Proton Pump Inhibitor Use May Increase the Risk of Diverticulitis but Not It’s Severity among Patients with Colonic Diverticulosis: A Multicenter Study

Colonic diverticular disease, especially diverticulitis constitutes a major cause of hospitalization and an economic burden in developed countries. Proton pump inhibitors (PPIs) are among the commonest drugs used to treat several diseases affecting the upper gastrointestinal tract. A few studies have reported that the use of Proton Pump Inhibitors PPIs caused dysbiosis. In this study, we searched for a relationship between PPI use and the onset and severity of diverticulitis in patients with colonic diverticulosis. In a retrospective study, patients who were hospitalized for documented diverticulitis were enrolled as cases and compared with a control group of patients with uncomplicated diverticulosis. Overall, 613 patients who had a diagnosis of diverticulosis were included in the study, 217 of whom had diverticulitis. After multivariate analysis, the non-modifiable risk factors associated with diverticulitis included: age (p < 0.0001), hypertension (p < 0.0001), chronic renal failure (p = 0.007), diabetes mellitus (p < 0.0001), and left colon location (p = 0.02). However, among the modifiable factors, only PPI use (p < 0.0001) showed a significant association. Advanced disease severity (according to Hinchey classification of diverticulitis stages II–IV) was associated with aspirin use (p = 0.0004) and pan-colonic location (p = 0.02). PPI use was the only modifiable factor significantly associated with diverticulitis, but not with its severity, among patients with diverticulosis. This observation should be confirmed in future multicenter prospective studies.

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Are Correlated with Complicated Diverticulitis and Hinchey Classification: A Simple Tool to Assess Disease Severity in the Emergency Department

Background and Aim. Rapid identification of patients with complications related to acute diverticulitis who require urgent intervention in the emergency department (ED) is essential. The aim of our study was to determine the role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting severity of diverticulitis as assessed by Hinchey classification. Patients and Methods. We performed a single retrospective study in EMMS Nazareth Hospital from 4/2014 to 4/2018. Patients were categorized into two groups: group A with mild to moderate complicated diverticulitis (Hinchey 1-2) and group B with severe complicated diverticulitis (Hinchey 3-4). Results. Two hundred twenty-five patients were included. Two hundred seven patients were in group A, and 18 patients were in group B. On univariate analysis, age, NLR, and PLR correlated with advanced Hinchey classification and disease severity (stages 3-4) (OR 1.038, 95% CI 1.001–1.076, P=0.0416; OR 1.192, 95% CI 1.093–1.300, P<0.0001; and OR 1.011, 95% CI 1.005–1.017, P=0.0005, respectively). On multivariate logistic regression analysis, the NLR and PLR remain significantly correlated with Hinchey 3-4 (OR 1.174, 95% CI 1.071–1.286, P=0.0006, and OR 1.008, 95% CI 1.001–1.015, P=0.0209, respectively). The area under the curve (AUC) for the NLR and PLR on univariate analysis was 0.7526 and 0.6748, respectively, and 0.7760 and 0.7391 on multivariate logistic regression analysis, respectively, and receiver-operating characteristic (ROC) curves were drawn. Conclusion. The NLR and PLR independently associated with diverticulitis severity and positively correlated with advanced Hinchey classification. This simple available laboratory tool can be implemented into clinical practice to optimize patient management.

Diverticular disease

Diverticular disease prevalence increases with age with up to 70% in octogenarians. Diverticulitis can be uncomplicated or complicated. The Hinchey classification is used to categorize complicated diverticulitis and guides urgent treatment, which may range from antibiotics to laparotomy. Recommended investigations are outlined, as well as conservative treatment. Management of diverticular bleeding may be problematic and guidelines in this area are outlined including urgent colonoscopy, CT angiography, and therapeutic superselective mesenteric angiography.

Hinchey Classification of Acute Diverticulitis

This chapter provides a summary of a landmark historical study in surgery: the Hinchey classification of acute diverticulitis. It describes the history of the disease, gives a summary of the study including study design and results, and relates the study to a modern-day principle of evidence-based medicine: validation of scoring systems. Hinchey’s classification of diverticulitis has become the most widespread system and while the Hinchey score may currently have less clinical relevance as it did in his time, its publication and eventual adoption marked a practice-changing paradigm shift in the way diverticulitis is viewed and managed today.

Diverticulosis and Diverticulitis

Diverticular disease has been considered a disease of the elderly, but recently, an increased incidence has been noted in younger patients. Diverticulosis is asymptomatic; however, when symptomatic, it is referred to as diverticular disease. When associated with any inflammation, it is diverticulitis. Diverticulitis is an acute illness, but symptoms may become chronic with recurrent episodes. When mucosal inflammation is present, segmental colitis associated with diverticula (SCAD) is identified. SCAD is a distinct, but uncommon, disorder sharing histological and clinical features of ulcerative colitis and Crohn disease. Only 1 to 2% of patients with diverticulosis will develop diverticulitis. This review covers the epidemiology, etiology and genetics, pathophysiology and pathogenesis, diagnosis, management, complications and prognosis of diverticulosis, and diverticulitis. Figures show diverticulosis, symptomatic uncomplicated diverticular disease, diverticulitis, computed tomography scan of acute diverticulitis, and a management algorithm. Tables list definitions, risk factors, pathophysiology, modified Hinchey classification, and acute diverticulitis differential diagnosis. This review contains 5 highly rendered figures, 5 tables and 105 references

Diverticulitis and Colitis

Diverticulitis and colitis (which may be broadly grouped into inflammatory, infectious, and ischemic categories) are commonly encountered in the emergency department, and patients’ conditions can range from mild to severe. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, dispositions and outcomes of diverticulitis and colitis. Figures include a computed tomographic scan showing diverticulitis, a bedside sonogram of a patient with diverticulitis, an ultrasound showing bowel wall thickening, a plain abdominal film showing grossly dilated small and large bowel (as seen in toxic megacolon in a patient with inflammatory bowel disease), a computed tomographic image of a patient presenting with known Crohn disease showing thickening of the distal ileum and a small abscess formation, and a computed tomographic image of a patient with ischemic colitis showing air in the small bowel. Tables list the Hinchey classification and the modified Hinchey classification showing stages of diverticulitis, differential diagnosis of left lower quadrant pain, empirical coverage for diverticulitis, indications for surgical treatment for acute diverticulitis, and differential diagnosis of colitis. This review contains 6 highly rendered figures, 5 tables, and 105 references.