Aspects on diverticular disease

Abstract

Objective: The aims of this thesis were to evaluate the influence of ethnicity and other sociodemographic factors on the rate of diverticular disease (DD) (Paper I), to compare findings specific for DD and acceptance of CT Colonography (CTC) and conventional Colonoscopy (CC) in patients examined after diverticulitis (AD) (Paper II), to evaluate the value of antibiotics in conservative treatment of patients with mild AD (Paper III) and to study patients with diverticular fistulas to the female genital tract (Paper IV).

Methods: In paper I, Swedish national registers with information about health and socio-demographic indicators were used to study ethnicity and other socio-demographic factors and the risk of hospital admission due to DD in a national cohort (4.4 millions) followed prospectively over a period of ten years. Paper II was a prospective comparative study of 57 patients examined with CTC and CC respectively. Paper III was an observational study of 311 patients; all treated for AD and included mailed questionnaires. Paper IV reviewed evaluation, management, morbidity and outcome in 60 women treated for DD fistulas to the genital tract.

Results: In all 25,123 patients were hospitalized because of DD during 1991-2000. The risk ratio (RR) of DD, after adjustment for age, sex and socio-economic indicators, was lower in non-western immigrants (RRs 0.5-0.7) compared with indigenous patients. The risk increased with time after settlement in Sweden. Women had a higher risk compared with men (R-R 1.50, CI 95% 1.46-1.54, p<0.001) and the difference increased with age. (Paper I) DD was found in 96 % of patients at CTC and in 90 % at colonoscopy. Eight suspected polyps sized ¡Ý5 mm were found in six patients. Patients experienced colonoscopy more discomforting (p<0.03), painful (p<0.001) and difficult (p<0.01) than CTC. Seventy-four % of patients preferred CTC. (Paper II) During first hospitalisation, patients treated with antibiotics had a more pronounced inflammation compared with patients treated without antibiotics. If initially treated with antibiotics three patients (3 %) failed to respond to medical management and had surgery. Seven patients (4 %) treated without antibiotics failed to respond and antibiotics were then added. In all, 29 % of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) during EU (mean 30 months, range 16-45), compared with 28 % (N.S.), if treated without antibiotics. In a multivariate analysis, antibiotics did not influence the risk for a further event (OR 1.03, Cl 95 % 0.61-1.74). (Paper III)

The most common presenting symptoms in women with a DD fistula to the genital tract were vaginal discharge of faeces or gas (95 %) and 75 % of them had previously had a hysterectomy. 57/60 patients had surgery, sigmoid resection and anastomosis was performed in 51 and a Hartmann's procedure with colostomy in six patients. In all, 26 % of the patients experienced morbidity after surgery, including anastomotic dehiscence (n=4) and ureteric injury (n=3). All operated patients were cured from their fistulas and outcome was satisfactory in 86 %. (Paper IV)

Conclusions: DD appears to be an acquired disorder and acculturation to a Western lifestyle has an impact on the risk for DD. Potential socio-demographic confounders, such as socio-economic status, residency and housing situation don't influence the risk. The diagnostic findings of CTC are comparable to colonoscopy in patients investigated after AD. CTC is less discomforting and preferred by a majority of patients. Thus, CTC seems to be a good alter-native in the follow-up of patients after AD. To omit antibiotics in the treatment of mild AD appears safe and does not influence the rate of further events. DD fistulas to the female genital tract mostly occur in elderly patients with a prior hysterectomy. Sigmoid resection and primary anastomosis is done safely in the majority of patients.