veggies and Fruit are good for you  Cereals…not so much Nuts/Seeds…?? High fibre diet- good Red meat- not that great  Fish and Chicken- better for you Vitamin D: Good

Role of Abs in acute diverticulitis ? Abs have been cornerstone of acute diverticulitis treatment for decades Why? Obstruction of diverticulum Mucosal abrasions Micro-perforation Bacterial translocation

And now?? Inflammatory process? 2 RCT’s No benefit for the use of antibiotics in the management of some patients with uncomplicated diverticulitis RCT 1: No statistical difference in outcome with/out ABS in uncomplicated diverticulitis ABS to be used in complicated disease only Chabok et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis Br J Surg 2012

No prolongation of recovery time in those treated without ABS DIABOLO RCT 2: Trial of observation vs. Abs for 1st episode of CT prove uncomplicated diverticulitis No prolongation of recovery time in those treated without ABS No significant difference between observational group and AB group in terms of complicated diverticulitis, ongoing diverticulitis, recurrence, sigmoid resection, mortality and morbidity AGA guidelines: Selective use of ABS in acute uncomplicated diverticulitis Daniels et al. A multicentre randomized clinical trial investigating the cost-effectiveness of treatment strategies with or without antibiotics for uncomplicated acute diverticulitis. BMC Surg 2010

probiotics Systematic review 11 studies Positive trend in the reduction and/or remission of abdominal symptoms with the implementation of probiotics AGA guidelines: Recommend against the use of probiotics after acute uncomplicated diverticulitis due to limited data available

MEsalamine 3 Randomized, double blind, placebo-controlled MCT evaluating efficacy of Mesalamine in preventing diverticulitis No reduction in rate of diverticulitis recurrence or the number of patients requiring surgery Further 3 trials Conclusion: Mesalamine is not recommended for prevention of recurrent diverticulitis

Obesity Rates of DD increase with rates of Obesity Pathophysiology ill- defined ? Relation to changes in gut microbiome

exercise Decrease in diverticulitis and diverticular bleeding Only seen with vigorous activity such as running

Surgery Obstruction Fistula Recurrent diverticulitis Perforation-macro ? Malignancy Life threatening bleeding ?Stoma

Take home messages Dietary fibre decreases diverticular disease complications Nuts/Seeds/Corn- Probably OK AB use to be used in selective acute uncomplicated diverticulitis. But await further trials ! Colonoscopy should be performed 6 weeks post complicated diverticulitis Mesalamine and Probiotics do not work in reducing diverticular recurrence Physical activity is good Elective surgery- for complicated diverticular disease or recurrent episodes