Prevalence and distribution of the colonic diverticulosis. Review of 417 cases from Lower Silesia in Poland.
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The prevalence of colonic diverticulosis increases with age and is the most common pathology of the large bowel in the elderly. Studies of the frequency of colon diverticulosis are performed in necroptic, radiological and endoscopic surveys.The assessment of the prevalence and distribution of colonic diverticulosis evaluated with barium enemas.1,912 consecutive barium enemas examinations, performed between 1999-2002 were reviewed. The patients were 1,228 females and 684 males (mean age 55.4 yrs).Diverticula were observed in 21.7 percent (417) of the patients (279 females /mean age 64.1/ and 138 males /mean age 64.5 yrs). The prevalence of diverticulosis among females was 22.7 percent and among males 20.2 percent. The frequency of diverticulosis in patients aged 30-39 years was 5.3 percent, 40-49 years - 8.7 percent, 50-59 years - 19.4 percent, 60-69 years - 29.6 percent, 70-79 years - 40.2 per cent, and in those aged over 80 years it was 57.9 percent.Diverticular disease of the colon is a significant problem in elderly patients, both females and males. The most common occurrence is in the sigmoid and descending colon.Keywords:
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Part I Diverticulosis and diverticulitisDiverticular disease of the colon is a common cause of morbidity among many western races, and, being especially a disease of the elderly, is becoming a problem of increasing magnitude.Abdominal symptoms are common in this age group, and in the absence of evidence of other disease, the finding of diverticula on x-ray examination is prone to lead to a diagnosis of 'diverticulitis'.The frequency with which such an association is a chance one, without causal relationship, would depend on the incidence of diverticulosis in the normal population.It is probable that the present safety of colonic surgery is the major reason for a tendency to treat diverticular disease by resection at an early stage, for there has been little work reported on the natural history of the disease when treated con- servatively to prove that routine surgical excision is justified.The work which has been reported suggests that the disease is not as inexorable in its progress to serious complications as much surgical literature implies (Bolt and Hughes, 1966; Horner, 1958).Detailed studies of the pathology of diverticular disease are also surprisingly few, considering its importance as a cause of morbidity, while very little indeed is known of its aetiology.Deficiences in knowledge of aetiology and basic pathology make rational treatment difficult.This, together with the tendency to frequent diagnosis and radical therapy, may readily lead to overtreatment.This work has been carried out to determine the incidence of diverticula and associated pathology in Queensland, to attempt to assess the relationship of diverticula to symptoms, and to seek any evidence which may throw light on the aetiology of this condition. MATERIALS AND METHODSeach of 100 consecutive colons, the first taken during winter and the second during summer.The colons in this series were fixed in the undistended state, and all personally examined 24 to 48 hours after fixation.The mesentery and associated fat was dissected from the left colon, and the bowel carefully examined from internal and external aspects for the presence of diver- ticula.In this way small diverticula 2 to 3 mm in diameter were readily found.The colon and pericolic tissues were carefully examined for signs of recent or old infection, and sections were taken from such areas for histological study.Among details routinely recorded during necropsies at this hospital are the presence or absence of gallstones, an assessment of the degree of atheroma of the aorta, and the thickness of the subcutaneous fat at the umbilicus.These details were taken from the postmortem records for correlation with the presence of diverti- cula.The clinical records of all patients were studied to determine the cause of death and the presence of coexistent disease, including hypertension, and the presence of bowel symptoms at the time of admission or as recorded in the past history.INCIDENCE AND RESULTS INCIDENCE OF DIVERTICULA IN THE COLON Diverticula were found in 90 of the 200 colons (Table I).TABLE I
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Diverticular disease imposes an impressive clinical burden to the United States population, with over 300,000 admissions and 1.5 million days of inpatient care annually. Consensus regarding the treatment of diverticulitis has evolved over time, with increasing advocacy of primary anastomosis for acute diverticulitis, and nonoperative treatment of recurrent mild/moderate diverticulitis. We analyzed whether these changes are reflected in patterns of practice in a nationally-representative patient cohort.We used the 1998 to 2005 nationwide inpatient sample to analyze the care received by 267,000 patients admitted with acute diverticulitis, and 33,500 patients operated electively for diverticulitis. Census data were used to calculate population-based incidence rates of disease and surgical treatment. Weighted logistic regression with cluster adjustment at the hospital level was used for hypothesis testing.Overall annual age-adjusted admissions for acute diverticulitis increased from 120,500 in 1998 to 151,900 in 2005 (26% increase). Rates of admission increased more rapidly within patients aged 18 to 44 years (82%) and 45 to 74 years (36%). Elective operations for diverticulitis rose from 16,100 to 22,500 per year during the same time period (29%), also with a more rapid increase (73%) in rates of surgery for individuals aged 18 to 44 years. Multivariate analysis found no evidence that primary anastomosis is becoming more commonly used.We are the first to report dramatic changes in rates of treatment for diverticulitis in the United States. The causes of this emerging disease pattern are unknown, but certainly deserve further investigation. For patients undergoing surgery for acute diverticulitis, there was little change over time in the likelihood of a primary anastomosis.
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Diverticulosis of the right colon has been increasing in the Far East; however, a considerable proportion of these patients includes cases of solitary right-sided diverticular disease. This study aimed to determine whether the incidence of such solitary diverticula (defined as 1 or 2 diverticula in this study) and multiple (3 or more) diverticula of the right colon is increasing in Japan.A total of 13,947 consecutive barium enema examinations, performed in the period from 1982 to 1997, were reviewed. Changes in the frequency (detection rate) and number of diverticula across time and with aging of three types of diverticula, right-sided, left-sided, and bilateral, were investigated, with special interest in those patients with one or two diverticula of the right colon.Right-sided and bilateral diverticula have increased in frequency across time; however, left-sided diverticula have not. Patients with one or two diverticula in the right colon of right-sided disease, unexpectedly, have increased across time in both genders, and patients with three or more diverticula in the right colon of right-sided disease have shown an increase in males. The number of diverticula of the right colon showed no increase across time or with aging.Diverticulosis of the right colon, both solitary and multiple, has been increasing steadily in Japan; therefore, diverticulitis and bleeding diverticula of the right colon may continue to increase. Diverticula of the right colon might be an acquired disease and self-limiting in development, because the frequency did not increase substantially in the elderly and because the number changed little across time and with aging.
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BACKGROUND: Diverticular disease is one of the most common gastrointestinal conditions affecting the Canadian population, yet very little is known about its epidemiology. OBJECTIVE: The aim of the present study was to measure the rate of hospital admission for diverticular disease by age and sex over a 14-year period in the population of Ontario. PATIENTS AND METHODS: The present study was a retrospective, population-based cohort study of all hospital admissions for diverticular disease from 1988 to 2002. RESULTS: There were 133,875 hospital admissions during the period. Admission rates increased with age, and women were admitted at higher rates than men across all age groups. CONCLUSION: Diverticular disease is an important cause of gastrointestinal morbidity. As the population ages, a rise in the incidence of diverticular disease can be anticipated. Future studies to explain sex difference in admissions are required.
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Purpose: Diverticular disease increased steadily concomitant with elevated rates of overweight and obesity during the 20th century. Therefore, the objective of this study was to investigate whether overweight and obesity in midlife predict future diverticular disease in men. Methods: This was a prospective cohort study of a general population of men living in Göteborg, Sweden. A community-based sample of 7,494 men, investigated when aged 47 to 55 years, were followed from baseline in 1970 to 1973 for a maximum of 28 years. Hospitalization with a discharge diagnosis of diverticular disease according to the Swedish hospital discharge register was measured. Results: Totally, 112 men (1.5 percent) were hospitalized with diverticular disease. A relationship between body mass index and diverticular disease was demonstrated; men with a body mass index between 20 and 22.5 kg/m2 had the lowest risk. After adjustment for covariates, the risk increased linearly in men who had a body mass index of 22.5 to 25 (multiple-adjusted hazard ratio, 2.3; 95 percent confidence interval, 0.9-6; 25-27.5 (hazard ratio, 3 (1.2-7.6)), 27.5-30 (hazard ratio 3.2, (1.2-8.6)), and 30 or greater (hazard ratio 4.4, (1.6-12.3)) kg/m2 (P for linear trend = 0.004). Men with a body mass index of ≤20 kg/m2 had a nonsignificantly elevated risk (hazard ratio, 3 (0.7-12.5)). Smoking (hazard ratio, 1.6 (1.1-2.3) and diastolic blood pressure (hazard ratio, 1.02 (1.01-1.04) per mmHg) also were independently related to risk of diverticular disease. Conclusions: In a large community-based sample of middle-aged men, overweight and obesity were strongly linked to future severe diverticular disease leading to hospitalization.
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Diverticula occur as a result of mucosa and submucosa herniation through the muscular layer of the colonic wall. Diverticulosis refers to the presence of one or more diverticula, and the disease has a clinical spectrum from asymptomatic to symptomatic disease with potentially lethal complications (Figure 1). Diverticula may be distributed throughout the colon but are most frequently located in the sigmoid colon, i.e. the distal loop of the colon approximately 20–60 cm from the anal verge. Endoscopic and radiological aspects of colonic diverticulosis. Symptomatic diverticular disease may include patients with chronic abdominal pain and diverticulosis, without evident infection or inflammation. The most common and significant complications include both diverticular bleeding and diverticulitis, the latter being responsible for the occurrence of peritonitis, fistulae and abscesses. It may also be responsible for colonic strictures. Although colonic diverticulosis is a very frequent condition, complications occur in a limited subset of patients. Diverticular disease is commonly found in developed countries, slightly more frequently in the USA than in Europe, and is a rare condition in Africa (Table 1). The prevalence is largely age-dependent and is uncommon (a prevalence of 5%) in those under the age of 40 years, increasing up to 65% in those aged 65 years or more.1, 2 In a French study published in 1986 that was based on barium enemas, the prevalence of colonic diverticulosis increased regularly with age, and progression appeared to be more rapid after the age of 60 years, although it must be pointed out that the number of patients in these older age groups was larger than in younger groups (Figure 2).2 Progression of colonic diverticulosis prevalence according to age. The true prevalence of diverticulosis is difficult to define as most individuals are asymptomatic. Necropsy series may overestimate the frequency of diverticula as they are performed in older age groups. Barium radiological studies and more recently, endoscopic series could also overestimate their frequency, as included subjects may have been referred because of gastrointestinal symptoms. Studies performed in western European countries are shown in Table 2. Prevalence appears to be quite homogenous throughout Europe, without a geographical gradient. Discrepancies between the studies reviewed here are mainly explained by differences in methodology and sampling size. They all concur that increasing age and European nationality are associated with increasing prevalence. Moreover, some indication is available that the prevalence of colonic diverticulosis is increasing over time throughout the world. The earliest autopsy and barium enema series date from the 1920s to 1940s, and report rates of 0.6–15%, while more recent studies describe a rate of up to 40–60% in those over the age of 70 years. Whether this is due to increased numbers of older individuals in the population, increased screening or a true rise in the prevalence is not known.11–13 Although diverticulosis increases with age, there seems to be no clear progression of the extent of colon affected or acceleration from asymptomatic to symptomatic disease over time. In a radiological study, Horner did not show any progression of the disease over a 4–5-year interval in 183 patients.16 Furthermore, uncomplicated diverticular disease is not associated with any specific symptoms and may coexist with undiagnosed functional bowel disorders.17 Few studies have evaluated the progression from uncomplicated to complicated diverticular disease. Lower gastrointestinal bleeding (occurring in about 5–15% of patients with colonic diverticula) and infection, resulting in abcesses, peritonitis and perforation, (occurring in about 15–20%), are the most frequent complications. Complications tend to appear more frequently in elderly patients, and represent a large portion of those admitted for diverticular disease. In an American survey, the rate of admissions correlated with increasing age, from 238/100 000 in patients aged 65–69 years to 631/100 000 for those aged > 85 years.18 In a recently published British study, the yearly incidence of perforation of colonic diverticula was 4/100 000, with a slightly higher rate in men than in women.19 The use of nonsteroidal anti-inflammatory drugs was frequently associated with the occurrence of a perforation. The outcomes in patients admitted for a complication of colonic diverticular disease has been examined in a British study; 76.3% had diverticulitis and 13.3% had lower gastrointestinal bleeding.20 The overall mortality rate was 11.3%, and 90% of bleeding cases and 75% of infectious complications were treated nonoperatively. Five-year follow-up on approximately half of the surviving patients revealed that 1% died from recurrent diverticular disease and one-third remained symptomatic.21 In another British study, 31.7% of patients admitted with complicated diverticular disease required surgery, with a post-operative mortality rate of 12%.22 In a series of 296 consecutive patients admitted with diverticulitis documented with computed tomography, 29% were operated on during their first episode and recurrence occurred in 20% during a 5-year follow-up.23 Diverticular disease has been increasingly recognized as a clinical entity over the last century and, as the population ages, it appears to be increasing in both asymptomatic and symptomatic presentations. Europe, like other industrialized areas in the world, is characterized by a high prevalence of the disease, which increases with age and represents a significant risk to health with subsequent indications for healthcare expenditure in the elderly population. No statistics are currently available on the clinical and financial burden of the condition in European countries. However, referring to a mathematical model used in the 1980s in the USA, where the prevalence of the disease is similar to Europe, it is possible to compile the available epidemiological data and calculate the possible burden of diverticular diseases in Europe (Table 3).24 In the US survey published in 1980, diverticulosis affected 30 million Americans, annually bringing 200 000 to the hospital and incurring healthcare costs of US$300 million per annum. The differences in healthcare systems across European countries preclude such an estimate for the European Union as a whole. Nevertheless, the impressive figures in Table 3 demonstrate that diverticular disease is the source of significant healthcare costs because its complications occur more frequently in elderly patients, and that it deserves a higher priority than it has received to date. Epidemiological studies and the geographical distribution of the disease both suggest that a high fibre intake could play a protective role. In a study comparing a group of vegetarians and controls, fibre intake was double in vegetarians (41.5 ± 12.6 g/day) than in controls (21.4 ± 8.2 g/day). The prevalence of diverticulosis was significantly lower in vegetarians (12%) than in controls (33%).25 In a prospective cohort study of 43 881 American male health professionals, the intake of the insoluble component of fibre was significantly correlated with a decreased risk of symptomatic diverticular disease (relative risk 0.63; confidence interval 0.44–0.9), and this inverse correlation was particularly strong for cellulose.26 The question may thus be posed: may we not prevent diverticular disease with a high-fibre diet? There are many factors that interfere in epidemiological and nutritional studies, so that a high-bulk diet cannot be recommended for everyone. Moreover, as shown by the study in US professionals, the type of fibre is of importance. However, in symptomatic uncomplicated diverticular disease, several studies demonstrated that a high-fibre diet is beneficial. Furthermore, a British study suggests that among those who already have diverticula, complications and recurrences of diverticulitis are reduced on such a diet.27 It does seem reasonable therefore to recommend a high-fibre diet to those who have symptomatic uncomplicated diverticular disease or those who have suffered a complication in the past. Healthcare costs are higher in these groups of patients and justify the use of intervention. Diverticulosis is extremely prevalent across Europe. Symptomatic disease and complications associated with the condition increase with increasing age. The ageing population in the European Union may account for the apparent increase in prevalence observed in recent times. However, additional factors such as diet may be involved. As with most diseases, prevention is better than cure. There is evidence to show that increasing the proportion of insoluble fibre in diets may prevent disease development and its complications, which account for significant morbidity in European populations.
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Diverticular disease emerged as a common problem in Western countries over the course of the 20th century.To determine the time trends in diverticular disease for hospital admissions in England between 1989/1990 and 1999/2000 and population mortality rates from 1979 to 1999.Hospital Episode Statistics were obtained from the Department of Health and mortality data from the Office for National Statistics.Between 1989/1990 and 1999/2000, annual age-standardized hospital admission rates for diverticular disease increased by 16% for males (from 20.1 to 23.2 per 100,000) and 12% for females (from 28.6 to 31.9 per 100,000). Female rates were significantly higher than male rates throughout the study period. The proportions of admissions with an operation increased by 16% for males (from 22.9% to 24.1%) and 14% for females (from 19.7% to 22.3%). Older patients were less likely to undergo operation than younger patients. In-patient case fatality rates and population mortality rates remained unchanged.Admission rates for diverticular disease increased over the study period. The proportion of patients who underwent operation increased, but in-patient and population mortality rates remained unchanged. With an ageing population, diverticular disease will become an increasingly important clinical problem in England.
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