Search

Case Report: A 43-year-old woman presented with a 3-week history of globus sensation and malaise. A computed tomography scan of her neck showed a large right paratracheal abscess secondary to an infected tracheal diverticulum. The patient was admitted under the ENT surgical team, and underwent incision and drainage of the abscess. There were no post-operative complications and she was discharged home after 2 days, on oral antibiotics., Conclusion: This case demonstrates that a tracheal diverticulum may become infected and present as a cervical abscess. To our knowledge, this is the fourth reported case in the international literature of abscess formation related to an infected tracheal diverticulum.

Background: The optimum biochemical or hematological marker to determine diagnosis and severity of acute diverticulitis has not been established. We aimed to compare the utility of hematological parameters in the diagnosis and severity of acute diverticulitis., Methods: Sixty-nine patients in diverticular disease (acute diverticulitis and diverticulosis subgroups) and 36 patients in control group were included in the study. The biochemical analysis performed at the time of diagnosis included white blood cell, mean platelet volume, neutrophil count, platelet count (PLT), C-reactive protein, and calculation of neutrophil count/lymphocyte and PLT/lymphocyte ratios. Patients in the diverticulitis group were divided into four stages according to the Hinchey classification based on abdominal CT findings., Results: The mean platelet-lymphocyte ratio in the diverticulitis and diverticulosis groups was significantly lower than that in the control group (p<0.05). The best sensitivity and specificity values to distinguish acute diverticulitis and diverticulosis were 63.64% and 72.22% for the neutrophil-lymphocyte ratio (NLR) at a cutoff value of 2.78 and above and 30.30% and 86.11% for the platelet-lymphocyte ratio at a cutoff value of 87.46 and above. The diagnostic accuracy rates to distinguish between the diverticulitis and the control groups that the best sensitivity and specificity values were found to be NLR at a cutoff value of 11.55 and above and 100% and 100% for the platelet-lymphocyte ratio at a cutoff value of 12.28 and above. The NLR values were significantly lower in patients with Hinchey Stage 1 disease than those in patients with Stages 2 and 3 disease (respectively, p=0.003 and p=0.006)., Conclusion: NLR and platelet-lymphocyte ratio can serve as useful biomarkers for the differential diagnosis and severity in acute diverticulitis.

Recent evidence showed that dietary habits play a role as risk factors for the development of diverticular complications. This systematic review aims to assess the effect of dietary habits in the prevention of diverticula complications (i.e., acute diverticulitis and diverticula bleeding) in patients with diverticula disease. PubMed and Scopus databases were searched up to 19 January 2021, 330 records were identified, and 8 articles met the eligibility criteria and were subjected to data extraction. The quality of the studies was evaluated by the Newcastle-Ottawa quality assessment form. No study meets the criteria for being a high-quality study. A high intake of fiber was associated to a decreased risk of diverticulitis or hospitalization due to diverticular disease, with a protective effect for fruits and cereal fiber, but not for vegetable fiber; whereas, a high red meat consumption and a generally Western dietary pattern were associated with an increased risk of diverticulitis. Alcohol use seemed to be associated to diverticular bleeding, but not to recurrent diverticulitis or diverticular complications. Further high-quality studies are needed to better define these associations. It is mandatory to ascertain the role of dietary habits for the development of recurrent acute diverticulitis and diverticular bleeding.

The authors reviewed the main researches devoted to pathophysiological mechanisms and international classification of diverticulitis, analyzed multiple-center retrospective and randomized prospective studies. Modern diagnostic and therapeutic approaches, certain unsolved problems in indications for surgeries and their technique, as well as the role of surgical interventions in prevention of recurrences and severe complications of diverticulitis are demonstrated.

Objectives: Most diverticulitis patients (80%) who are referred to secondary care have uncomplicated diverticulitis (UD) which is a self-limiting disease and can be treated at home. The aim of this study is to develop a diagnostic model that can safely rule out complicated diverticulitis (CD) based on clinical and laboratory parameters to reduce unnecessary referrals., Methods: A retrospective cross-sectional study was performed including all patients who presented at the emergency department with CT-proven diverticulitis. Patient characteristics, clinical signs and laboratory parameters were collected. CD was defined as > Hinchey 1A. Multivariable logistic regression analyses were used to quantify which (combination of) variables were independently related to the presence or absence of CD. A diagnostic prediction model was developed and validated to rule out CD., Results: A total of 943 patients were included of whom 172 (18%) had CD. The dataset was randomly split into a derivation and validation set. The derivation dataset contained 475 patients of whom 82 (18%) patients had CD. Age, vomiting, generalized abdominal pain, change in bowel habit, abdominal guarding, C-reactive protein and leucocytosis were univariably related to CD. The final validated diagnostic model included abdominal guarding, C-reactive protein and leucocytosis (AUC 0.79 (95% CI 0.73-0.84)). At a CD risk threshold of ≤7.5% this model had a negative predictive value of 96%., Conclusion: This proposed prediction model can safely rule out complicated diverticulitis. Clinical practitioners could cautiously use this model to aid them in the decision whether or not to subject patients to further secondary care diagnostics or treatment.

Diverticular disease accounts for approximately 300,000 hospitalizations per year in the United States, resulting in 1.5 million days of inpatient care. Diverticulitis is defined as an inflammation of the diverticulum, which can be asymptomatic or symptomatic. This disease is the third most common gastrointestinal illness that requires hospitalization and the leading indication for elective colon resection. Abdominal pain is the most common complaint in patients with acute diverticulitis. The pain can be described as cramping, constant, and persistent for several days. Medical management is most often provided with antibiotics and clear liquid diet., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Colostomy reversal after Hartmann's procedure for diverticulitis is a morbid procedure, and studies investigating factors associated with outcomes are lacking. This study identifies patient, surgeon, and hospital-level factors associated with perioperative outcomes after stoma reversal., Methods: The Statewide Planning and Research Cooperative System was queried for urgent/emergency Hartmann's procedures for diverticulitis between 2000-2012 in New York State and subsequent colostomy reversal within 1 year of the procedure. Surgeon and hospital volume were categorized into tertiles based on the annual number of colorectal resections performed each year. Bivariate and mixed-effects analyses were used to assess the association between patient, surgeon, and hospital-level factors and perioperative outcomes after colostomy reversal, including a laparoscopic approach; duration of stay; intensive care unit admission; complications; mortality; and 30-day, unscheduled readmission., Results: Among 10,487 patients who underwent Hartmann's procedure and survived to discharge, 63% had the colostomy reversed within 1 year. After controlling for patient, surgeon, and hospital-level factors, high-volume surgeons (≥40 colorectal resections/yr) were independently associated with higher odds of a laparoscopic approach (unadjusted rates: 14% vs 7.6%; adjusted odds ratio = 1.84, 95% confidence interval = 1.12, 3.00), shorter duration of stay (median: 6 versus 7 days; adjusted incidence rate ratio = 0.87, 95% confidence interval = 0.81, 0.95), and lower odds of 90-day mortality (unadjusted rates: 0.4% vs 1.0%; adjusted odds ratio = 0.30, 95% confidence interval = 0.10, 0.88) compared with low-volume surgeons (1-15 colorectal resections/yr)., Conclusion: High-volume surgeons are associated with better perioperative outcomes and lower health care utilization after Hartmann's reversal for diverticulitis. These findings support referral to high-volume surgeons for colostomy reversal., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Killian-Jamieson diverticulum (KJD) is a pharyngoesophageal diverticulum that can be observed during a neck ultrasound examination. Because of its position, it is frequently misinterpreted as a thyroid nodule. We present a case of an incidental finding of KJD, where changes in shape during dynamic scanning led to the correct diagnosis, preventing from invasive procedures such as fine needle aspiration., Competing Interests: The authors have no conflict of interest. Informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. All patients provided written informed consent for enrolment in the study and for the inclusion in this article of information that could potentially lead to their identification. Human and animal studies The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.

Background: The aim of the present study was to report the trajectory of heart rate variability (HRV) indices during a low-grade acute inflammation and their associations to biomarkers for infection., Methods: Twelve patients with uncomplicated acute diverticulitis completed this observational study, which composed of 3 sessions of continuous HRV recording from 9 PM to 8 AM during ongoing diverticulitis and at complete remission (baseline). The blood samples were collected at each study session measuring C-reactive protein (CRP) and leukocytes., Results: This study showed that the trajectories of the HRV indices were decreased both in time and frequency domains during acute diverticulitis compared to baseline. In particular, the indices reflecting the balance of sympathetic and parasympathetic activities were affected: standard deviation of normal-to-normal beats (P = .003), low-frequency power (P < .001), and total power (P = .001). These HRV changes indicate alterations in the autonomic nervous system during acute inflammation. All reductions of mean HRV indices had significant (P < .001) correlations to increased CRP correlations to increased CRP levels during diverticulitis suggesting inflammatory involvement in the observed HRV alterations., Conclusion: We found substantial HRV depression in relation to acute uncomplicated diverticulitis, and this was associated with the elevated CRP levels., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The decision whether to operate for diverticular disease and the appropriate selection of right candidates for elective colectomy after recovery from an uncomplicated episode of acute diverticulitis remains controversial. Although both the impact of symptomatic disease and occurrence of its complications are extensively studied, there is no consensus about the role of elective colonic resection in the management of symptomatic recurrent diverticulitis. In this study, the database of ERIC, the Web of Science, EMBASE, and MEDLINE were searched for the English-language published articles about the functional outcomes and symptomatic improvement in patients after elective surgery for diverticular disease. A majority of clinical trials showed that elective surgery following a successful conservative treatment of acute diverticulitis resulted in significantly better social and functional well-being. In addition, elective surgery greatly reduces the potential events of disease recurrence, thus decreasing financial burden on the national health services. However, to obtain the best functional outcome surgical intervention must be individualized and tailored to meet every single patient's specific indigenous symptomatology.

Acute diverticulitis is a common disease with increasing incidence. In most of cases, diagnosis is made at an uncomplicated stage offering a curative attempt under medical treatment and use of antibiotics. There is a risk of diverticulitis recurrence. Uncomplicated diverticulitis is opposed to complicated forms (perforation, abscess or fistula). Recent insights in the pathophysiology of diverticulitis, the natural history, and treatments have permitted to identify new treatment strategies. For example, the use of antibiotics tends to decrease; surgery is now less invasive, percutaneous drainage is preferred, peritoneal lavage is encouraged. Treatments of the diverticulitis are constantly evolving. In this review, we remind the pathophysiology and natural history, and summarize new recommendations for the medical and surgical treatment of acute diverticulitis., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Aim: To evaluate the impact of mesalamine administration on inflammatory response in acute uncomplicated diverticulitis., Methods: We conducted a single centre retrospective cohort study on patients admitted to our surgical department between January 2012 and May 2014 with a computed tomography -confirmed diagnosis of acute uncomplicated diverticulitis. A total of 50 patients were included in the analysis, 20 (study group) had received 3.2 g/d of mesalamine starting from the day of admission in addition to the usual standard treatment, 30 (control group) had received standard therapy alone. Data was retrieved from a prospective database. Our primary study endpoints were: C reactive protein mean levels over time and their variation from baseline (ΔCRP) over the first three days of treatment. Secondary end points included: mean white blood cell and neutrophile count over time, time before regaining of regular bowel movements (passing of stools), time before reintroduction of food intake, intensity of lower abdominal pain over time, analgesic consumption and length of hospital stay., Results: Patients characteristics and inflammatory parameters were similar at baseline in the two groups. The evaluation of CRP levels over time showed, in treated patients, a distinct trend towards a faster decrease compared to controls. This difference approached statistical significance on day 2 (mean CRP 6.0 +/- 4.2 mg/dL and 10.0 +/- 6.7 mg/dL respectively in study group vs controls, P = 0.055). ΔCRP evaluation evidenced a significantly greater increment of this inflammatory marker in the control group on day 1 (P = 0.03). A similar trend towards a faster resolution of inflammation was observed evaluating the total white blood cell count. Neutrophile levels were significantly lower in treated patients on day 2 and on day 3 (P < 0.05 for both comparisons). Mesalamine administration was also associated with an earlier reintroduction of food intake (median 1.5 d and 3 d, study group vs controls respectively, P < 0.001) and with a shorter hospital stay (median 5 d and 5.5 d, study group vs controls respectively, P = 0.03)., Conclusion: Despite its limitations, this study suggests that mesalamine may allow for a faster recovery and for a reduction of inflammatory response in acute uncomplicated diverticulitis.

Background: Immunosuppression could increase the complication rate in patients with acute diverticulitis. This would justify a low threshold for elective sigmoid resection in these patients after an episode of diverticulitis. Well-documented groups of immunocompromised patients are transplant patients, in which many prospective studies have been conducted., Objectives: The aim of this systematic review is to assess the incidence of complicated diverticulitis in post-transplant patients., Data Source: We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases for papers published between January 1966 and January 2014., Study Selection and Intervention: Publications dealing with post-transplant patients and left-sided diverticulitis were eligible for inclusion. The following exclusion criteria were used for study selection: abstracts, case-series and non-English articles., Main Outcome Measures: Primary outcome measure was the incidence of complicated diverticulitis. Secondary outcome was the incidence of acute diverticulitis and the proportion of complicated diverticulitis. Pooling of data was only performed when more than five reported on the outcome of interest with comparable cohorts. Only studies describing proportion of complicated diverticulitis and renal transplant studies were eligible for pooling data., Results: Seventeen articles met the inclusion criteria. Nine renal transplant cohorts, four mixed lung-heart-heart lung transplant cohorts, two heart transplant cohorts, and two lung cohorts. A total of 11,966 post-transplant patients were included in the present review. Overall incidence of complicated diverticulitis in all transplantation studies ranged from 0.1 to 3.5%. Nine studies only included renal transplant patients. Pooled incidence of complicated diverticulitis in these patients was 1.0% (95% CI 0.6 to 1.5%). Ten studies provided proportion of complicated diverticulitis. Pooled incidence of acute diverticulitis in these studies was 1.7% (95% CI 1.0 to 2.7%). Pooled proportion of complicated diverticulitis among these patients was 40.1% (95% CI 32.2 to 49.7%). All studies were of moderate quality using the MINORS scoring scale., Conclusion: The incidence of complicated diverticulitis is about one in 100 transplant patients. Additionally when a transplant patient develops an episode of acute diverticulitis, a high proportion of patients have a complicated disease course.

Meckel's diverticulum results from a partial persistence of the omphalomesenteric duct and is the most common congenital anomaly of the gastrointestinal tract, affecting about 2% of the general population. Its presentation as a giant Meckel's diverticulum (>5 cm) is rare and is associated with major complications. We report a case of a 53 year-old woman with constipation for at least ten years. A colonoscopy from eight years ago suggested megacolon. The patient consults in the last month for abdominal pain associated with anorexia. The computed tomography scan image suggested an ileal megadiverticulum. An exploratory laparotomy revealed a saccular dilatation of the distal ileum of 6 x 15.5 cm, located 20 cm away from the ileocecal valve. We resected the involved segment of distal ileum and performed a manual ileo-ascendo anastomosis. The biopsy showed a saccular dilatation of the wall, lined by small intestinal mucosa with areas of gastric metaplasia, supporting the diagnosis of giant Meckel's diverticulum.

We present a case of a young boy with an unusual cause of right iliac fossa pain. His history, examination and laboratory investigations suggested a diagnosis of acute appendicitis. However preoperative abdominal CT revealed an inflamed solitary caecal diverticulum and a normal appendix. He was subsequently treated conservatively and recovered well, saving him from undergoing a general anaesthetic and abdominal surgery.

Background: Traditionally regarded as a disease of the elderly, the incidence of diverticulitis of the colon has been on the rise, especially in younger cohorts. These patients have been found to experience a more aggressive disease course with more frequent hospitalization and greater need for surgical intervention., Objective: To characterize factors that portend a poor prognosis in patients diagnosed with diverticulitis; in particular, to evaluate the role of demographic variables on disease course., Methods: Using the Canadian Institute for Health Information Discharge Abstract Databases, readmission rates, length of stay, colectomy rates and mortality rates in patients hospitalized for diverticulitis were examined. Data were stratified according to age, sex and comorbidity (as defined by the Charlson index)., Results: In the cohort ≤30 years of age, a clear male predominance was apparent. Colectomy rate in the index admission, stratified according to age, demonstrated a J-shaped curve, with the highest rate in patients ≤30 years of age (adjusted OR 2.3 [95% CI 1.62 to 3.27]) compared with the 31 to 40 years of age group. In-hospital mortality increased with age. Cumulative rates of readmission at six and 12 months were 6.8% and 8.8%, respectively., Conclusion: In the present nationwide cohort study, younger patients (specifically those ≤30 years of age) were at highest risk for colectomy during their index admission for diverticulitis. It is unclear whether this observation was due to more virulent disease among younger patients, or surgeon and patient preferences.

Diverticular disease imposes a significant burden on Western and industrialized societies. The traditional pathogenesis model posits that low dietary fiber predisposes to diverticulosis, and fecalith obstruction prompts acute diverticulitis that is managed with broad-spectrum antibiotics or surgery. However, a growing body of knowledge is shifting the paradigm of diverticular disease from an acute surgical illness to a chronic bowel disorder composed of recurrent abdominal symptoms and considerable psychosocial impact. New research implicates a role for low-grade inflammation, sensory-motor nerve damage, and dysbiosis in a clinical picture that mimics irritable bowel syndrome (IBS) and even inflammatory bowel disease (IBD). Far from being an isolated event, acute diverticulitis may be the catalyst for chronic symptoms including abdominal pain, cramping, bloating, diarrhea, constipation, and "post-diverticulitis IBS." In addition, studies reveal lower health-related quality of life in patients with chronic diverticular disease vs. controls. Health-care providers should maintain a high index of suspicion for the multifaceted presentations of diverticular disease, and remain aware that it might contribute to long-term emotional distress beyond traditional diverticulitis attacks. These developments are prompting a shift in therapeutic approaches from widespread antimicrobials and supportive care to the use of probiotics, mesalamine, and gut-directed antibiotics. This review addresses the emerging literature regarding epidemiology, pathophysiology, and management of chronic, symptomatic diverticular disease, and provides current answers to common clinical questions.

Background: In the intestine, the tachykinins substance P (SP) and neurokinin A (NKA) are found in neurons and have key roles in motility, secretion, and immune functions. A new tachykinin, hemokinin (HK-1), has been identified in non-neuronal cells in recent years and its role in intestinal inflammation is unclear. We aimed to examine the expression of genes encoding tachykinin peptides and receptors in colon from patients with ulcerative colitis (UC), Crohn's disease (CD), and acute diverticular disease (DD)., Methods: Human colon segments were dissected into mucosa and muscle, and evaluated for tachykinin and tachykinin receptor gene expression by real-time PCR., Key Results: In UC mucosa, the TAC4 gene (encoding HK-1) was 10-fold more abundant than in control mucosa (P < 0.01). Similarly, TAC1 (encoding SP and NKA) and TACR1 (encoding NK1 receptor) displayed 6-fold and 12-fold upregulation, respectively, in UC mucosa, but no change occurred in UC muscle. In contrast to UC, no difference was observed for any tachykinin genes in CD mucosa. In CD muscle, expression of TAC1 (P < 0.01), TAC4 and TACR1 (both P < 0.05) were moderately upregulated. In DD, there was a decrease in TACR1 (P < 0.05), and TACR2 (encoding NK2 receptor, P < 0.0001) in muscle compared with control. Histological staining showed increased collagen fibers between muscle bundles in DD smooth muscle., Conclusions & Inferences: We provide evidence for the first time that HK-1, like SP, may be involved in the pathophysiology of inflammatory bowel disease. Distinctly different expression patterns of tachykinin-related genes occur in UC, CD and DD., (© 2011 Blackwell Publishing Ltd.)

Background: Nonperforating appendicitis is primarily a disease of children, and nonperforating diverticulitis affects mostly older adults. Apart from these age differences, the diseases share many epidemiological features, such as association with better hygiene and low-fiber diets., Hypothesis: Nonperforating appendicitis and nonperforating diverticulitis are different manifestations of the same underlying colonic process and, if so, should be temporally related., Design: Data from the National Hospital Discharge Survey were analyzed to investigate the incidence of admissions for appendicitis in children and diverticulitis in adults between 1979 and 2006., Setting: Statistical sampling of all US hospitals., Patients: Children admitted for appendicitis and adults with diverticulitis., Main Outcome Measures: Time trends were assessed for stationarity using unit root analysis, and similarities between time trends were tested using cointegration analysis., Results: The incidence rates of nonperforating appendicitis and nonperforating diverticulitis exhibited U-shaped secular trends. The rates of perforating appendicitis and perforating diverticulitis rose slowly across all the study years. Cointegration analysis demonstrated that the rates of nonperforating and perforating diverticulitis did not cointegrate significantly over time. The rates of nonperforating and perforating appendicitis did not vary together. Nonperforating appendicitis and nonperforating diverticulitis rates were significantly cointegrated over time., Conclusions: Childhood appendicitis and adult diverticulitis seem to be similar diseases, suggesting a common underlying pathogenesis. Secular trends for their nonperforating and perforating forms are strikingly different. At least for appendicitis, perforating disease may not be an inevitable outcome from delayed treatment of nonperforating disease. If appendicitis represents the same pathophysiologic process as diverticulitis, it may be amenable to antibiotic rather than surgical treatment.

Diverticular disease is one of the most prevalent gastrointestinal conditions to afflict Western populations. Although the majority of patients with diverticulosis remain asymptomatic, about one third will develop symptoms at some point in their lives. Symptomatic diverticular disease can range from chronic mild gastrointestinal distress to acute bouts of diverticulitis complicated by abscess or frank colonic perforation. The mainstay of treatment of symptomatic diverticular disease has long been bowel rest, antibiotics, and pain control, reserving surgery for those with complicated disease. This review discusses the epidemiology, pathophysiology, clinical presentation, and management of the spectrum of diverticular disease, including recent advances in the treatment of chronic diverticular disease.

Colonic diverticulosis is a common, usually asymptomatic, entity of Western countries, with an incidence that increases with age. When these diverticula become infected and inflamed, patients can present with a wide variety of clinical manifestations. Management of acute, uncomplicated diverticulitis can often be treated successfully with antibiotics alone and the decision to proceed with more aggressive measures such as surgical intervention is made on a case-by-case basis. The treatment algorithm for diverticular disease continues to evolve as the pathophysiology, etiology, and natural history of the disease becomes better understood.

Some patients with colonic diverticula suffer recurrent abdominal pain and exhibit visceral hypersensitivity, though the mechanism is unclear. Prior diverticulitis increases the risk of being symptomatic while experimental colitis in animals increases expression of neuropeptides within the enteric nervous system (ENS) which may mediate visceral hypersensitivity. Our aim was to determine the expression of neuropeptides within the ENS in diverticulitis (study 1) and in patients with symptomatic disease (study 2). Study 1 - Nerves in colonic resection specimens with either acute diverticulitis (AD, n = 16) or chronic diverticulitis (CD, n = 16) were assessed for neuropeptide expression recording % area staining with protein gene product (PGP9.5), substance P (SP), neuropeptide K (NPK), pituitary adenylate cyclase activating polypeptide (PACAP), vasoactive intestinal polypeptide (VIP) and galanin. Study 2 - Seventeen symptomatic and 15 asymptomatic patients with colonic diverticula underwent flexible sigmoidoscopy and multiple peridiverticular mucosal biopsies. Study 1- Neural tissue, as assessed by PGP staining was increased to a similar degree in circular muscle in both AD and CD. The CD specimens showed significant increases in the immunoreactivity of SP, NPK and galanin in both mucosal and circular muscle layer compared with controls. Study 2 - Mucosal histology was normal and PGP9.5 staining was similar between groups however patients with symptomatic diverticular disease demonstrated significantly higher levels of SP, NPK, VIP, PACAP and galanin within the mucosal plexus. Patients with symptomatic diverticular disease exhibit increased neuropeptides in mucosal biopsies which may reflect resolved prior inflammation, as it parallels the changes seen in acute and chronic diverticulitis.

There are no controlled studies evaluating symptoms of diverticular disease or diverticulitis. Monitoring symptoms are reported repeatedly in research studies but yet an evaluation of the significance of recording these symptoms in a controlled study does not exist. The older literature was reviewed. The literature largely classifies the disease in stages, which are reviewed in this paper. Symptomatic uncomplicated diverticular disease and its evolution and the present literature on this are discussed.

The understanding of diverticulitis has advanced little beyond the initial postulates of Burkitt and Painter who proposed that diverticular disease results from a deficiency of dietary fiber. Diverticular disease and diverticulitis are viewed simply as a consequence of a diet, which takes in relatively little fiber. Our understanding of diverticulitis has not advanced beyond these basic concepts. As many as two-thirds of individuals in the West have diverticular disease by the age of 85 years, but only 10% to 25% will manifest any related clinical symptoms. Other than age, several risk factors have been identified for the development of diverticular disease and diverticulitis. In particular, obesity and red meat intake are risk factors. Smoking is more controversial and alcohol, coffee, and caffeine have not shown to be risk factors. Vegetable intake, a strict vegetable diet, and increased fiber intake decreases the risk of development of diverticular disease, as well as diverticulitis. Physical activity also seems protective. Despite these evidences, the risk factors and pathophysiology progression from asymptomatic diverticular disease to diverticulitis have been inadequately studied. This subject is reviewed in more detail in this manuscript.

Diverticular disease of the colon is a common civilisatory phenomenon. Its clinical relevance is defined by the typical manifestations diverticulitis (incl. its complications abscess formation and fistulation), diverticular bleeding, and chronic pain. Although clear evidence criteria are missing on many aspects of the therapy, there is broad consensus on the suitable diagnostics as well as conservative and surcigal therapy. Nevertheless, there remain open questions, and due to new data, several aspects have to be put up to discussion. As long as there are no mandatory evidence-based guidelines, in-house clinical standards should be developed in interdisciplinary working groups.

Objectives: Meckel diverticulum, a congenital gastrointestinal anomaly, is well studied in pediatrics, but less so in the adult population. At the Charleston Area Medical Center (CAMC), in addition to the removal of Meckel diverticula in symptomatic patients, diverticula are commonly removed when found incidentally during other procedures. We present our experience over the past ten years with this condition, unusual in the adult population., Methods: From 1992 to 2002 at the Charleston Area Medical Center, Meckel diverticula were removed from 47 patients older than 18 years of age. We reviewed the age, sex, indication for removal, pathologic findings, and perioperative complications of these cases., Results: Diverticula were removed most often from female patients (31 female, 66%; 16 male, 34%). The removal of the diverticulum was incidental in 35 patients (74.5%) and symptomatic in 12 (25.5% percent). Symptomatic patients presented with: obstruction (n = 4), acute bleeding (n = 1) and diverticulitis (n = 7). Female patients were significantly less likely than male patients to be symptomatic (4 of 31, 13% among females, and 8 of 16, 50% among males; P < 0.05). Heterotopic mucosa was identified in six patients, two of whom were symptomatic at the time of removal. Gastric mucosa was found in all six of the diverticula with ectopic mucosa, although one of the six had a mixed gastric and pancreatic cell population. One asymptomatic patient had a malignancy identified as a 1.5 cm carcinoid with no evidence of metastatic disease. An adenomyoma was found incidentally in one patient upon pathologic evaluation. Hospital complications that could possibly be attributed to removal of diverticula included two wound infections and two anastomotic leaks requiring exploration (8.5% morbidity). Complications were experienced by two asymptomatic females, one asymptomatic male, and a symptomatic male. There were no mortalities., Conclusions: Meckel diverticulum is found infrequently in the adult population. Adults rarely become symptomatic, but symptoms that do arise are associated with significant morbidity. Complications directly attributable to diverticulum removal are uncommon; however, those that do occur are often life threatening. Therefore, incidental removal of asymptomatic diverticula, particularly in women, is not recommended.

Diverticulitis involving the right colon is uncommon in the Occident; only one case for every 300 cases of appendicitis occurs in Western countries compared to a ratio of 1/40-1/180 in Asia. The preferential localization of diverticula in the right colon among Asiatics is probably due to genetic factors. In Asia as in the West, a right colon diverticulum is more likely to cause hemorrhage than diverticulitis. The peak age of symptoms is 40-45 years and the sex ratio is 1:1. The patient most commonly presents with symptoms suggestive of acute appendicitis, acute localized peritonitis, or, more rarely, a psoas abscess. Clinical exam reveals an inflammatory mass in the right lower quadrant in 30% of cases; diffuse peritonitis, large abscesses, and fistulae are rare. Helical CT scan is the best tool for establishing the diagnosis and also helps to rule out other possible etiologies in the differential diagnosis-particularly a perforated right colon cancer. In noncomplicated cases with convincing evidence for the diagnosis by CT scan, a conservative (non-surgical) treatment with antibiotics is possible; a later stage colonoscopy will rule out other colonic lesions. More commonly, the correct diagnosis is only made after embarking on an appendectomy via a McBurney incision; the surgical strategy thereafter depends on the level of suspicion regarding the diagnosis and the extent and complexity of the diverticulitis. Therapeutic options may be conservative (appendectomy), limited (diverticulectomy, or extensive (ileocecal resection or right hemicolectomy). For complicated disease (abscess, localized perforation), an aggressive surgical approach is warranted. Surgical strategies need to be validated, particularly in the light of the increasing use of the laparoscopic approach for suspected appendicitis.

Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment., (Copyright 2003 Wiley Periodicals, Inc.)

The characteristics of [(125)I]Bolton-Hunter[Sar(9),Met(O(2))(11)]substance P ([(125)I]BH-SarSP) binding were investigated in membranes of human ascending, transverse, distal, and sigmoid colon circular muscle. Binding of [(125)I]BH-SarSP was of high affinity (K(D) = 68 nM) and low capacity (B(max) = 0.31 fmol/mg of wet weight tissue), and showed no regional differences. [(125)I]BH-SarSP binding was inhibited by SP approximately equal to [Pro(9)]SP > or = (2S,3S)-3-(2-methoxybenzylamino)-2-phenylpiperidine (CP99994) >> neurokinin (NK) A > or = neuropeptide gamma > [Lys(5),MeLeu(9),Nle(10)]-NKA(4-10) approximately (S)-N-methyl-N[4-acetylamino-4-phenylpiperidino)-2-(3,4-dichlorophenyl) butyl]benzamide (SR48968) >> senktide, suggesting binding to NK-1 sites. Most agonists seemed to bind to two sites. In autoradiographic studies, dense binding for [(125)I]BH-SarSP was associated with submucosal and longitudinal muscle blood vessels, and the submucosal margin of circular muscle (corresponding to interstitial cells of Cajal), with moderate binding over most of the circular muscle. In normal colon circular muscle strips, [Pro(9)]SP was almost ineffective, and SP caused contractions with pD(2) values of 5.3 to 5.7. No regional differences were observed in potency or efficacy. Responses to SP were inhibited by the NK-2 receptor antagonist SR48968, but not by NK-1 antagonist CP99994, indicating the involvement of NK-2 rather than NK-1 receptors. Atropine significantly inhibited contractions induced by SP, indicating a minor cholinergic component. Contractile responses to SP were considerably reduced in preparations from patients with diverticular disease, and marginally reduced in ulcerative colitis compared with control. This study clearly demonstrates an NK-1 binding site on human colon circular muscle, but its role in this tissue remains unclear and may not involve contractile mechanisms. The attenuated contractility in specimens with diverticular disease may reflect disease-related alterations of the tachykinin receptor system.

Appendiceal diverticulitis as the etiology of right lower quadrant pain is an uncommon entity in younger populations. The incidence is <1 per cent among patients under 30 years of age undergoing appendectomy. Herein, we present a case of a 17-year-old male with perforated appendiceal diverticulitis. The history, physical findings, diagnosis, and treatment are outlined. Additionally the literature concerning appendiceal diverticulitis is reviewed.

A 49-year-old man was seen with an unusual complication of diverticulitis--a giant sigmoid diverticulum. This patient had undergone an extensive workup during a 5-year period, ranging from multiple extensive gastroenterology evaluations and procedures to an eventual psychiatric evaluation to rule out the possibility of a functional cause for his chronic, intermittent abdominal pain. Later, an accurate diagnosis of a giant sigmoid diverticulum resulted in an en bloc resection of the sigmoid colon and cyst. The patient had an uncomplicated recovery with no return of his previous symptoms. The authors review the many proposed causes of the giant sigmoid diverticulum and possible differential diagnoses. Initially, the diagnosis is usually missed as plain roentgenograms, upper and lower gastrointestinal x-ray studies, and computed tomography scans generally show no abnormality. Management methods are also discussed.

An epiphrenic diverticulum is usually accompanied by esophageal motor disorders, diaphragmatic hernia, or esophagitis. Symptoms are rarely attributable to the diverticulum except very rarely when no other explanation for dysphagia or chest pain is demonstrated. We describe acute esophageal obstruction from food accumulating in an epiphrenic diverticulum and compressing the gastroesophageal junction, and we confirm the mechanism with an artificial balloon.

Operations were performed on 30 patients with scarred constrictions of the distal portion of the choledochus and dilatation of the common bile duct with the clinical picture of mechanical jaundice and cholangitis. In none of the patients concrements were detected in the gallbladder and duct. The authors do not consider the peripheral diverticula to be the decisive factor in pathogenesis of cholelithiasis in this category of patients.

The effects of pentazocine on colonic motor activity were studied in five normal subjects, five patients with irritable bowel syndrome, and five patients with diverticular disease. The drug decreased intraluminal colonic pressures in all patients but one. Since morphine, which increases intraluminal colonic pressures, is contraindicated in patients with abdominal pain of colonic origin (diverticular disease, irritable bowel syndrome), we suggest that pentazocine may be a useful drug in such cases.